Evaluation of a prehospital endovascular therapy stroke bypass program.

INTRODUCTION: Prehospital stroke endovascular therapy bypass transports patients with suspected large vessel occlusion directly to an endovascular therapy capable center. Our objective was to determine if an endovascular therapy bypass protocol improved access to stroke treatments. Secondary objectives were to determine safety, effectiveness, and rate of subsequent interfacility transfers. METHODS: Endovascular therapy bypass in 2018 was implemented in Eastern Ontario, for patients with a Los-Angeles-Motor-Scale ≥ 4 (positive large vessel occlusion screen) with a 90-min transport time if < 6 h from last seen well. A before-after health record review was conducted from Dec 1, 2017 to Nov 30, 2019. A piloted data form was used to extract demographics, times, primary outcomes (endovascular therapy and intravenous (IV) tissue plasminogen activator (tPA) rate), and secondary outcomes (redirect to closer hospital, airway intervention, and subsequent interfacility transfer). We present descriptive statistics and odds ratios (OR) with 95% confidence intervals (CI) from multivariable logistic regression. RESULTS: We included 379 stroke patients (165 pre and 214 post-implementation). The endovascular therapy rate between groups was similar (14.1% vs 15.1%). The bypass had an OR of 0.98 (95% CI 0.54-1.78) for receiving endovascular therapy. IV tPA was given to 25.4% of patients pre vs 27.4% post-implementation (OR 1.06, 95% CI 0.65-1.74). No patients became unstable during transport, only one patient had an intubation attempt. The inappropriate bypass (false positive) rate was 12.7% pre vs 12.8% post-implementation (positive predictive value 87%). The bypass protocol had an OR of 1.06 (95% CI 0.58-1.95) for subsequent interfacility transfer with a mean of 2.7 h at the community site before transfer. CONCLUSIONS: Endovascular therapy stroke bypass with 90-min transport radius and Los-Angeles-Motor-Scale ≥ 4 was safe and well executed by paramedics. Our study did not show any difference in endovascular therapy rate from its implementation. The IV tPA rate was similar between groups despite potentially bypassing thrombolysis capable centers.

ABSTRAIT: INTRODUCTION: Le pontage de la thérapie endovasculaire pré-hospitalière transporte les patients présentant une occlusion suspectée de gros vaisseaux directement vers un centre capable de thérapie endovasculaire. Notre objectif était de déterminer si un protocole de pontage endovasculaire améliore l'accès aux traitements d'AVC. Les objectifs secondaires étaient de déterminer l'innocuité, l'efficacité et le taux des transferts d'interfacilité subséquents. MéTHODES: Le pontage par thérapie endovasculaire en 2018 a été mis en œuvre dans l'Est de l'Ontario, pour les patients ayant un test Los-Angeles-Motor-Scale 4 (test positif d'occlusion des gros vaisseaux) avec un temps de transport de 90 minutes si < 6 heures après la dernière observation. Un examen du dossier de santé avant-après a été effectué du 1er décembre 2017 au 30 novembre 2019. Un formulaire de données pilote a été utilisé pour extraire les données démographiques, les heures, les résultats primaires (traitement endovasculaire et taux d'activation du plasminogène par voie intraveineuse (IV) et les résultats secondaires (réorientation vers un hôpital plus proche, intervention sur les voies respiratoires et transfert d'interfacilité subséquent). Nous présentons des statistiques descriptives et des rapports de cotes (RC) avec des intervalles de confiance (IC) à 95 % à partir d'une régression logistique multivariée. RéSULTATS: Nous avons inclus 379 AVC (165 avant et 214 après la mise en œuvre). Le taux de traitement endovasculaire entre les groupes était similaire (14,1 % vs 15,1 %). Le pontage avait un RC de 0,98 (IC à 95 %, 0,54-1,78) pour le traitement endovasculaire. Le tPA IV a été administré à 25,4% des patients avant vs 27,4% après la mise en œuvre (OR 1,06, 95%CI 0,65-1,74). Aucun patient n'est devenu instable pendant le transport, seulement 1 patient a eu une tentative d'intubation. Le taux de pontage inapproprié (faux positif) était de 12,7 % avant et de 12,8 % après la mise en œuvre (valeur prédictive positive de 87 %). Le protocole de contournement avait un RC de 1,06 (IC à 95 % 0,58-1,95) pour le transfert d'interfacilité ultérieur avec une moyenne de 2,7 heures sur le site de la communauté avant le transfert. CONCLUSIONS: Le pontage d'AVC de thérapie endovasculaire avec un rayon de transport de 90 minutes et Los-Angeles-Motor-Scale 4 était sûr et bien exécuté par les ambulanciers. Notre étude n'a montré aucune différence dans le taux de thérapie endovasculaire par rapport à sa mise en œuvre. Le taux de tPA IV était similaire entre les groupes malgré le fait que les centres capables de contourner la thrombolyse étaient potentiellement contournés.

Closing the Loop: The Value of Outcome Letters for Prehospital Pediatric Care.

OBJECTIVES: Providing emergency care to acutely ill or injured children is stressful and requires a high level of training. Paramedics who provide prehospital care are typically not involved in the circle of care and do not receive patient outcome information. The aim of this quality improvement project was to assess paramedics' perceptions of standardized outcome letters pertaining to acute pediatric patients that they had treated and transported to an emergency department. METHODS: Between December 2019 and December 2020, 888 outcome letters were distributed to paramedics who provided care for 370 acute pediatric patients transported to the Children's Hospital of Eastern Ontario in Ottawa, Canada. All paramedics who received a letter (n = 470) were invited to participate in a survey that collected their perceptions and feedback about the letters, as well as their demographic information. RESULTS: The response rate was 37% (172/470). Approximately half of the respondents were Primary Care Paramedics and half Advanced Care Paramedics. The respondents' median age was 36 years, median years of service was 12 years, and 64% identified as male. Most agreed that the outcome letters contained information pertinent to their practice (91%), allowed them to reflect on care they had provided (87%), and confirmed clinical suspicions (93%). Respondents indicated that they found the letters useful for 3 reasons: 1) increases capacity to link differential diagnoses, prehospital care, or patient outcomes; 2) contributes to a culture of continuous learning and improvement; and 3) gives closure, reduces stress, or provides answers for difficult cases. Suggestions for improvement included providing more information, provision of letters on all patients transported, faster turnaround time between call and receipt of letter and inclusion of recommendations or interventions/assessments. CONCLUSIONS: Paramedics appreciated receiving hospital-based patient outcome information after their provision of care and reported that the letters offered opportunities for closure, reflection, and learning.