Evolution of a US County System for Acute Comprehensive Stroke Care.

BACKGROUND AND PURPOSE: In Orange County, California, patients with suspected acute stroke are taken to stroke neurology receiving centers that are designated by County Emergency Medical Services authorities as either hubs or spokes based on endovascular treatment capability. We examined relationships between stroke details, reperfusion therapies, hospital transfers, and their change over time. METHODS: All patients from January 1, 2013, to December 31, 2015, for whom 911 was called within 7 hours of onset in whom Emergency Medical Services personnel suspected acute stroke were evaluated. RESULTS: Among 6132 patients, 3924 (64%) had confirmed diagnosis of stroke (74% ischemic/26% hemorrhagic), yielding diagnostic precision of 64% in the field. Of the 2892 patients with acute ischemic stroke, acute reperfusion therapy was given to 29.2% (21.7% intravenous tPA [tissue-type plasminogen activator] only and 7.5% endovascular treatment). Rates of endovascular treatment of patients with ischemic stroke increased over time, more than doubling from 5.6% in 2013 to 12.5% (odds ratio per 3-month quarter=1.09; 95% confidence interval, 1.04-1.14; P<0.0001). Only 3.4% of patients with acute ischemic stroke were transferred from a spoke to a hub hospital; transfer rates were inversely related to age (P<0.0001), and reperfusion therapy rates did not vary according to transfer status. CONCLUSIONS: Favorable features of this acute stroke care system include reperfusion therapy in 29.2% of patients with ischemic stroke and substantial increases in endovascular treatment rates over time. Continued efforts to optimize acute stroke systems of care can be directed toward improving access to best acute stroke therapies.

Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens.

BACKGROUND AND PURPOSE: Prehospital scales have been developed to identify patients with acute cerebral ischemia (ACI) because of large vessel occlusion (LVO) for direct routing to Comprehensive Stroke Centers (CSCs), but few have been validated in the prehospital setting, and their impact on routing of patients with intracranial hemorrhage has not been delineated. The purpose of this study was to validate the Los Angeles Motor Scale (LAMS) for LVO and CSC-appropriate (LVO ACI and intracranial hemorrhage patients) recognition and compare the LAMS to other scales. METHODS: The performance of the LAMS, administered prehospital by paramedics to consecutive ambulance trial patients, was assessed in identifying (1) LVOs among all patients with ACI and (2) CSC-appropriate patients among all suspected strokes. Additionally, the LAMS administered postarrival was compared concurrently with 6 other scales proposed for paramedic use and the full National Institutes of Health Stroke Scale. RESULTS: Among 94 patients, age was 70 (±13) and 49% female. Final diagnoses were ACI in 76% (because of LVO in 48% and non-LVO in 28%), intracranial hemorrhage in 19%, and neurovascular mimic in 5%. The LAMS administered by paramedics in the field performed moderately well in identifying LVO among patients with ACI (C statistic, 0.79; accuracy, 0.72) and CSC-appropriate among all suspected stroke transports (C statistic, 0.80; accuracy, 0.72). When concurrently performed in the emergency department postarrival, the LAMS showed comparable or better accuracy versus the 7 comparator scales, for LVO among ACI (accuracies LAMS, 0.70; other scales, 0.62-0.68) and CSC-appropriate (accuracies LAMS, 0.73; other scales, 0.56-0.73). CONCLUSIONS: The LAMS performed in the field by paramedics identifies LVO and CSC-appropriate patients with good accuracy. The LAMS performs comparably or better than more extended prehospital scales and the full National Institutes of Health Stroke Scale.

Prehospital use of magnesium sulfate as neuroprotection in acute stroke.

