The Association between Presentation by EMS and EMS Prenotification with Receipt of Intravenous Tissue-Type Plasminogen Activator in a State Implementing Stroke Systems of Care

Abstract

Collaboration between emergency medical services (EMS) and hospitals receiving stroke patients is critical to ensure prompt, effective treatment, and is a key component of the stroke systems of care (SSoC). The goal of our study was to evaluate the association between presentation by EMS and EMS prenotification with odds of receiving Tissue-type Plasminogen Activator (IV-tPA) in a state implementing SSoC while rigorously accounting for missing data. We utilized data from the Massachusetts Paul Coverdell Stroke Registry for this study, and analyzed adult patients presenting with ischemic stroke to Massachusetts Coverdell hospitals between 2016 and 2018. Patients with contraindications to IV-tPA were excluded. We used generalized estimating equations to assess associations between presentation by EMS, EMS prenotification, and receipt of IV-tPA. We also performed a sensitivity analysis using multiple imputation to assess the sensitivity of our findings to missing data. We identified 9,230 eligible patients with ischemic stroke during the study period. In multivariate complete case regressions, presentation by EMS and EMS prenotification were associated with statistically significant increased odds of receiving IV-tPA (odds ratio [OR] 1.52, 95% confidence interval [CI] 1. OR 1.75, respectively). Analysis of imputed data indicated level or stronger associations. Our analysis indicates that presentation by EMS and EMS prenotification are associated with increased odds of receiving IV-tPA in a state implementing the SSoC. Our results lend importance to the critical role of EMS in the SSoC. Future interventions should work to increase rates of prenotification by EMS and assess inequities in receipt of IV-tPA.

Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th Edition Practice Guidelines Update, 2022

“…30 The odds of a patient receiving treatment with intravenous thrombolysis were increased by 52% if the patient was transported by EMS, and increased by 75% if a system of hospital prenotification was employed. 31 Given the time sensitive nature of acute stroke treatment, it is imperative that patients who https://doi.org/10.1017/cjn.2022.344 Published online by Cambridge University Press may be candidates for these therapies be transported directly to comprehensive stroke centres as quickly as possible and whenever possible. The 90-day outcomes of patients who received endovascular thrombectomy following direct transport have been shown to be better than those who were first transported to a primary stroke centre.…”

The relationship between stroke system organization and disparities in access to stroke center care in California

“…Other limitations of the data include that we lacked a measure of stroke severity (ie, National Institutes of Health Stroke Scale), lacked contraindications or time‐based clinical data to determine patients’ eligibility for reperfusion interventions, and data on ambulance transport, which may contribute to reperfusion delivery and have previously been shown to vary by race or ethnicity. 22 , 23 , 24 We also lacked data on patient language preference, though the contribution of language to acute stroke care is not clear. 25 , 26 , 27 Finally, there may have been unmeasured differences between groups that were unable to be accounted for in our analysis.…”

“…In addition, we chose to use these data because it gives the ability to link patients across emergency and inpatient data sources to track patients across all hospitals (except federal institutions) in the state. Other limitations of the data include that we lacked a measure of stroke severity (ie, National Institutes of Health Stroke Scale), lacked contraindications or time‐based clinical data to determine patients’ eligibility for reperfusion interventions, and data on ambulance transport, which may contribute to reperfusion delivery and have previously been shown to vary by race or ethnicity 22–24 . We also lacked data on patient language preference, though the contribution of language to acute stroke care is not clear 25–27 .…”

Prehospital emergency medical service utilization and associated factors among critically ill COVID-19 patients treated at centers in Addis Ababa, Ethiopia

“…Severe infection with COVID-19 can induce a life-threatening condition such as acute respiratory distress syndrome (ARDS) [8][9][10], which needs urgent transfer to specialized centers for escalating treatment [11,12]. Transport by EMS, as opposed to self-transport, is associated with better patient outcomes by providing access to prehospital lifesaving interventions and rapid transport to appropriate facilities [13][14][15]. However, the majority of the population in low-income countries are living in areas with no access or limited access to formal emergency care systems [16].…”