Improving EMS Transport Protocols to Optimize Stroke Treatment

Donald Frei, MD

The saying “time is brain” is a way of life for most stroke specialists as they race against the clock to save acute stroke patients from enduring neurologic deficits or worse, death.

That responsibility often falls on neurointerventional surgeons like Donald Frei, MD, who work to clear major blockages in patients who present with emergent large vessel occlusion via endovascular treatment. Frei, who is affiliated with Swedish Medical Center and Radiology Imaging Associates in Denver, Colorado, understands just how efficacious endovascular therapy can be if the patient reaches his operating table in time.

“You're losing 1.9 million neurons per minute; if the patient is taken to the hospital 5 minutes away from where EMS picked them up, but the hospital can't perform thrombectomy, then it's 1 to 2 hours of intrahospital transport time, or they never get transferred to the right hospital. Those patients, instead of having a potentially reversible neurological deficit, have a severe, disabling, or fatal stroke,” Frei told NeurologyLive in an interview.

Frei recently spoke at a meeting of the National EMS Advisory Council, where he appealed to national EMS directors regarding the need to change EMS transport protocols. The changes, Frei argued, would mean that patients whose symptoms are suggestive of an ELVO would be transported directly to a comprehensive or level 1 stroke center that is capable of performing thrombectomy around the clock, regardless of whether or not it is the closest care center.

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Those protocols, which are being pushed by the Society of Neurointerventional Surgery, of whom Frei is a past president, aren’t completely aligned with similar efforts being put forth by the American Stroke Association (ASA), which has proposed a 4-tier system of stroke centers. In terms of transport, the ASA recommends that no more than 15 minutes of additional transport time should be undertaken when there are several intravenous alteplase-capable hospitals within the region.

To learn more about Frei’s efforts to change the way we triage and transport stroke patients, check out part of our interview with him below. Check back on Friday, January 17 to hear the full interview on the Mind Moments podcast.

NeurologyLive: What do you feel is the current state of stroke treatment? What are some of the specific pain points being faced?

Donald Frei, MD: My background is neurointerventional surgery, so I treat large vessel occlusion endovascular. I certainly work very closely with a lot of really good stroke neurologists and we're not treating enough patients, and that's both intravenous and in my subspecialty endovascular. The number of large vessel occlusion strokes in the US is somewhere between maybe 150,000 and 200,000, and we're treating about 10% or 15% of the eligible patients, so that just means there's a lot of patients that are dying or have long-term disability that actually -- if they got to the right hospital first -- could walk out of the hospital potentially and have no neurological deficit at all. Endovascular treatment is very effective; it has a number needed to treat of 2 to 3, which is probably one of the most effective treatments in medicine, about 10 times more effective than coronary stenting for acute myocardial infarction. All these papers were published about 5 years ago and the systems of care need to catch up with the science.

One of the biggest problems we see is that these patients with severe strokes are not getting directly to the hospital that can perform a thrombectomy. EMS has state health department-directed guidelines and the standard guideline says bring the patient to the nearest hospital, period. Now there are some exceptions; if there's a high-level trauma patient, they bring them to a level 1 trauma center. If they think the patient is having a myocardial infarction, they bring them to a hospital that can perform coronary intervention. We need to change the guidelines for patients with large vessel occlusion, stroke because it's probably one of the most time sensitive medical emergencies out there. You're losing 1.9 million neurons per minute; if the patient is taken to the hospital 5 minutes away from where EMS picked them up, but the hospital can't perform thrombectomy, then it's 1 to 2 hours of intrahospital transport time, or they never get transferred to the right hospital. Those patients, instead of having a potentially reversible neurological deficit, have a severe, disabling, or fatal stroke. That's where I think we need to get the systems of care caught up with the science.

NeurologyLive: In terms of geographical and population barriers, what action is being taken to increase the amount of hospitals that are certified as level 1 stroke centers and increase access to specialists?

Donald Frei, MD: Even within cities with the largest geographical density, not every hospital can be a comprehensive stroke center, just like every hospital can't do open heart surgery. I live in Denver, and we have 6 comprehensive stroke centers, and there's about 40 hospitals. So you're never going to have every hospital be a comprehensive or level 1 stroke center. I think even in areas where population density is high, there are still issues. There are certainly increasing numbers of centers that perform thombectomy; 5 years ago in Colorado there were 3, now there are 8. So the numbers of centers that can do this is increasing, but part of the problem is that this is a hot subspecialty for hospitals to get behind. So centers that just say, 'Hey, we can do thrombectomy' may not really be able to do it well. So that's an issue. There are different levels of quality, but you're never going to have every hospital do everything. So I think what you need to do is -- and this is what we've been working on in our Western state for over 20 years -- is making sure that if you're in a small remote area where there is only one hospital in a county because it's very sparsely populated, you have to have a plan for transfer in place already where the wheels are set in motion very quickly. That's a solution for areas that are very minimally populated, but I think in the densely populated areas, maybe 10% of the hospitals can do thrombectomy and 90% can't, so that's where I think these EMS triage and transport protocols and guidelines are really important.

Transcript edited for clarity.