The neurological emergency room and prehospital stroke alert: the whole is greater than the sum of its parts

Mandy J Binning, Geri Sanfillippo, William Rosen, Michael D ľambrosio, Erol Veznedaroglu, Kenneth Liebman, Cynthia Diaz, Rosemary Silva, Daniel Eichorn, Mitchell Rubin
Neurosurgery 2014, 74 (3): 281-5; discussion 285

BACKGROUND: Emergency medical services (EMS) prenotification to hospitals regarding the arrival of patients who have had a stroke is recommended to facilitate the workup once the patient arrives. Most hospitals have the patient enter the emergency department (ED) before obtaining a head computed tomography (CT) scan. At Capital Health, prehospital stroke-alert patients are delivered directly to CT and met by a neurological emergency team. The goal of bypassing the ED is to reduce the time to treatment.

OBJECTIVE: To evaluate (1) door-to-CT and door-to-needle time in patients with an acute stroke who arrive as prehospital stroke alerts and (2) the accuracy of EMS assessment.

METHODS: A prospective database of all prehospital stroke alert patients was kept and data retrospectively reviewed for patients who were seen between July 2012 and July 2013.

RESULTS: Between July 2012 and July 2013, 141 prehospital stroke alerts were called to our emergency department, and the patients were stable enough to bypass the ED and go directly to CT. EMS assessment of stroke was accurate 66% of the time, and the diagnosis was neurological 89% of the time. The average time between patient arrival and acquisition of CT imaging was 11.8 minutes. Twenty-six of the 141 patients (18%) received intravenous tissue plasminogen activator. The median time from arrival to intravenous tissue plasminogen activator bolus was 44 minutes.

CONCLUSION: Trained EMS responders are able to correctly identify patients who are experiencing neurological/neurosurgical emergencies and deliver patients to our comprehensive stroke center in a timely fashion after prenotification. The prehospital stroke alert protocol bypasses the ED, allowing the patient to be met in CT by the neurological ED team, which has proven to decrease door-to-CT and door-to-needle times from our historical means.

ABBREVIATIONS: ASLS, Advanced Stroke Life SupportDTN, door-to-needleED, emergency departmentEMS, emergency medical servicesEMT, emergency medical technicianIV, intravenousMEND, Miami Emergency Neurological DeficitPHSA, prehospital stroke alerttPA, tissue plasminogen activator.

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