1
|
Rasool A, Bailey M, Lue B, Omeaku N, Popoola A, Shantharam SS, Brown AA, Fulmer EB. Policy implementation strategies to address rural disparities in access to care for stroke patients. FRONTIERS IN HEALTH SERVICES 2023; 3:1280250. [PMID: 38130727 PMCID: PMC10733855 DOI: 10.3389/frhs.2023.1280250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023]
Abstract
Context Stroke systems of care (SSOC) promote access to stroke prevention, treatment, and rehabilitation and ensure patients receive evidence-based treatment. Stroke patients living in rural areas have disproportionately less access to emergency medical services (EMS). In the United States, rural counties have a 30% higher stroke mortality rate compared to urban counties. Many states have SSOC laws supported by evidence; however, there are knowledge gaps in how states implement these state laws to strengthen SSOC. Objective This study identifies strategies and potential challenges to implementing state policy interventions that require or encourage evidence-supported pre-hospital interventions for stroke pre-notification, triage and transport, and inter-facility transfer of patients to the most appropriate stroke facility. Design Researchers interviewed representatives engaged in implementing SSOC across six states. Informants (n = 34) included state public health agency staff and other public health and clinical practitioners. Outcomes This study examined implementation of pre-hospital SSOCs policies in terms of (1) development roles, processes, facilitators, and barriers; (2) implementation partners, challenges, and solutions; (3) EMS system structure, protocols, communication, and supervision; and (4) program improvement, outcomes, and sustainability. Results Challenges included unequal resource allocation and EMS and hospital services coverage, particularly in rural settings, lack of stroke registry usage, insufficient technologies, inconsistent use of standardized tools and protocols, collaboration gaps across SSOC, and lack of EMS stroke training. Strategies included addressing scarce resources, services, and facilities; disseminating, training on, and implementing standardized statewide SSOC protocols and tools; and utilizing SSOC quality and performance improvement systems and approaches. Conclusions This paper identifies several strategies that can be incorporated to enhance the implementation of evidence-based stroke policies to improve access to timely stroke care for all patient populations, particularly those experiencing disparities in rural communities.
Collapse
Affiliation(s)
- Aysha Rasool
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, United States
| | - Moriah Bailey
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Brittany Lue
- Chenega Corporation, Anchorage, AK, United States
| | - Nina Omeaku
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Adebola Popoola
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sharada S. Shantharam
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amanda A. Brown
- Applied Science, Research and Technology, Inc., Atlanta, GA, United States
| | - Erika B. Fulmer
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| |
Collapse
|
2
|
Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
Collapse
Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
3
|
Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
Collapse
Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Chennareddy S, Kalagara R, Smith C, Matsoukas S, Bhimani A, Liang J, Shapiro S, De Leacy R, Mokin M, Fifi JT, Mocco J, Kellner CP. Portable stroke detection devices: a systematic scoping review of prehospital applications. BMC Emerg Med 2022; 22:111. [PMID: 35710360 PMCID: PMC9204948 DOI: 10.1186/s12873-022-00663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The worldwide burden of stroke remains high, with increasing time-to-treatment correlated with worse outcomes. Yet stroke subtype determination, most importantly between stroke/non-stroke and ischemic/hemorrhagic stroke, is not confirmed until hospital CT diagnosis, resulting in suboptimal prehospital triage and delayed treatment. In this study, we survey portable, non-invasive diagnostic technologies that could streamline triage by making this initial determination of stroke type, thereby reducing time-to-treatment. METHODS Following PRISMA guidelines, we performed a scoping review of portable stroke diagnostic devices. The search was executed in PubMed and Scopus, and all studies testing technology for the detection of stroke or intracranial hemorrhage were eligible for inclusion. Extracted data included type of technology, location, feasibility, time to results, and diagnostic accuracy. RESULTS After a screening of 296 studies, 16 papers were selected for inclusion. Studied devices utilized various types of diagnostic technology, including near-infrared spectroscopy (6), ultrasound (4), electroencephalography (4), microwave technology (1), and volumetric impedance spectroscopy (1). Three devices were tested prior to hospital arrival, 6 were tested in the emergency department, and 7 were tested in unspecified hospital settings. Median measurement time was 3 minutes (IQR: 3 minutes to 5.6 minutes). Several technologies showed high diagnostic accuracy in severe stroke and intracranial hematoma detection. CONCLUSION Numerous emerging portable technologies have been reported to detect and stratify stroke to potentially improve prehospital triage. However, the majority of these current technologies are still in development and utilize a variety of accuracy metrics, making inter-technology comparisons difficult. Standardizing evaluation of diagnostic accuracy may be helpful in further optimizing portable stroke detection technology for clinical use.
