Most States Lack Specific Prehospital Guidelines on Transport of Suspected LVO Patients

(Reuters Health) – Most U.S. states do not have emergency medical services (EMS) guidelines that address transport of patients with suspected stroke caused by large vessel occlusion (LVO), and among those that do, there is substantial variability in protocols, a new study suggests.

An analysis of adult stroke EMS protocols from the 35 states that have made theirs publicly available revealed that just 16 states included specific transport considerations addressing suspected LVO cases, with five others suggesting that regional algorithms be followed, according to the report published in JAMA Neurology.

Among the states with protocols, the authors found five different LVO screening tools being recommended, and widely differing advice on where to take suspected LVO patients.

“Despite the critically important nature of prehospital triage in the early treatment of patients with stroke caused by large vessel occlusion (LVO), we found that there was substantial variability in prehospital LVO triage protocols nationwide,” said senior study author Dr. Michael Reznik of Brown University’s Alpert Medical School in Providence, Rhode Island. “This degree of variability may impact patient care and outcomes by keeping some eligible patients from receiving certain treatments like mechanical thrombectomy.”

Dr. Reznik and his colleagues performed a cross-sectional analysis of publicly available statewide EMS protocols in December of 2020, and included states with mandated or recommended protocols as well as those with relevant state health department-issued guidelines in their analysis.

The researchers then determined the frequency of LVO-specific transport algorithms, use of LVO screening tools criteria for determining transport to an alteplase-capable center (ACC) versus a thrombectomy-capable center (TCC), and specific time-based cutoffs considered in transport decision making.

Of the 16 states with specific transport considerations for suspected LVO cases, five different screening tools were recommended: Rapid Arterial Occlusion Exam (RACE); Field Assessment Stroke Triage for Emergency Destination (FAST-ED); Cincinnati Stroke Triage Assessment Tool (C-STAT); Los Angeles Motor Scale (LAMS); and visual, aphasia, and neglect assessment (VAN).

Among these states, nine recommended bypassing ACCs in favor of TCCs for potentially alteplase-eligible patients, while six recommended transport of alteplase-eligible patients to the nearest ACC and alteplase-ineligible patients to a TCC; one state defers transportation decisions of alteplase-eligible patients to potential receiving hospitals.

Among states that recommended bypassing ACCs for TCCs, seven did not indicate a maximum acceptable transportation delay, while the others allowed maximum delays ranging from 15 to 60 minutes.

Three states (Kentucky, Nevada, and West Virginia) explicitly prioritized comprehensive stroke centers over other TCCs, and five states (Iowa, Idaho, Nevada, Washington, and West Virginia) suggested air medical transport to expedite hospital arrival.

According to a consensus statement published in March, it is now recommended that patients with suspected LVO should be preferentially triaged to a TCC if within a certain range, depending on geographical setting, and specific prehospital procedures to identify such patients are also recommended, the study team notes.

“Timely intervention for stroke caused by LVO requires appropriate prehospital triage, as only certain centers are equipped to perform a thrombectomy procedure for eligible patients” Dr. Reznik said by email.

The new study is “interesting and the authors should be commended for bringing this to our attention,” said Dr. Matthew J. Levy, an associate professor of emergency medicine at the Johns Hopkins University School of Medicine and an emergency medicine physician at The Johns Hopkins Hospital in Baltimore. “I would also add that the protocol analysis was performed around late 2020. It’s still very much current but I can say that there are operational programs that have come online since then.”

Because the research letter was published in a large, well-read journal it has the ability to make an impact, Dr. Levy said. With a big audience, that could lead to more states developing protocols, he added.

SOURCE: JAMA Neurology, online September 20, 2021.

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