Abstract
Introduction
Time delay is the key obstacle for receiving successful stroke treatment. Alteplase therapy must start within 4.5 hours from stroke occurrence. Rapid transport to a primary stroke center (PSC) or acute stroke–ready hospital (ASRH) by the emergency medical system (EMS) paramedics is vital. We determined transport time and destination data for EMS-identified and -delivered stroke suspects in Arkansas during 2013. Our objective was to analyze transport time and the hospital qualification for stroke care across the state.
Methods
The state's 75 counties were placed into 8 geographical regions (R1–R8). Transport time and hospital qualification were determined for all EMS-identified strokes. Each hospital's stroke care status was categorized as PSC, ASRH, a nonspecialty or unknown care facility (NSCF), out-of-state, or nonapplicable designation facilities.
Results
There were 9588 EMS stroke ground transports with median within-region transport times of 29–40 minutes. Statewide, only 65% of EMS-transported stroke patients were transported to either PSC (12%) or ASRH (53%) facilities. One-third of the patients (30.6%) were delivered to NSCFs, where acute stroke therapy may rarely be performed. Regions with the highest suspected-stroke cases per capita also had the highest percentage of transports to NSCFs.
Conclusion
With only a few PSCs in Arkansas, EMS agencies should prioritize transporting stroke patients to ASRHs when PSCs are not regionally located.
1. Introduction
Choice of hospital destination is a critical decision in the emergency management of acute stroke patients because unprepared or inadequate facilities, personnel, and policies can cause treatment delays and may increase interfacility transports that may preclude receiving time-sensitive stroke therapy. Direct transport to medical facilities geographically accessible and qualified for stroke care is crucial for acute ischemic stroke patients [1–3]. Hospital selection for stroke treatment was the choice of the patient or family in 50.6% of cases in one study, but otherwise, the paramedics can suggest appropriate treatment facilities based on their knowledge of the hospital specialty, suspected diagnosis, last known well time, and the estimated travel time. [4] To reduce delays to treatment, some states have begun implementing emergency medical system (EMS) direct routes to stroke subspecialty hospitals [2,5,6].
In Arkansas, where the age-adjusted stroke mortality rate of 53.7 per 100,000 in 2009 remained the highest in the nation, the deployment of a statewide telestroke network that improved access to care in rural areas was not accompanied by a statewide guideline describing destination protocols for suspected stroke cases [7–9] (Fig. 1).
Fig. 1.
Arkansas stroke systems of care. Thirty- and 60-minute drive times to PSCs and AR SAVES sites in Arkansas in 2012 showing 68% and 95% of state's population covered, respectively, by county.
Source: AR-SAVES Annual Report 2012. Courtesy of AHA, 2012.
In this study, we aimed to evaluate the EMS performance time parameters and choice of destination facility according to stroke care certification in the context of regional demographic variables in Arkansas. We hypothesized that EMS paramedics were transporting patients for acute stroke evaluation and management to nonqualified facilities even when there were nearby stroke-ready specialty centers available.
2. Methods
This study was a retrospective review of EMS transport records of patients diagnosed by paramedics as potentially having an acute stroke in Arkansas during calendar year 2013. The data were provided by the Arkansas Department of Health (ADH), deidentified, HIPPA compliant, and determined as not Human Subject Research by the University of Arkansas for Medical Sciences' Institutional Review Board. Each EMS agency reported to the EMS division of ADH all transport data on a daily basis using the Arkansas EMScan KeyData Web Version 1 (EMS Data Systems, Inc Windows) or monthly using third-party software. Submitted data included agency profile, EMS qualifications (paramedic or other), EMS origin by state region, transport mode (air or ground), type of transportation (911 calls or interfacility transfer), destination facility type, and various time points. Time intervals were calculated as follows: call received by 911 dispatch to agency, agency to scene (response time), scene arrival to scene departure (on-scene time), scene departure to arrival at destination (transport time), and call received by 911 dispatch to destination arrival (total time).