Collapse
Affiliation(s)
- Susmita Chennareddy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA.
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Abhiraj Bhimani
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Steven Shapiro
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| |
Collapse
|
5
|
Al Saiegh F, Munoz A, Velagapudi L, Theofanis T, Suryadevara N, Patel P, Jabre R, Chen CJ, Shehabeldin M, Gooch MR, Jabbour P, Tjoumakaris S, Rosenwasser RH, Herial NA. Patient and procedure selection for mechanical thrombectomy: Toward personalized medicine and the role of artificial intelligence. J Neuroimaging 2022; 32:798-807. [PMID: 35567418 DOI: 10.1111/jon.13003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 12/27/2022] Open
Abstract
Mechanical thrombectomy (MT) for ischemic stroke due to large vessel occlusion is standard of care. Evidence-based guidelines on eligibility for MT have been outlined and evidence to extend the treatment benefit to more patients, particularly those at the extreme ends of a stroke clinical severity spectrum, is currently awaited. As patient selection continues to be explored, there is growing focus on procedure selection including the tools and techniques of thrombectomy and associated outcomes. Artificial intelligence (AI) has been instrumental in the area of patient selection for MT with a role in diagnosis and delivery of acute stroke care. Machine learning algorithms have been developed to detect cerebral ischemia and early infarct core, presence of large vessel occlusion, and perfusion deficit in acute ischemic stroke. Several available deep learning AI applications provide ready visualization and interpretation of cervical and cerebral arteries. Further enhancement of AI techniques to potentially include automated vessel probe tools in suspected large vessel occlusions is proposed. Value of AI may be extended to assist in procedure selection including both the tools and technique of thrombectomy. Delivering personalized medicine is the wave of the future and tailoring the MT treatment to a stroke patient is in line with this trend.
Collapse
Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alfredo Munoz
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Neil Suryadevara
- Department of Neurology, Upstate Medical University, Syracuse, New York, USA
| | - Priyadarshee Patel
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Ramos A, Guerrero WR, Pérez de la Ossa N. Prehospital Stroke Triage. Neurology 2021; 97:S25-S33. [PMID: 34785601 DOI: 10.1212/wnl.0000000000012792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center ("drip and ship"), direct transfer of the patient to an endovascular center ("mothership"), transfer of the neurointerventional team to a local primary center ("drip and drive"), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed. RECENT FINDINGS Local observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol. SUMMARY Prehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.
Collapse
Affiliation(s)
- Anna Ramos
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Waldo R Guerrero
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Natalia Pérez de la Ossa
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa.
| |
Collapse
|
7
|
Jumaa MA, Salahuddin H, Burgess R. The Future of Endovascular Therapy. Neurology 2021; 97:S185-S193. [PMID: 34785617 DOI: 10.1212/wnl.0000000000012807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 04/13/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article summarizes a broad range of the most recent advances and future directions in stroke diagnostics, endovascular robotics, and neuromodulation. RECENT FINDINGS In the past 5 years, the field of interventional neurology has seen major technological advances for the diagnosis and treatment of cerebrovascular diseases. Several new technologies became available to aid in complex prehospital stroke triage, stroke diagnosis, and interpretation of radiologic findings. Robotics and neuromodulation promise to expand access to established treatments and broaden neuroendovascular indications. SUMMARY Mobile applications offer a solution to simplify prehospital diagnostic and transfer decisions. Several prehospital devices are also under development to improve the accuracy of detection of large vessel occlusion (LVO). Artificial intelligence is now routinely used in early diagnosis of LVO and for detecting salvageability of the affected brain parenchyma. Technological advances have also paved the way to incorporate endovascular robotics and neuromodulation into practice. This may expand the deliverability of established treatments and facilitate the development of cutting-edge treatments for other complex neurologic diseases.
