Introduction/Purpose Management of acute ischemic stroke (AIS) in patients with an emergent large vessel occlusion (ELVO) has changed dramatically with endovascular therapy (EVT). Stroke systems of care have evolved to ensure timely EVT in addition to IV thrombolysis (IVT). In collaboration with the Greater New York Hospital Association and American Heart Association, the Fire Department of New York (FDNY) created the first triage protocol in our region to directly route suspected ELVO patients to the nearest thrombectomy capable stroke center (TSC). We sought to describe the results of this triage protocol from initiation in April 2019 to February 2020.
Materials and Methods The FDNY and regional emergency medical advisory committee adapted the Los Angeles Motor Scale (LAMS), with the addition of ‘Speech,’ to develop a clinical stroke scale for EMS personnel to use in the field: S-LAMS. With a S-LAMS score >4, EMS contact the main operating center for permission to reroute to the nearest TSC. We conducted a retrospective review of patients triaged to our urban health system using this protocol. The main outcome was the percentage of patients successfully triaged with confirmed ELVO. Time metrics, final diagnosis, National Institute of Health Stroke Scale (NIHSS), and other AIS measures were also analyzed.
Results There were 125 patients (58% female; median age 71±15) triaged directly to a TSC. ELVO was confirmed in 32% (n=40) of patients and 26% (n=32) underwent EVT. Eight ELVO patients were ineligible for EVT due to either high Modified Rankin Score (mRS) (n=3), infarct evolution (n=3), recanalization after IVT (n=1), or lesion chronicity (n=1). A stroke diagnosis was verified in 75% (n=94) of triaged patients (71 ischemic and 23 hemorrhagic) regardless of ELVO status. The median S-LAMS score amongst ELVO patients was 6±1 (initial provider NIHSS 16±7); score for non-ELVO stroke patients was 5±1 (initial provider NIHSS 9±7). The median hospital arrival to IVT was 41±36 minutes (58% [n=72] eligible, 30% [n=37] received) and hospital arrival to groin puncture was 1 hour 42±35 minutes. The median time from EMS triage to hospital notification was 6±3 minutes and notification to arrival was 10±6 minutes. Occluded vessels included Left M1 (n=12), Left M2 (n=6), Right M1 (n=7), Right M2 (n=3), Left ICA (n=3), R ICA (n=4), and Basilar (n=1) arteries. Top non-stroke diagnoses were seizures (n=12), brain neoplasm (n=4), and transient ischemic attack (n=2).
Conclusion S-LAMS >4 correctly identified 32% ELVO and 75% stroke patients in this cohort. One quarter of triaged patients received EVT; those excluded mainly had high mRS or established infarct. Relatively short times from triage to notification and arrival, in addition to high yield of correctly triaged ELVO and AIS patients suggest benefit from this triage protocol. Non-stroke patients were diagnosed with conditions that could mimic strokes on presentation. Further analysis is indicated to compare this alternative triage protocol to traditional stroke service delivery models.
Disclosures B. Kim: None. J. Morey: None. L. Stein: None. M. Redlener: None. J. Fifi: None.
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