Triage of stroke severity in the field dramatically improves endovascular treatment times for OVL

Findings recently published in the Journal of Neurointerventional Surgery showed that implementation of severity-based triage in emergency medical services (EMS) significantly reduced time to endovascular treatment (EVT) and improved overall outcomes for patients with emergent occlusion of the major vessels (LVO). Given the time-sensitive nature of stroke, these new data underscore the importance of the importance of evolving EMS protocols for patient survival.1.2

The study compared treatment times for 2 adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). In state 1 (n = 407), scene-EVT time decreased by 6% to 8.13 minutes (P = 0.0004), each year, while no decrease was observed in State 2 (n = 232), which did not implement field triage (P = 0.94). Cumulatively over 5.5 years, there was a reduction of 43 minutes in the time required for EVT in state 1 compared to no change in state 2.2

“The time lost in transferring from the nearest hospital to the best-equipped facility clearly compromises a patient’s chances of recovery,” said lead researcher Mahesh Jayaraman, MD, neurointerventional radiologist and professor of imaging. Diagnostics, Neurology and Neurosurgery at Brown University. and Director, Neurovascular Center, Rhode Island Hospital, said in a statement.1 “We hope this research will convince state governments to take a hard look at their stroke care protocols and implement changes to improve triage and transportation.”

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For patients with OLV, the rationale for using stroke triage in the field is that it can better serve these individuals by facilitating direct referral to endovascular centers that can thereby avoid dangerous delays between the primary and the CSCs. In addition to the reduction in treatment times, the researchers observed lower rates of disability in condition 1, both for the entire cohort (odds ratio [OR], 1.22; 95% CI, 1.07-1.40; P = 0.0032) and for those who were independent at baseline (OR, 1.36; 95% CI, 1.15-1.59; P = .0003).2

Jayaraman previously published similar research in 2020 comparing treatment and outcomes between patients taken to the nearest primary stroke center (PSC; n=144) with those field triaged to a more distant CSC (n=88 ). Over 2 years, the median additional transport time to CSC was 7 minutes. Time from scene departure to alteplase (50 vs. 62 minutes; P <.001 and arterial puncture vs minutes>P <.001 were faster in the direct group. among patients who independent before stroke or for less disability group was ci>P = 0.003) and 2.06 (95% CI, 1.10-3.89; P = 0.01) for matched pairs.3

The FAST-ED scale (Field Assessment Stroke Triage for Emergency Destination) has already been constructed and evaluated to identify OVL in the prehospital setting. It was based on the National Institutes of Health Stroke Scale (NIHSS) with higher predictive value for OVG and tested in the Screening Technology and Outcomes Project in Stroke (STOPStroke) cohort, in which patients underwent CT angiography within the first 24 hours after the stroke. beginning.

In a 2016 analysis, OVL was detected in 33% of the cohort of 727 patients. The results showed that FAST-ED had comparable accuracy in predicting OLV to the NIHSS and superior accuracy to the Rapid Arterial Occlusion Assessment Scale (RACE) and Stroke Severity Scale Cincinnati Prehospital Hospital (CPSS) (area under the receiver operating curve: FAST-ED = 0.81; NIHSS = 0.80, P = 0.28; STROKE = 0.77; P = 0.02; SCSP=0.75; P = .002). A FAST-ED of at least 4 had a sensitivity of 0.60, a specificity of 0.89, a positive predictive value of 0.72 and a negative predictive value of 0.82 compared to RACE scores of at least 5 of 0.55, 0.87, 0.68, and 0.79, and CPSS scores at minus 2 of 0.56, 0.85, 0.65, and 0.78, respectively.4

REFERENCES
1. A new study shows that triaging stroke patients directly to Level 1 (Full) Stroke Centers reduces treatment time and improves patient outcomes. Press release. Neurointerventional Surgery Society. July 27, 2022. Accessed July 27, 2022. https://www.prnewswire.com/news-releases/new-study-shows-triaging-stroke-patients-directly-to-level-1-comprehensive-stroke-centers – reduces-treatment-time-and-improves-patient-outcomes-301594212.html
2. Jayaraman M, Baird G, Ouediat K, et al. long-term effect of field triage on endovascular treatment times for emerging large vessel occlusion. J Neurointerv Surg. Published online July 27, 2022. doi:10.1136/jnis-2022-019250.
3. Field triage for endovascular stroke therapy: a population-based comparison. J Neurointerv Surg. 2020;12:233-239.
4. Lima FO, Silva GS, Furle KL, et al. Field assessment stroke triage for emergency destination: a simple and accurate prehospital scale for detecting large vessel occlusion strokes. Stroke. 2016;47:1997-2002. doi:10.1161/STROKEAHA.116.013301

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