Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research.
OBJECTIVE
Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research.


METHODS
We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs.


RESULTS
There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation.


CONCLUSIONS
The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial.


BACKGROUND
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.). sanossia@yahoo.com.
Nerses
N
Sanossian
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
David S
DS
Liebeskind
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Marc
M
Eckstein
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Sidney
S
Starkman
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Samuel
S
Stratton
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Franklin D
FD
Pratt
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
William
W
Koenig
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Scott
S
Hamilton
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
May
M
Kim-Tenser
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Robin
R
Conwit
From the Departments of Neurology (N.S., M.K.-T.) and Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology and Stroke Center (D.S.L., S. Starkman, J.L.S.), and School of Public Health (S. Stratton), University of California Los Angeles; Los Angeles County Fire Department, CA (F.D.P.); Los Angeles County Emergency Medical Services Agency, CA (W.K.); School of Medicine, Stanford University, Palo Alto, CA (S.H.); and National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.).
Jeffrey L
JL
Saver
D000368:Aged; D000369:Aged, 80 and over; D064422:Ambulance Diversion; D000552:Ambulances; D035843:Biomedical Research; D002545:Brain Ischemia / Q000150:complications / Q000628:therapy*; D002543:Cerebral Hemorrhage / Q000150:complications / Q000628:therapy*; D015331:Cohort Studies; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D006297:Health Services Accessibility; D006782:Hospitals, Special; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010360:Patient Transfer; D011446:Prospective Studies; D011787:Quality of Health Care; D020521:Stroke / Q000209:etiology / Q000628:therapy*; D015912:Thrombolytic Therapy; D013997:Time Factors; D061665:Time-to-Treatment
emergency medical services; emergency service, hospital; prehospital emergency care; stroke; triage