EMS Prenotification of Hospitals Lags for Incoming Stroke Patients

When emergency medical services personnel alert hospitals of incoming stroke patients, evaluation and treatment are improved, but prenotification occurs in only about two-thirds of cases, according to findings from two new American Heart Association/American Stroke Association (AHA/ASA) studies.

Both of the Get With The Guidelines–Stroke program studies involved the same group of nearly 372,000 patients with acute ischemic stroke, who were transported by emergency medical services to one of 1,585 participating hospitals between April 2003 and April 2011. One of the studies showed that compared with no notification, prenotification of an incoming stroke patient was associated with significantly more rapid evaluation and treatment, and with a significantly greater likelihood of treatment with tissue plasminogen activator (TPA) within 3 hours, Cheryl B. Lin of the Duke–National University of Singapore Graduate Medical School, Singapore, and her colleagues reported online in Circulation: Cardiovascular Quality and Outcomes.

For example, among patients who arrived at the hospital within 3 hours of symptom onset, median door-to-imaging time was 26 minutes, compared with 31 minutes for those without prenotification. Door-to-imaging time was within 25 minutes for 48.8% and 40.5% of those with and without prenotification, respectively. Also, symptom onset–to-door times were lower with prenotification (113 vs. 150 minutes) (Circ. Cardiovasc. Qual. Outcomes 2012 July 10 [doi: 10.1161/circoutcomes.112.965210]).

Prenotification also significantly improved door-to-needle time and symptom onset–to-needle time, and more eligible patients who arrived at the hospital within 2 hours were treated with TPA within 3 hours (71.8% vs. 62.2%).

The problem is that prenotification occurred in only 67% of cases, the authors said.

"Our analysis supports the role [of EMS prenotification] as a potentially important but underused means to improving rapid triage, evaluation, and treatment of patients with acute ischemic stroke," they wrote, noting that although prenotification is recommended in guidelines from both the AHA/ ASA and the National Association of Emergency Medical Services Physicians, it appears many hospitals "still find difficulty in meeting these performance goals."

In the related study published online in the Journal of the American Heart Association, Ms. Lin and her colleagues found that prenotification varied widely by hospital and region, with rates of prenotification ranging from 0% to 100%.

In Washington, D.C., for example, the prenotification rate was 19.7%, compared with 93.4% in Montana, the investigators said (J. Am. Heart Assoc. 2012 July 10 [doi: 10.1161/jaha.112.002345]).

Patient factors associated with increased likelihood of prenotification were younger age, white race, past history of atrial fibrillation, no medical history of previous stroke or transient ischemic attack, diabetes mellitus, and peripheral vascular disease.

"In particular, black patients had decreased odds [of EMS prenotification] when compared to their white counterparts, with adjusted odds ratio of 0.94," the investigators noted.

Hospital factors associated with reduced likelihood of prenotification were academic affiliation, location in the northeastern United States, and lower annual volume of TPA administration.

Rates of prenotification did increase modestly and significantly over time, from 58% to 67% between 2003 and 2011, with a high of 71.1% in 2008, followed by a decline to about 65% in 2009 and 2010, and an increase to 67.3% in 2011, but targeted improvements in rates of EMS prenotification are needed, they said.

"These findings demonstrate gaps in the quality of stroke care provided and support the need for initiatives targeted to improve [EMS prenotification rates] on a national level," they concluded, explaining that a systems approach is needed involving increasing symptom recognition and rapid activation of EMS, adequate training of EMS staff in proper use of stroke-screening instruments and the need for hospital prenotification, and implementation of systems of care in receiving hospitals.

A stroke system-of-care process measure reporting the use of EMS prenotification should be considered, they said.

The Get With the Guidelines (GWTG)–Stroke program is provided by the AHA/ASA and is supported in part by a charitable contribution from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and the AHA Pharmaceutical Roundtable. Past support has been provided by Boehringer Ingelheim and Merck. Ms. Lin reported having no relevant conflicts of interest. Several coauthors have worked with GWTG committees, and some have received research grant support from pharmaceutical companies. Some researchers are employees of the University of California, which holds a patent on retriever devices for stroke.

