Reducing disability and death: What is next for stroke triage and transport?

Michael Chen (Rush University Medical Center, Chicago, USA) discusses the growing awareness around the need for timely interventions in stroke care in the USA, and outlines efforts being undertaken by the Get Ahead of Stroke campaign to address this moving forward.

The need to improve stroke triage and transport has never been more important. Since 2015, the New England Journal of Medicine has published seven positive studies proving the efficacy of thrombectomy—a minimally invasive, catheter-based procedure to physically remove blood clots within arteries and improve disability after stroke. Patients with severe strokes secondary to large clots blocking a major brain artery have a nearly-75% chance of being dependent or dying. Thrombectomy can reduce the chance of this poor outcome by 50%.

However, thrombectomy is extremely time-dependent. During a stroke, the brain is essentially holding its breath. Appropriate triage and transport can save the wasted precious hours that would have otherwise been spent at a hospital not equipped to perform thrombectomy. The Get Ahead of Stroke campaign, sponsored by the Society of NeuroInterventional Surgery (SNIS) and its corporate partners, has been working on passing legislation and protocols state-by-state since 2016 that allow first responders to triage and transport large vessel occlusive (LVO) stroke patients directly to Level 1 stroke centres capable of performing thrombectomy.

The campaign has helped to update protocols in six states (Arizona, Colorado, Florida, North Carolina, Ohio, Tennessee) and several other states have followed suit to change protocols on their own (Delaware, Kentucky, Louisiana, Maine, Maryland, Mississippi, Nebraska, New Hampshire, Utah, Vermont, Washington). The goal is that, once a critical mass of states has adopted LVO stroke assessment, triage and transport into their protocols, surrounding states should quickly follow suit.

Stroke triage and transport that is protocolised also has the best chance of addressing entrenched healthcare disparities. Research from Adam Wallace (Ascension Columbia St Mary’s Hospital, Milwaukee, USA) et al, presented at the SNIS annual meeting in 2021, highlights that Black individuals have the highest rate of death due to stroke, are 30% less likely to be diagnosed with blockage of a large artery in the brain when they did arrive and 28% less likely to have a thrombectomy. By standardising the approach across the country, groups that are currently underserved, including certain racial groups, neighborhoods and those who are economically disadvantaged, may truly have better odds of more efficient and effective stroke treatment.

But, passing legislation that changes local stroke triage and transport protocols is not enough.  We are partnering with emergency medical services (EMS) and first responder leaders to find effective ways to educate about stroke assessment, and the importance of triage and transporting severe stroke patients to equipped centres. Given turnover and the fact that the large majority of first responder calls are not for stroke patients, educational efforts need to increase. We also must educate the public on stroke symptoms and the importance of calling 911 instead of driving themselves to the hospital—where they will lose time, as they could have been assessed in-transit.

As critical stakeholders with a depth of knowledge, EMS also must be engaged in the development of technologies that can further assist in stroke severity detection. There are several technologies to rapidly diagnose an LVO stroke, similar to what an electrocardiogram does for acute myocardial infarction. As an initial tool, Get Ahead of Stroke created a free mobile app, Stroke Scales for EMS, to help first responders assess stroke severity, and in the field, to determine where to transport. The app can be downloaded from the Apple Store and Google Play.

Other challenges besides sufficient education currently interfere with rapid adoption of effective stroke triage. Financial interests from smaller hospitals may block first responder transport protocols out of fear of decreasing their admission volumes. The ability to accurately diagnose a stroke rapidly also makes strict transport protocols difficult to adhere to if the diagnostic information is limited.

Nevertheless, more so than better designed thrombectomy devices or faster in-hospital workflows, reducing the time it takes for a patient to arrive to a thrombectomy-capable hospital can make the biggest impact on patient outcomes. Efficiently and effectively triaging and transporting these patients to Level 1 stroke centres where they can receive mechanical thrombectomy from a specialised team would have a disproportionately large benefit to any population of LVO stroke patients.

Michael Chen is a neurointerventionist and professor of Neurology, Neurosurgery and Radiology at Rush University Medical Center in Chicago, USA, and the current president of the Society of NeuroInterventional Surgery (SNIS).