Studies find hospitals not always alerted of incoming stroke patients

Issue: August 2012

Two new studies provide evidence that treatment is delivered faster to patients with stroke when emergency medical services personnel notify hospitals that a patient is en route; however, prenotification does not occur nearly one-third of the time, researchers found.

Both studies examined the records of 371,988 patients with acute ischemic stroke who were transported by EMS to one of 1,585 hospitals participating in the Get With The Guidelines–Stroke quality improvement program from 2003 to 2011.

Benefits of prenotification

Prenotification by EMS resulted in faster diagnosis and treatment, according to the study published in Circulation: Cardiovascular Quality & Outcomes.

Among patients arriving within 2 hours of symptom onset, patients with EMS prenotification were more likely to be treated with tPA within 3 hours (82.8% vs. 79.2%), have shorter door-to-imaging times (26 minutes vs. 31 minutes), have shorter door-to-tPA treatment times (78 minutes vs. 80 minutes) and have shorter symptom onset-to-tPA treatment times (141 minutes vs. 145 minutes; P<.0001 for all).

Further analysis revealed an independent association between prenotification and better stroke treatment times, including:

Door-to-imaging times of 25 minutes or less.
Door-to-treatment with tPA within 60 minutes.
Symptom onset-to-tPA treatment times of 120 minutes or less.
More eligible patients treated with tPA.

Patterns and trends in prenotification

Prenotification occurred in only 67% of patients in 2011, only a modest increase from 58% in 2003, according to the study published in the Journal of the American Heart Association.

In this study, researchers found substantial variations by geographic region and state, ranging from 19.7% in Washington, D.C., to 93.4% in Montana, according to information from a press release. Older age and history of diabetes and peripheral vascular disease were also identified as factors associated with lower use of prenotification. In addition, prenotification was less likely to occur for black patients compared with white patients.

Hospital factors associated with greater EMS prenotification included the absence of academic affiliation, higher annual volume of tPA administration and geographic location outside the Northeast, according to the study results.

“The large variation by state and hospital are really striking and should be a concern because the potential for ideal patient care isn’t being met,” Gregg C. Fonarow, MD, senior researcher for both studies and professor of cardiovascular medicine at the University of California-Los Angeles said in a press release. “We’ve developed a map of rates by state. This tool can identify areas that are most in need of improved stroke care symptoms.”

Gregg C. Fonarow

Targets to increase prenotification

The researchers concluded that these data support the need for initiatives that target increasing EMS prenotification rates to improve quality of care and outcomes for patients with stroke.

“EMS hospital prenotification is guideline recommended, yet among patients transported with Get With The Guidelines–Stroke hospitals it is not provided for one in three EMS-arriving patients with acute ischemic stroke and varies substantially by hospital state and region,” the researchers wrote in the Journal of the American Heart Association.

The studies included only data from Get With The Guidelines–Stroke hospitals, which comprise about one-third of US hospitals and are considered representative of all hospitals in terms of pre-hospital care, according to the press release.

“With these powerful new findings demonstrating substantial benefits with prenotification, we have a tremendous opportunity to make positive changes in this component of stroke care,” Fonarow stated in the release.

For more information:

Lin CB. Circ Cardiovasc Qual Outcomes. 2012;doi:10.1161/CIRCOUTCOMES.112.965210.

Lin CB. J Am Heart Assoc. 2012;doi:10.1161/JAHA.112.002345.

Disclosure: Dr. Fonarow receives research support from the NIH and is an employee of the University of California, which holds a patent on retriever devices for stroke.