When emergency medical services personnel alert hospitals of incoming stroke patients, evaluation and treatment are improved, but prenotification occurs in only about two-thirds of cases, according to findings from two new American Heart Association/American Stroke Association (AHA/ASA) studies.

Both of the Get With The Guidelines–Stroke program studies involved the same group of nearly 372,000 patients with acute ischemic stroke, who were transported by emergency medical services to one of 1,585 participating hospitals between April 2003 and April 2011. One of the studies showed that compared with no notification, prenotification of an incoming stroke patient was associated with significantly more rapid evaluation and treatment, and with a significantly greater likelihood of treatment with tissue plasminogen activator (TPA) within 3 hours, Cheryl B. Lin of the Duke–National University of Singapore Graduate Medical School, Singapore, and her colleagues reported online in Circulation: Cardiovascular Quality and Outcomes.

For example, among patients who arrived at the hospital within 3 hours of symptom onset, median door-to-imaging time was 26 minutes, compared with 31 minutes for those without prenotification. Door-to-imaging time was within 25 minutes for 48.8% and 40.5% of those with and without prenotification, respectively. Also, symptom onset–to-door times were lower with prenotification (113 vs. 150 minutes) (Circ. Cardiovasc. Qual. Outcomes 2012 July 10 [doi: 10.1161/circoutcomes.112.965210]).

Prenotification also significantly improved door-to-needle time and symptom onset–to-needle time, and more eligible patients who arrived at the hospital within 2 hours were treated with TPA within 3 hours (71.8% vs. 62.2%).

The problem is that prenotification occurred in only 67% of cases, the authors said.

"Our analysis supports the role [of EMS prenotification] as a potentially important but underused means to improving rapid triage, evaluation, and treatment of patients with acute ischemic stroke," they wrote, noting that although prenotification is recommended in guidelines from both the AHA/ ASA and the National Association of Emergency Medical Services Physicians, it appears many hospitals "still find difficulty in meeting these performance goals."

In the related study published online in the Journal of the American Heart Association, Ms. Lin and her colleagues found that prenotification varied widely by hospital and region, with rates of prenotification ranging from 0% to 100%.

In Washington, D.C., for example, the prenotification rate was 19.7%, compared with 93.4% in Montana, the investigators said (J. Am. Heart Assoc. 2012 July 10 [doi: 10.1161/jaha.112.002345]).

Patient factors associated with increased likelihood of prenotification were younger age, white race, past history of atrial fibrillation, no medical history of previous stroke or transient ischemic attack, diabetes mellitus, and peripheral vascular disease.

"In particular, black patients had decreased odds [of EMS prenotification] when compared to their white counterparts, with adjusted odds ratio of 0.94," the investigators noted.

Hospital factors associated with reduced likelihood of prenotification were academic affiliation, location in the northeastern United States, and lower annual volume of TPA administration.

Rates of prenotification did increase modestly and significantly over time, from 58% to 67% between 2003 and 2011, with a high of 71.1% in 2008, followed by a decline to about 65% in 2009 and 2010, and an increase to 67.3% in 2011, but targeted improvements in rates of EMS prenotification are needed, they said.

"These findings demonstrate gaps in the quality of stroke care provided and support the need for initiatives targeted to improve [EMS prenotification rates] on a national level," they concluded, explaining that a systems approach is needed involving increasing symptom recognition and rapid activation of EMS, adequate training of EMS staff in proper use of stroke-screening instruments and the need for hospital prenotification, and implementation of systems of care in receiving hospitals.

A stroke system-of-care process measure reporting the use of EMS prenotification should be considered, they said.

The Get With the Guidelines (GWTG)–Stroke program is provided by the AHA/ASA and is supported in part by a charitable contribution from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and the AHA Pharmaceutical Roundtable. Past support has been provided by Boehringer Ingelheim and Merck. Ms. Lin reported having no relevant conflicts of interest. Several coauthors have worked with GWTG committees, and some have received research grant support from pharmaceutical companies. Some researchers are employees of the University of California, which holds a patent on retriever devices for stroke.