Collapse
Affiliation(s)
- Mouhammad A Jumaa
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH.
| | - Hisham Salahuddin
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH
| | - Richard Burgess
- From the Department of Neurology, ProMedica Neurosciences Institute; and Department of Neurology, University of Toledo College of Medicine, OH
| |
Collapse
|
8
|
Desai SM, Leslie-Mazwi TM, Hirsch JA, Jadhav AP. Optimal transfer paradigm for emergent large vessel occlusion strokes: recognition to recanalization in the RACECAT trial. J Neurointerv Surg 2021; 13:97-99. [PMID: 33500255 DOI: 10.1136/neurintsurg-2020-017227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Shashvat M Desai
- Department of Neurology and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashutosh P Jadhav
- Department of Neurology and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| |
Collapse
|
9
|
Patel MD, Thompson J, Cabañas JG, Williams JG, Lewis E, Bachman M, Al Masry M, LaVigne C, Morantes L, Becske T, Kass-Hout O. Performance of the vision, aphasia, neglect (VAN) assessment within a single large EMS system. J Neurointerv Surg 2021; 14:341-345. [PMID: 33893209 DOI: 10.1136/neurintsurg-2020-017217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is limited evidence on the performance of emergent large-vessel occlusion (LVO) stroke screening tools when used by emergency medical services (EMS) and emergency department (ED) providers. We assessed the validity and predictive value of the vision, aphasia, neglect (VAN) assessment when completed by EMS and in the ED among suspected stroke patients. METHODS We conducted a retrospective study of VAN performed by EMS providers and VAN inferred from the National Institutes of Health Stroke Scale performed by ED nurses at a single hospital. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAN by EMS and in the ED for LVO and a combined LVO and intracerebral hemorrhage (ICH) outcome. RESULTS From January 2018 to June 2020, 1,547 eligible patients were identified. Sensitivity and specificity of ED VAN were similar for LVO (72% and 74%, respectively), whereas EMS VAN was more sensitive (84%) than specific (68%). PPVs were low for both EMS VAN (26%) and ED VAN (21%) to detect LVO. Due to several VAN-positive ICHs, PPVs were substantially higher for both EMS VAN (44%) and ED VAN (39%) to detect LVO or ICH. EMS and ED VAN had high NPVs (97% and 96%, respectively). CONCLUSIONS Among suspected stroke patients, we found modest sensitivity and specificity of VAN to detect LVO for both EMS and ED providers. Moreover, the low PPV in our study suggests a significant number of patients with non-LVO ischemic stroke or ICH could be over-triaged with VAN.
Collapse
Affiliation(s)
- Mehul D Patel
- Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - José G Cabañas
- Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Emergency Medical Services, Wake County, Raleigh, North Carolina, USA
| | - Jefferson G Williams
- Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Emergency Medical Services, Wake County, Raleigh, North Carolina, USA
| | - Erin Lewis
- Neurology, UNC Rex Healthcare, Raleigh, North Carolina, USA
| | - Michael Bachman
- Emergency Medical Services, Wake County, Raleigh, North Carolina, USA
| | | | | | | | - Tibor Becske
- Neurology, UNC Rex Healthcare, Raleigh, North Carolina, USA
| | - Omar Kass-Hout
- Neurology, UNC Rex Healthcare, Raleigh, North Carolina, USA
| |
Collapse
|
10
|
McTaggart RA, Holodinsky JK, Ospel JM, Cheung AK, Manning NW, Wenderoth JD, Phan TG, Beare R, Lane K, Haas RA, Kamal N, Goyal M, Jayaraman MV. Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy. Stroke 2020; 51:1951-1960. [PMID: 32568640 DOI: 10.1161/strokeaha.119.026735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan A McTaggart
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Andrew K Cheung
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.)
| | - Nathan W Manning
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Jason D Wenderoth
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.)
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children's Research Institute Melbourne Australia (R.B.)
| | - Kendall Lane
- Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Richard A Haas
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| |
Collapse
|
11
|
Leslie-Mazwi TM. Invited Commentary on "Imaging-based Selection for Endovascular Treatment in Stroke". Radiographics 2019; 39:1714-1716. [PMID: 31589583 DOI: 10.1148/rg.2019190188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Thabele M Leslie-Mazwi
- Departments of Neurology and Neurosurgery, Massachusetts General Hospital, Harvard Medical School.,Boston, Massachusetts
| |
Collapse
|
12
|
Chiu YC, Tang SC, Sun JT, Tsai LK, Hsieh MJ, Lee CW, Jeng JS, Lee YC, Chien YC, Wang YC, Chiang WC, Ma MHM. Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy. J Neurointerv Surg 2019; 12:104-108. [PMID: 31337733 DOI: 10.1136/neurintsurg-2019-015171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs. METHODS All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital. RESULTS In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals. CONCLUSIONS A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.
Collapse
Affiliation(s)
- Yu-Chen Chiu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Chun Chien
- Fire Department of the City of Taipei, Taipei, Taiwan
| | | | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital YunlinBranch, Yunlin County, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital YunlinBranch, Yunlin County, Taiwan
| |
Collapse
|