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January 25, 2019

Why the 'hodgepodge' of ambulance routing protocols may hurt severe stroke patients

Daily Briefing

    While emerging evidence suggests patients suffering from severe strokes fare better when taken to a hospital where they can receive a thrombectomy, America's "hodgepodge" of ambulance protocols can often take them to other hospitals first, Thomas Burton reports for the Wall Street Journal.

    Toolkit: Reduce stroke care variation

    A 'revolutionary improvement' for which timing is key

    Research suggests that patients suffering from a type of severe stroke caused by a blood clot in a major artery in the brain have a much better chance at recovery if they receive a thrombectomy. But only 175 hospitals across the United States are certified to perform the procedure, which requires a surgeon to insert a catheter through the artery system into the brain to remove the clot before brain tissue is severely damaged. If all goes well, the blockage is removed on the first try, and blood flow is restored, effectively ending the stroke.

    Ryan McTaggart, director of interventional neuroradiology at Rhode Island Hospital, said, "There is no more revolutionary improvement in medicine than the thrombectomy. But it is very time-dependent." In fact, some patients can lose critical brain tissue within just an hour of a stroke, Burton writes, which means getting a patient a thrombectomy quickly is key.

    While some patients may benefit from the procedure up to 24 hours after the stroke, in many cases, delaying a thrombectomy can lower the chances of a full recovery, Burton writes. Mahesh Jayaraman, director of Rhode Island Hospital's neurovascular center, said a one-hour delay "leads to one patient out of five who is disabled and not able to care for themselves."

    How ambulance protocols cause delays in treatment

    Despite the time-sensitive nature of the procedure, there is no nationwide standard for how stroke patients are routed to hospitals that are capable of performing it. As such, ambulance protocols vary widely throughout the country, Burton writes.

    Many states have protocols to rush stroke patients to one of the nearest "primary stroke centers," a certification provided by the Joint Commission.

    However, only 30% of these primary stroke centers are able to perform thrombectomies. As a result, these hospitals—which are equipped to treat the majority of stroke patients—must transfer patients who require a thrombectomy to a hospital that can perform one, which can cause delays. Delays for these most severe patients often have an outsized impact as these severe strokes are the most likely to cause long-term disability, Burton reports.

    The debate over getting to thrombectomy-capable hospitals sooner

    A number of studies suggest that bypassing non-thrombectomy-capable hospitals for hospitals that can perform the procedure significantly improves outcomes, Burton writes. One 2017 study of 562 severe stroke patients found that patients who were transferred to a hospital able to perform a thrombectomy from one unable to do it were five times more likely to be disabled or die compared with those initially taken to a thrombectomy-capable hospital. A separate study in 2018 concluded that longer time spent at primary stroke centers "appears to have a deleterious effect on outcome."

    Jayaraman, McTaggart, and others believe that primary stroke centers should be bypassed if there's a hospital able to perform a thrombectomy 45 father minutes away, Burton writes.

    However, such a proposal would leave ambulance services saddled with the task of distinguishing severe strokes that would benefit from a thrombectomy from more routine ones. As Burton writes, thrombectomy-capable hospitals would be swamped if they treated every stroke patient, so any protocols about routing patients would require appropriate triaging as a first step.

    The American Heart Association (AHA) and American Stroke Association (ASA) are currently re-evaluating evidence on the topic. In January 2018, AHA and ASA issued guidelines that concluded the benefit of bypassing hospitals for thrombectomy centers was "uncertain." However, the organizations later retracted the guidance in response to outcry from many in the neurology community.

    Ameer Hassan, head of neuroscience at Valley Baptist Medical Center, said, "All of us were up in arms, because there is data," that supports bypassing primary stroke centers (Burton, Wall Street Journal, 11/28).

    Toolkit: Reduce stroke care variation

    Hospitals and health systems investing in care variation reduction (CVR) often focus on stroke care. Stroke is a top-opportunity condition for CVR nationally, from both a quality improvement and cost savings perspective.

    This toolkit provides downloadable templates and examples from a successful stroke care variation reduction strategy. Use these tools to jumpstart your own care variation reduction efforts, and scale those efforts system-wide.

    Get the Toolkit

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