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Montgomery County Hospital District EMS Publishes Study to Examine Pre-Hospital Evaluation of LVO Stroke

Picture of Hannah Ostrem Hannah Ostrem : Aug 23, 2016

Stroke EMS

Montgomery County Hospital District EMS Publishes Study to Examine Pre-Hospital Evaluation of LVO Stroke

EMS often has the first contact with stroke patients, and as such, plays a major role in the ultimate treatment of patients afflicted with the condition. It is up to the medics that arrive on scene to determine the severity of the stroke, and using the information they gather, decide which facility to take that patient to, based on the hospitals' resources and patient needs. Since recent data has shown that large vessel occlusion (LVO) strokes can be treated much more efficiently when a combination of t-PA and a clot retrieval device are used together (versus t-PA alone), a burden lies with first responders to distinguish LVO strokes and take those patients directly to intervention-capable facilities in order to achieve the fastest treatment and best patient outcomes.

Montgomery County Hospital District EMS (MCHD) is a non-fire based EMS service located in Montgomery County, TX. Of the 58,000 calls they serve each year, more than 500 of them are strokes. Because stroke has proven time and again to be such a time-sensitive condition, and because there are currently few effective protocols to distinguish and triage large vessel occlusion (LVO) strokes in particular, the medical directors and first responders at MCHD have designed a study to evaluate their current measures in identifying LVO and in determining whether to take those patients to primary or comprehensive stroke centers, the results of which were published this week in JEMS. They are also in the process of collecting data for a follow-up study to evaluate the efficacy of adding a novel stroke score to their current protocols for stroke patient evaluation and hospital destination determination.

To analyze the sensitivity of MCHD's current practice in identifying severity of strokes and in distinguishing LVO strokes, the team looked back at their past stroke alert patients over a period of 21 months, examining cases their EMS personnel had identified as strokes using the South East Texas Regional Advisory Committee (SETRAC) guideline and stroke severity assessment. Within this data, the team looked at whether the identified stroke patients were taken to primary or comprehensive stroke centers and quantified those decisions.

MCHD found that their paramedics decided to take patients to comprehensive stroke centers in 41% of identified stroke cases. In May 2016, MCHD began conducting a complementary study, the Validation of Integrating a Stroke Algorithm (VISA) study, which will include and evaluate the RACE score as a means of determining severity of strokes and LVO when added to the current SETRAC tool. They will then compare the rate at which their team elected to take stroke patients to comprehensive centers with the added RACE score to their previous rate, as a means of determining whether this tool can help further identify patients who need the specialized care these centers provide.

In their paper, MCHD also sites data that suggests use of mobile care coordination technology can help improve door-to-needle times, saying "the use of mobile technologies from Pulsara - Stop Stroke and Stop STEMI - have shown promising improvements of up to 46% in door-to-therapy times in STEMI and [Acute Ischemic Stroke (AIS)]."

Because new technologies and protocols are fast emerging in the treatment of LVO stroke patients, it is imperative that all clinicians evaluate their current systems against emerging tools to decide whether there is a need to update their processes to provide the best possible care for these extremely sensitive patients. Facilities like MCHD are leading the charge in this initiative and in so doing, continue to uphold their commitment to excellence for their patients.

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