Special Considerations in Access to Care and Transport
Douglas J. Floccare, M.D., M.P.H., F.A.C.E.P.
Maryland Institute of Emergency Medical Services Systems, Baltimore
Robert R. Bass, M.D.
Maryland Institute of Emergency Medical Services Systems, Baltimore
Daniel Hankins, M.D., F.A.C.E.P.
Mayo Clinic, Rochester, Minnesota
Thomas M. Stein, M.D.
Allegheny General Hospital, Pittsburgh, Pennsylvania
Patients experiencing acute stroke will often receive initial evaluation at hospitals without 24-hour definitive stroke care* capabilities. The likelihood of this occurring increases in proportion to the distance that the patient is located from a metropolitan area. While timely neurosurgical intervention has been advocated for patients with subarachnoid hemorrhage, there has not been a movement, through public education or changes in prehospital protocols, to direct these patients initially to centers capable of definitive stroke care because they represent only a small portion of patients with change in mental status, headache, stiff neck, or ataxia. Small community hospitals play a critical role in the initial evaluation of these patients, with subsequent triage to centers capable of neurosurgical intervention.
The Food and Drug Administration granted approval for the use of t-PA in ischemic stroke in June of 1996. In September of 1996, the American Academy of Neurology published a Practice Advisory (1), which recommends the use of intravenous t-PA for treatment of ischemic stroke within 3 hours of the onset of symptoms. Thrombolytic therapy is not advocated, however, unless: (a) the diagnosis is established by a "physician who has expertise in the diagnosis of stroke"; (b) a head CT is assessed by a physician with expertise in reading head CTs; (c) the treatment facility is readily able to "handle bleeding complications"; and (d) there is adequate emergent ancillary care.
Physicians and the general public have a strong desire for more effective methods of treating stroke due to the number of permanent disabilities and deaths that occur each year. While there may be a developing role for the use of intravenous t-PA, it does not appear that there is sufficient data to advocate a universal rerouting of patients (with any potential symptoms of ischemic stroke) only to centers with advanced neurological intervention capabilities. Rather, at the present time, community hospitals will need to play an essential role in the initial evaluation of patients with potential ischemic stroke when centers capable of definitive stroke care are not in the immediate vicinity. In metropolitan areas with multiple hospitals, it would appear appropriate to bring the subset of patients with a high likelihood of stroke preferentially to centers with full neurological intervention capabilities if there are minimal differences in transport times.
Implementation of the following general concepts is best directed at the local level, where there is a full understanding of available hospital and out-of-hospital resources and the best means of their integration.
Patients who are within 3 hours of onset of loss of strength or sensation on one side of the body should be considered to be time-critical in nature. Emergency medical services personnel should strive to get such patients to definitive stroke care as rapidly as possible. In communities with multiple medical facilities, this may mean bypassing hospitals that are not able to deliver definitive stroke care immediately.
In communities that do not have facilities that can provide definitive stroke care, the patient with possible acute stroke should be transported expeditiously to the closest emergency care facility. The patient should then be rapidly evaluated and transferred if this can reasonably be expected to improve the chance of a good outcome.1 When the potential benefits of transfer are uncertain, consultation should be made with a referral center capable of definitive stroke care. Air medical transport may play a critical role in the management of patients who could not otherwise reach definitive care within a therapeutic window if transported by ground. It may also play an important role in managing patients who may not have a specific therapeutic window but have a need to minimize out-of-hospital time because they are dependent on ongoing intervention.
There are no data at the present time regarding the safety or effectiveness of administering t-PA for stroke prior to transfer. The use of t-PA for ischemic stroke may evolve in a fashion similar to the use of thrombolysis for myocardial infarction, in which treatment was administered only in tertiary centers when the treatment was new, but then was moved into community hospitals once more experience and data were gained. Previous controlled trials of thrombolysis for stroke have demonstrated that subtle signs of hemorrhage on CT may be missed with potentially catastrophic results. Future research may determine whether approaches such as focused training modules for community physicians or the use of telemedicine can improve the accuracy of identification of patients appropriate for t-PA therapy. The safety of such treatment prior to the patient's arrival at a center capable of treating the potential bleeding complications must also be investigated. Furthermore, although transport of myocardial infarct patients after thrombolytic therapy has not been noted to result in unanticipated complications, before this approach can be widely advocated the risk of complications secondary to transport itself should be studied in ischemic stroke patients who have received t-PA. Further evaluation is also needed regarding the optimal approach to post-thrombolytic blood pressure management in the out-of-hospital setting.
Patients with a high likelihood of ischemic stroke2 should be considered for air medical transport directly from the scene if: (a) they are more than 1 hour by ground to the closest hospital, (b) the closest hospital is not capable of definitive stroke care, and (c) air transport will get them to a center capable of definitive stroke care within 3hoursof symptom onset. If such patients were to be taken by ground to the closest hospital more than an hour away, it is highly unlikely that they could be transferred to a center capable of definitive stroke care within the therapeutic window.
1. Quality Standards Subcommittee of the American Academy of Neurology. Practice Advisory: Thrombolytic therapy for acute ischemic stroke--summary statement. Neurology 1996;47:835-839.
* Defined as a hospital with 24-hour availability of the following: (1) physician with expertise in the diagnosis of stroke; (2) head CT, with assessment by physician with expertise in reading head CTs; (3) ability to treat bleeding complications, including neurosurgical coverage; and (4) emergent ancillary care.
1 For ischemic stroke, this would mean the ability to receive t-PA at the referral center within 3 hours of symptom onset, without contraindications to t-PA therapy.
2 Acute onset of loss of strength or sensation on one side of the body.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last Modified May 17, 2011