Arkansas's 75 counties were previously divided into 8 regions by the EMS division of ADH (Fig. 2). We collected data for these 8 regions (R1–R8) including public statistics on county population, square miles of land, the number of available EMS agencies, and the number of paramedics [9,10] to analyze descriptive demographics, and we assigned a region of origin and a region of destination to each transport record. Destination facilities were classified as primary stroke center (PSC) (n = 3), acute stroke–ready hospitals (ASRHs) (n = 42), nonspecialty care facilities (NSCFs) (n = 42), out-of-state facility (OSF) (n = 7), or nonapplicable designation facility (NADF) (n = 5). Two of the PSCs are “hub” hospitals for the telemedicine spoke sites, and all 3 are Joint Commission–certified primary stroke centers. We performed a survey and identified 42 telemedicine spoke sites (40 Arkansas Stroke Assistance through Virtual Emergency Support network [AR SAVES] spoke sites and 2 Mercy Health System hospitals) that were considered ASRH because they met the criteria of the Brain Attack Coalition. The NSCFs were those that did not have stroke care accreditation or telemedicine stroke support. The OSFs were hospitals located in neighboring states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas). The NADFs were listed in transport records as home, extended care, outpatient services, hospice, or nonidentified Arkansas hospital.
Fig. 2.
Illustration of the statewide county map of Arkansas divided into 8 regions. Regions R1–R8 are based on the ADH coded map (EMS Series) for EMS service areas located throughout all 75 counties.
Source: ADH, EMS Series Map. Courtesy of ADH, 2012.
The Statistical Analysis System, version 9.3, software was used for calculating frequency and percentages of transports, median time, and interquartile range (IQR) and to compare between transports to NSCFs vs transports to PSC or ASRH facilities.
3. Results
There were 9691 EMS ground transport records of suspected stroke patients in Arkansas during 2013. Three transport records that had erroneous total transport time (= 0 minute) and 100 records that consisted of duplicated data were excluded, resulting in a total of 9588 records included in the study (Table 1).
Table 1.
Agency and regional characteristics: call volume in 8 geographical regions in Arkansas, 2013a
| EMS origin by state regions | ||||||||
|---|---|---|---|---|---|---|---|---|
| R1 | R2 | R3 | R4 | R5 | R6 | R7 | R8 | |
| Total EMS agencies, n | 29 | 23 | 22 | 21 | 22 | 32 | 12 | 20 |
| Private EMS agencies, n (%) | 16 (55) | 13 (56) | 12 (54) | 15 (71) | 18 (82) | 24 (75) | 6 (50) | 17 (85) |
| Total EMS staff, n | 1217 | 622 | 1498 | 451 | 538 | 649 | 397 | 666 |
| EMS paramedics, n (%) | 390 (33) | 156 (25) | 299 (20) | 164 (35) | 155 (29) | 217 (33) | 138 (35) | 194 (29) |
| Population,b n | 598,553 | 238,688 | 697,983 | 209,231 | 230,180 | 390,011 | 260,811 | 315,822 |
| Area,b square miles | 6482.3 | 6690.7 | 3550.1 | 8072.7 | 7490.6 | 7982.5 | 4192 | 7045.8 |
| Population density, person/square mile | 92.3 | 35.7 | 196.6 | 25.9 | 30.7 | 48.9 | 62.2 | 44.8 |
| Stroke transports, n (% per capita)c | 1668 (0.3) | 962 (0.4) | 1907 (0.3) | 393 (0.2) | 859 (0.4) | 1862 (0.5) | 717 (0.3) | 1593 (0.5) |
Arkansas Department of Health 2013 EMS data.
State statistics (2012) from the free public access, www.us-places.com.
Percentage of regional population who had a stroke suspected by EMS during 911 calls in 2013.
All Arkansas counties were grouped into 8 defined regions as shown in Fig. 2. From the demographic data in Table 1, we observed that regions R6 and R8 had a higher percentage of EMS-identified stroke transports per capita compared with the rest (0.5% vs 0.2%–0.4%). Overall, there was a high proportion of private EMS agencies (67%), and the vast majority of transports were covered by EMS with paramedic level of training (Table 2).
Table 2.