When emergency medical services personnel alert hospitals of incoming stroke patients, evaluation and treatment are improved, but prenotification occurs in only about two-thirds of cases, according to findings from two new American Heart Association/American Stroke Association (AHA/ASA) studies.

Both of the Get With The Guidelines–Stroke program studies involved the same group of nearly 372,000 patients with acute ischemic stroke, who were transported by emergency medical services to one of 1,585 participating hospitals between April 2003 and April 2011. One of the studies showed that compared with no notification, prenotification of an incoming stroke patient was associated with significantly more rapid evaluation and treatment, and with a significantly greater likelihood of treatment with tissue plasminogen activator (TPA) within 3 hours, Cheryl B. Lin of the Duke–National University of Singapore Graduate Medical School, Singapore, and her colleagues reported online in Circulation: Cardiovascular Quality and Outcomes.

For example, among patients who arrived at the hospital within 3 hours of symptom onset, median door-to-imaging time was 26 minutes, compared with 31 minutes for those without prenotification. Door-to-imaging time was within 25 minutes for 48.8% and 40.5% of those with and without prenotification, respectively. Also, symptom onset–to-door times were lower with prenotification (113 vs. 150 minutes) (Circ. Cardiovasc. Qual. Outcomes 2012 July 10 [doi: 10.1161/circoutcomes.112.965210]).

Prenotification also significantly improved door-to-needle time and symptom onset–to-needle time, and more eligible patients who arrived at the hospital within 2 hours were treated with TPA within 3 hours (71.8% vs. 62.2%).

The problem is that prenotification occurred in only 67% of cases, the authors said.

"Our analysis supports the role [of EMS prenotification] as a potentially important but underused means to improving rapid triage, evaluation, and treatment of patients with acute ischemic stroke," they wrote, noting that although prenotification is recommended in guidelines from both the AHA/ ASA and the National Association of Emergency Medical Services Physicians, it appears many hospitals "still find difficulty in meeting these performance goals."

In the related study published online in the Journal of the American Heart Association, Ms. Lin and her colleagues found that prenotification varied widely by hospital and region, with rates of prenotification ranging from 0% to 100%.

In Washington, D.C., for example, the prenotification rate was 19.7%, compared with 93.4% in Montana, the investigators said (J. Am. Heart Assoc. 2012 July 10 [doi: 10.1161/jaha.112.002345]).

Patient factors associated with increased likelihood of prenotification were younger age, white race, past history of atrial fibrillation, no medical history of previous stroke or transient ischemic attack, diabetes mellitus, and peripheral vascular disease.

"In particular, black patients had decreased odds [of EMS prenotification] when compared to their white counterparts, with adjusted odds ratio of 0.94," the investigators noted.

Hospital factors associated with reduced likelihood of prenotification were academic affiliation, location in the northeastern United States, and lower annual volume of TPA administration.

Rates of prenotification did increase modestly and significantly over time, from 58% to 67% between 2003 and 2011, with a high of 71.1% in 2008, followed by a decline to about 65% in 2009 and 2010, and an increase to 67.3% in 2011, but targeted improvements in rates of EMS prenotification are needed, they said.

"These findings demonstrate gaps in the quality of stroke care provided and support the need for initiatives targeted to improve [EMS prenotification rates] on a national level," they concluded, explaining that a systems approach is needed involving increasing symptom recognition and rapid activation of EMS, adequate training of EMS staff in proper use of stroke-screening instruments and the need for hospital prenotification, and implementation of systems of care in receiving hospitals.

A stroke system-of-care process measure reporting the use of EMS prenotification should be considered, they said.

The Get With the Guidelines (GWTG)–Stroke program is provided by the AHA/ASA and is supported in part by a charitable contribution from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and the AHA Pharmaceutical Roundtable. Past support has been provided by Boehringer Ingelheim and Merck. Ms. Lin reported having no relevant conflicts of interest. Several coauthors have worked with GWTG committees, and some have received research grant support from pharmaceutical companies. Some researchers are employees of the University of California, which holds a patent on retriever devices for stroke.