BACKGROUND: Magnesium sulfate is neuroprotective in preclinical models of stroke and has shown signals of potential efficacy with an acceptable safety profile when delivered early after stroke onset in humans. Delayed initiation of neuroprotective agents has hindered earlier phase 3 trials of neuroprotective agents. METHODS: We randomly assigned patients with suspected stroke to receive either intravenous magnesium sulfate or placebo, beginning within 2 hours after symptom onset. A loading dose was initiated by paramedics before the patient arrived at the hospital, and a 24-hour maintenance infusion was started on the patient's arrival at the hospital. The primary outcome was the degree of disability at 90 days, as measured by scores on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability). RESULTS: Among the 1700 enrolled patients (857 in the magnesium group and 843 in the placebo group), the mean (±SD) age was 69±13 years, 42.6% were women, and the mean pretreatment score on the Los Angeles Motor Scale of stroke severity (range, 0 to 10, with higher scores indicating greater motor deficits) was 3.7±1.3. The final diagnosis of the qualifying event was cerebral ischemia in 73.3% of patients, intracranial hemorrhage in 22.8%, and a stroke-mimicking condition in 3.9%. The median interval between the time the patient was last known to be free of stroke symptoms and the start of the study-drug infusion was 45 minutes (interquartile range, 35 to 62), and 74.3% of patients received the study-drug infusion within the first hour after symptom onset. There was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the magnesium group and those in the placebo group (P=0.28 by the Cochran-Mantel-Haenszel test); mean scores at 90 days did not differ between the magnesium group and the placebo group (2.7 in each group, P=1.00). No significant between-group differences were noted with respect to mortality (15.4% in the magnesium group and 15.5% in the placebo group, P=0.95) or all serious adverse events. CONCLUSIONS: Prehospital initiation of magnesium sulfate therapy was safe and allowed the start of therapy within 2 hours after the onset of stroke symptoms, but it did not improve disability outcomes at 90 days. (Funded by the National Institute of Neurological Disorders and Stroke; FAST-MAG ClinicalTrials.gov number, NCT00059332.).

Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity.

BACKGROUND AND PURPOSE: The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region. METHODS: We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy-Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals. RESULTS: Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20-50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119-180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120-180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were r=0.49 for the prehospital LAMS and r=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale, r=-0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74-0.78); EPA LAMS, 0.85 (95% confidence interval 0.83-0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85-0.88). CONCLUSIONS: In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.

Research in prehospital and disaster health and medicine: developing a research objective statement.

A concise, well-designed research objective statement for proposed research is important for directing and coordinating a study.While often only a single or a few sentences in a manuscript, the research objective statement is usually the single most important element in the design and conduct of a research study.

Characteristics of hospitals diverting ambulances in a California EMS system.

INTRODUCTION: While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics. HYPOTHESIS/PROBLEM: The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system. METHODS: A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed. RESULTS: Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate. CONCLUSIONS: Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

Water and power reserve capacity of health facilities in the Greek islands.

INTRODUCTION: Geographically isolated islands are vulnerable during natural or technological disasters. During disasters, island health facilities should be able to secure power and water in order to continue operations. OBJECTIVE: This study sought to determine the existence of Greek island health facility backup systems for water and power. When such systems existed, reserve capacity was quantified and compared to the Pan American Health Organization (PAHO) Hospital Safety Index standards. METHODS: A standardized, self-administered questionnaire was sent to major health care facilities belonging to the national health system in all Greek islands. The biggest facility available in each island was included (hospital, health center, or health post). For Crete and Euboea, all hospitals were included. RESULTS: Fifty-four of 85 facilities queried (27 hospitals, 17 health centers and 41 health posts) responded, for a response rate of 64%. Responding to the survey were 16 hospitals, 12 health centers and 26 health posts. In 70% of responding facilities (all 16 hospitals, 10 health centers, and 12 health posts) a backup water tank was available, while 72% (all 16 hospitals, 11 health centers, and 12 health posts) had a backup power supply system. Twenty-seven facilities provided data on water reserve, with 15 (56%) reporting a reserve for three or more days. Twenty facilities provided data on fuel stock and power consumption; six (30%) had energy reserves for more than 72 hours, and eight (40%) had reserves for 24-72 hours. CONCLUSIONS: Greek state-supported island health facilities responding to the questionnaire had water and power reserves for use in an emergency. Health centers and health posts were less prepared than hospitals. Of the responding health facilities, half had a water backup system and approximately one-third had power backup systems with reserves that would last for at least 72 hours.

Purposeful Sampling: Advantages and Pitfalls.

This editorial monograph explores the advances and pitfalls of the common forms of purposeful sampling. Purposeful sampling is a common research design in qualitative research.

Epinephrine for prehospital cardiac arrest with non-shockable rhythm.

Cardiopulmonary arrest research and guidelines have generally focused on the treatment and management of ventricular fibrillation and pulseless ventricular fibrillation (electrical shockable rhythms). Less investigation has been done on the subpopulation of cardiopulmonary arrest victims that present with non-shockable rhythms. In a new paper, Goto, Maeda, and Goto present evidence that early use of epinephrine for treatment is associated with better survival with functional outcome. While there is a lack of evidence to support epinephrine for management of cardiopulmonary arrest presenting with initial shockable rhythms (presumed primary cardiac origin), there is now evidence that epinephrine may potentially benefit those presenting with non-shockable cardiopulmonary arrest (presumed heterogeneous origins). Further research on non-shockable rhythm cardiopulmonary arrest is needed to understand the subpopulation and develop better treatment guidelines.

