title: A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass.
abstract: BACKGROUND
  Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals.
  
  
  METHODS
  Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation.
  
  
  RESULTS
  Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65).
  
  
  CONCLUSIONS
  Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.
authors.affiliation: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina. Electronic address: aasimos@carolinas.org.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Asimos
authors.affiliation: Dickson Advanced Analytics Group, Carolinas HeathCare System, Charlotte, North Carolina.
authors.forename: Shana
authors.initials: S
authors.lastname: Ward
authors.affiliation: Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Jane H
authors.initials: JH
authors.lastname: Brice
authors.affiliation: Health & Spatial Analysis Unit, State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina.
authors.forename: Dianne
authors.initials: D
authors.lastname: Enright
authors.affiliation: Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Wayne D
authors.initials: WD
authors.lastname: Rosamond
authors.affiliation: Duke Comprehensive Stroke Center, Duke University Medical Center, Durham, North Carolina.
authors.forename: Larry B
authors.initials: LB
authors.lastname: Goldstein
authors.affiliation: Mecklenburg EMS Agency, Charlotte, North Carolina.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Studnek
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002391:Catchment Area, Health; D016208:Databases, Factual; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D040362:Geographic Information Systems; D006297:Health Services Accessibility / Q000458:organization & administration*; D006764:Hospitals, Community; D006801:Humans; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D015397:Program Evaluation; D012040:Regional Health Planning / Q000458:organization & administration*; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D061665:Time-to-Treatment / Q000458:organization & administration; D014187:Transportation of Patients / Q000458:organization & administration*; D016896:Treatment Outcome; D014218:Triage / Q000458:organization & administration
keywords: EMS; bypass; protocols; stroke; transport