Agency characteristics and total time
| EMS origin by state region | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| R1 | R2 | R3 | R4 | R5 | R6 | R7 | R8 | R9a | |
| No. of EMS agencies called, n | 27 | 18 | 14 | 18 | 18 | 24 | 12 | 20 | 1 |
| Private EMS agencies called, n (%) | 16 (59.3) | 11 (61.1) | 10 (71.4) | 14 (77.8) | 15 (83.3) | 20 (83.3) | 6 (50) | 15 (75) | 1 (100) |
| Calls transported by EMS paramedics, n (%) | 1642 (99.9) | 930 (97.2) | 1905 (100) | 387 (100) | 767 (97.8) | 1722 (98.7) | 695 (99.7) | 1459 (99.3) | 1 (100) |
| Total time,b median (IQR) min | 39 (30–55) | 41 (28–58) | 39 (31–50) | 31 (24–54) | 37 (26–55) | 37 (27–52) | 37 (28–52) | 39 (29–53) | 102 |
EMS suspected strokes after response to 911 calls in 8 geographical regions in Arkansas, 2013 (ground transportation).
Out-of-state EMS.
Total time is from call received by 911 dispatch to arrival at the destination.
Twelve percent of patients were transported to PSC and 53% to an ASRH, for a total of only 65% of patients transported to centers with known stroke care capability. The other 35% were transported to hospitals with limited or unknown stroke care capability (NSCF or OSF). The PSCs received less than 50% of transports delivered to their region. The regions (R6 and R8) with higher stroke transports per capita had fewer patients transported to ASRH compared with the rest (43%–52% vs 64%–97%). Overall, 3 regions (R3, R6, and R8) stood out as having the highest percentage of transports to NSCF destinations (35.8%, 48.4%, and 57.3%, respectively) (Table 3).
Table 3.
Destination facility qualification
| Total | Destination Facility Region | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| R1 | R2 | R3 | R4 | R5 | R6 | R7 | R8 | OSFd | NADFe | ||
| PSCsa | 1116 (11.6) | – | – | 786 (39.5) | – | – | – | 330 (47.1) | – | – | – |
| ASRHsb | 5049 (52.7) | 1382 (85.4) | 741 (84.5) | 493 (24.8) | 338 (97.1) | 447 (86.0) | 824 (51.6) | 206 (29.4) | 618 (42.7) | – | – |
| NSCFsc | 2934 (30.6) | 237 (14.6) | 136 (15.5) | 713 (35.8) | 10 (2.9) | 73 (14.0) | 772 (48.4) | 164 (23.4) | 829 (57.3) | – | – |
| OSFsd | 423 (4.4) | – | – | – | – | – | – | – | – | 423 (100) | – |
| NADFse | 66 (0.7) | – | – | – | – | – | – | – | – | – | 66 (100) |
| Total | 9588 | 1619 (16.9) | 877 (9.2) | 1992 (20.8) | 348 (3.6) | 520 (5.4) | 1596 (16.7) | 700 (7.3) | 1447 (15.1) | 423 (4.4) | 66 (0.7) |
EMS suspected strokes after response to 911 calls in 8 geographical regions in Arkansas, 2013 (n [%]).
PSCs are hospitals accredited by the Joint Commission.
ASRHs are the 40 care facilities in the AR SAVES telestroke network and 2 Mercy Health System hospitals.
NSCFs are facilities which are not PSCs or ASRH with no known stroke care accreditation.
OSFs are out-of-state facilities and include hospitals located in Louisiana, Oklahoma, Texas, Tennessee, Mississippi, and Missouri.
NADF destinations include the nonhospital destination facilities, such as home, extended care, outpatient services, hospice, and nonidentified Arkansas hospital.
Except region R5 (64%), the majority (87%–99%) of transports in the other regions were made to destinations within the EMS region of origin, and all regions had median total transport times of ≤40 minutes (Table S1), whereas transfers across regions had significantly increased times. On-scene times were comparable across destination regions. Median transport times between NSCF and PSC/ASRH were significantly different in some regions. Among deliveries to qualified hospitals, R4, R5, and R6 were the regions with the shortest median transport time, and R1 and R2 had the longest (Table 5).