Validation of a modified Medical Resource Model for mass gatherings.

INTRODUCTION: A modified Medical Resource Model to predict the medical resources required at mass gatherings based on the risk profile of events has been developed. This study was undertaken to validate this tool using data from events held in both a developed and a developing country. METHODS: A retrospective study was conducted utilizing prospectively gathered data from individual events at Old Trafford Stadium in Manchester, United Kingdom, and Ellis Park Stadium, Johannesburg, South Africa. Both stadia are similar in design and spectator capacity. Data for Professional Football as well as Rugby League and Rugby Union (respectively) matches were used for the study. The medical resources predicted for the events were determined by entering the risk profile of each of the events into the Medical Resource Model. A recently developed South African tool was used to predetermine medical staffing for mass gatherings. For the study, the medical resources actually required to deal with the patient load for events within the control sample from the two stadia were compared with the number of needed resources predicted by the Medical Resource Model when that tool was applied retrospectively to the study events. The comparison was used to determine if the newly developed tool was either over- or under-predicting the resource requirements. RESULTS: In the case of Ellis Park, the model under-predicted the basic life support (BLS) requirement for 1.5% of the events in the data set. Mean over-prediction was 209.1 minutes for BLS availability. Old Trafford displayed no events for which the Medical Resource Model would have under-predicted. The mean over-prediction of BLS availability for Old Trafford was 671.6 minutes. The intermediate life support (ILS) requirement for Ellis Park was under-predicted for seven of the total 66 events (10.6% of the events), all of which had one factor in common, that being relatively low spectator attendance numbers. Modelling for ILS at Old Trafford did not under-predict for any events. The ILS requirements showed a mean over-prediction of 161.4 minutes ILS availability for Ellis Park compared with 425.2 minutes for Old Trafford. Of the events held at Ellis Park, the Medical Resource Model under-predicted the ambulance requirement in 4.5% of the events. For Old Trafford events, the under-prediction was higher: 7.5% of cases. CONCLUSION: The medical resources that are deployed at a mass gathering should best match the requirement for patient care at a particular event. An important consideration for any model is that it does not continually under-predict the resources required in relation to the actual requirement. With the exception of a specific subset of events at Ellis Park, the rate of under-prediction for this model was acceptable.

Editorial Comments: The 2023 Model Core Content of Disaster Medicine.

The recently published Model Core Content of Disaster Medicine introduces proposed curriculum elements for specialized education and training in Disaster Medicine. This editorial comments on the publishing decision for the manuscript.

Organization of a United States county system for comprehensive acute stroke care.

BACKGROUND AND PURPOSE: Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a county-wide system of spoke-and-hub stroke neurology receiving centers (SNRC) that incorporated several comprehensive stroke center recommendations. METHODS: Observational study of patients with suspected stroke of <5 hours duration transported by emergency medical system personnel to an SNRC during the first year of this system. RESULTS: A total of 1360 patients with suspected stroke were evaluated at 9 hub SNRC, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous tissue-type plasminogen activator was administered to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus in which 25.1% (99/395) of the patients with ischemic stroke received acute intravenous or intra-arterial reperfusion therapy, and in which provision of such therapies was less common with milder stroke, older age, and Hispanic origin. The door-to-needle time for intravenous tissue-type plasminogen activator met the <60-minute target in only 25% of patients and was 37% longer (P=0.0001) when SNRC were neurointerventional-ready. CONCLUSIONS: A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.

A graduate curriculum in emergency public health.

The increase in adverse health impacts of disasters has raised awareness of the need for education in the field of emergency public health. In the past, most traditional models of graduate education in schools of public health have not incorporated the theory and practice of disaster public health into their curricula. This paper describes the development of a curriculum in emergency public health within a US masters program in public health, and provides a description of the courses that comprise an area of specialization in the field. The interdisciplinary nature of the faculty, close ties with public health practitioners, and practical applications of the nine courses in this program are highlighted. The curriculum is presented as one model that can be used to meet the educational needs of professionals who will assume the responsibility for planning for and responding to the public health impacts of mass-populations disasters.