Table 5.
EMS time intervals and destination facility qualification
| Destination region | Total (%) | On-scene timea (median [IQR] min) | Transport timeb (median [IQR] min) P value | |||
|---|---|---|---|---|---|---|
| NSCFc | PSC/ASRHd | NSCF | PSC/ASRH | |||
| R1 | n = 1619 (17.8) | n = 237 16 (12–21) | n = 1382 15 (11–20) | 9 (6–18) | 14 (9–23) | <.0001 |
| R2 | n = 877 (9.6) | n = 136 16.5 (12–20.5) | n = 741 13 (10–16) | 20.5 (12.5–29) | 14 (7–24) | <.0001 |
| R3 | n = 1992 (21.9) | n = 713 17 (13–22) | n = 1279 16 (13–22) | 15 (10–22) | 13 (9–20) | <.0001 |
| R4 | n = 348 (3.8) | n = 10 19.5 (15–21) | n = 338 14 (11–18) | 5.5 (5–9) | 7 (5–20) | .4140 |
| R5 | n = 520 (5.7) | n = 73 16 (11–19) | n = 447 13 (10–17) | 8 (5–10) | 9 (5–18) | .0761 |
| R6 | n = 1596 (17.5) | n = 772 15 (11–19) | n = 824 15 (10–19) | 14 (6–28.5) | 8 (5–17) | <.0001 |
| R7 | n = 700 (7.7) | n = 164 13.5 (11–18) | n = 536 12 (9–17) | 5.5 (4–12) | 12 (8–21) | <.0001 |
| R8 | n = 1447 (15.9) | n = 829 15 (11–20) | n = 618 15 (12–19) | 12 (7–23) | 12 (7–21) | .1014 |
Boldface indicates statistical significance.
EMS suspected strokes after response to 911 calls in 8 geographical regions in Arkansas, 2013 (ground transport).
The time from scene arrival to scene departure.
The transport time from scene departure to destination arrival.
The NSCFs were non–AR SAVES care facilities with unknown stroke care accreditation.
The PSC and ASRH facilities were Joint Commission–certified primary stroke centers and acute stroke–ready hospitals, respectively.
4. Discussion
We analyzed the characteristics of suspected stroke patient transports made by EMS in Arkansas focusing on 2 important areas: the destination's level of stroke care and the transport time to hospitals. Whereas other states may incorporate plans for bypassing NSCFs [5], Arkansas EMS paramedics have no guidelines in place and rely on patient choice or the closest available center. ASRHs are appropriate stroke care facilities [6,7], but they are underused and too many stroke suspects go to NSCFs. There also seems to be an underutilization of PSCs. These can be addressed by bypassing NSCFs and/or by promoting their upgrade to ASRH level. The benefit of patients receiving care at a PSC is demonstrated by increased rates of screening, thrombolytic therapy, follow-up care, and positive outcomes and decreased use of long term care [11]. Because of the large percentage of private EMS agencies in the state (67%), a statewide guideline would also serve to unify all public and private agencies for destination protocols during stroke transports.
Overall, the performance of EMS services for suspected stroke cases was very good and comparable with similar reports in the literature [12]; however, the appropriateness of destination choice was not confirmed, and the goal to improving care still remains.
Limitations of this study include the lack of information on whether destination decisions were affected by facility qualification, availability, distance, individual patient characteristics, or other factors, thus limiting the generalizations of the results. The comparisons across regions serve as internal controls and point to areas that need further investigation. Because of lack of facility-specific qualification information on the OSF facilities, the transport time to those facilities may be irrelevant if the destination was chosen because it was a known PSC or ASRH.
We also acknowledge the possibility of including transport records of patients with stroke mimics as well as not capturing stroke patients misdiagnosed in the field. But the main objective of this study was to describe the response of the EMS to all “prehospital-evaluated stroke suspects” regardless of final diagnosis confirmation that would only occur after arriving to the hospital.
In conclusion, the reasons for the observed differences in stroke patients being transported to stroke centers vs other hospitals in each region need to be further investigated. These transport decisions are potential areas to improve the stroke system of care. This is particularly important for regions with a higher proportion of stroke transports per capita.
Finally, because of the limited number of primary stroke center hospitals in this geographically disperse and mostly rural state, it is important to educate paramedics, EMS agencies, and the general population about the ASRHs and to effectively integrate them in a regional stroke system of care that uses agreed guidelines and destination protocols to provide timely and effective acute stroke treatment.
Supplementary Material
Table 4.
EMS total timea
| Destination facility region | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| EMS origin |
R1 | R2 | R3 | R4 | R5 | R6 | R7 | R8 | OSFc | NADFd | Total |
| R1 | 39 (29–54) | 58 (50–69) | 224.5 (200–249) |
37 (37-37) | 42 (42-42) | 123 (42–153) | 87.5 (69–112) |
89 (72–148) |
39 (30–55) | ||
| R2 | 89 (69–105) |
40 (28–55) | 75.5 (62.5–97.5) |
83 (79–103) | 29 (23–43) | 56.5 (35–82) |
66 (35–78) | 41 (28–58) | |||
| R3 | 75.5 (68–99.5) |
39 (31–49) | 73 (36–78) | 39 (36–42) | 61 (61-61) | 37 (23–76) | 39 (31–50) | ||||
| R4 | 64 (64-64) | 111 (111-111) |
70.5 (57–90) | 29 (23–44) | 57 (57-57) | 51.5 (40.5–61.5) |
56 (43–59) | 44 (38–50) | 31 (24–54) | ||
| R5 | 168 (130–181) | 75 (71–78) | 31 (23–46) | 82 (76–97) | 48 (36–61) | 58.5 (36–69) |
37 (26–55) | ||||
| R6 | 77 (74–80) | 42 (32–52) | 132 (132-132) |
35 (26–51) | 47.5 (37–59) |
42 (31–68) | 37 (27–52) | ||||
| R7 | 52 (45–73.5) |
43 (26–49) | 147.5 (139–155) |
36 (27–49) | 68.5 (58.5–77.5) |
48 (48-48) | 76.5 (59–84) |
37 (28–52) | |||
| R8 | 63.5 (44–91) | 38.5 (35–54.5) |
75 (65–85) | 38 (29–52) | 35 (35-35) | 72 (27–94) | 39 (29–53) | ||||
| R9b | 102 (102-102) |
102 (102-102) |
|||||||||
| Total | 39 (30–55) | 41 (28–56) | 40 (32–51) | 30 (23–44.5) | 31 (23–46) | 36 (26–51) | 35 (27–48.5) | 39 (29–54) | 48 (36–62) | 68.5 (38–84) |
|
EMS suspected strokes after response to 911 calls in 8 geographical regions in Arkansas, 2013. Median (IQR) minutes (ground transport).
Total time is from call received by 911 dispatch to arrival at the destination.
EMS from out of state driving into Arkansas for patient transport.
OSFs are out-of-state facilities and include hospitals located in Louisiana, Oklahoma, Texas, Tennessee, Mississippi, and Missouri.
NADF facility destinations include the nonhospital destination facilities, such as home, extended care, outpatient services, hospice, and nonidentified Arkansas hospital.
Acknowledgments
Sources of funding: This project was partly supported by the National Center for Research Resources, National Institute of Health, U.S. Department of Health and Human Services through grant #1UL1RR029884 (FW), by the University of Arkansas for Medical Sciences, College of Medicine supported FUND TO CURE STROKE intramural grant (NB), by the G-36458 Genentech CGN, NIGMS IDeA Award P30 GM110702 and by the Translational Research Institute (TRI), NIH grant UL1TR000039 (ATB).
Footnotes
Conflicts of interest: none.
Author contributions statement: ATB, NB, and GB conceived the study and designed the data collection. ATB and NB obtained research funding. RT, ATB, and FW managed the data. NB and FW provided statistical advice on study design, and FW analyzed the data. ATB and NB drafted the manuscript, and all authors contributed to its revision.
Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ajem.2016.06.044.
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