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Feb. 16, 2006

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Abstracts P45, P27

American Stroke Association meeting report:
Stroke patients arriving to ER by ambulance treated differently than walk-ins

KISSIMMEE, Fla., Feb.16 – Stroke patients arriving to the emergency room (ER) by ambulance receive the care they need sooner than those arriving by other means, according to research presented today at the American Stroke Association’s International Stroke Conference 2006.

Nationally, only about half of stroke patients arrive at the nation’s ERs by ambulance, said the lead author of one the studies, Yousef M. Mohammad, M.D., M.Sc.

Ischemic strokes, which are caused by a blood clot lodged in an artery feeding part of the brain, can be treated with tissue plasminogen activator (tPA).  But the clot-busting drug must be given within three hours of symptom onset.   tPA is the only stroke therapy approved by the U.S. Food and Drug Administration to break up blood clots in the brain and reduce permanent disability.

Researchers from Ohio State University in Columbus and the Zeenat Qureshi Stroke Research Center in Newark, New Jersey explored whether patients’ mode of arrival to the ER makes a difference in the care they receive after stroke symptom onset (Abstract P45).

Mohammad and colleagues analyzed one of the largest databases detailing ER services.  Researchers identified 630,402 patients in the study who had been evaluated for stroke in an ER.  Patients’ arrivals were categorized into three groups: 1) those arriving by ambulance, either air or ground; 2) walk-ins, including car, taxi, bus or by foot; and 3) public services, such as police, social service vehicle or an unknown mode of transportation.

About half (331,760 of patients) arrived by ambulance; 43 percent (271,268) were in the walk-in category; and 4 percent (27,374) arrived by public service or unknown.

“Patients with acute stroke who arrived to the ER by ambulance were more likely to be evaluated by an ER physician sooner, get the necessary testing for stroke and be admitted to the hospital or intensive care unit than patients in the other two groups,” said Mohammad, an assistant professor of neurology and director of the stroke fellowship program at Ohio State University in Columbus.

According to the study, patients who came by ambulance were seen and evaluated by an ER physician within 30 minutes compared to 34 minutes if patients walked in and 55 minutes for those who arrived by public service/unknown transportation.

“In acute stroke treatment every minute counts, so a few minutes delay in evaluation may deprive some patients from receiving the time-sensitive treatment,” he said.  

“The findings are a wake-up call for the public and ER triage staff,” he said. “Whether patients arrive by foot or ambulance, ER triage staff need to have these patients evaluated urgently — as if they are having a heart attack,” said Mohammad.

He said it is a mistake to think you can drive yourself to the hospital.

“Call 9-1-1 and the emergency medical staff will get you to the hospital quicker than you driving yourself.  In addition, your symptoms may worsen and impair driving ability,” he warned.

Seventy-three percent of patients who came by ambulance received the diagnostic imaging (computed tomography or magnet resonance imaging) needed to diagnose stroke.   Sixty-three percent of walk-ins received imaging and public service or unknown arrivals got the imaging 60 percent of the time.

The ambulance arrivals were also more likely to be admitted to the hospital or intensive care, at 93 percent of the time, rather than being sent home.   Walk-ins with a diagnosis of stroke were admitted 58 percent of the time, versus public services/unknown arrivals, at 52 percent.

In addition, 97 percent of patients arriving by ambulance were evaluated by a staff physician as opposed to a nurse, physician assistant or resident.   Eighty-nine percent of walk-ins and 82 percent of those arriving by other means were seen by a staff physician.

Mohammad and colleagues plan to study what percentage of patients coming by ambulance receive tPA compared to the walk-ins and public service arrivals.

“People who have symptoms of stroke need to be evaluated and treated urgently,” he said.  “Sadly, less than one percent of acute stroke patients who arrive at emergency rooms in the United States receive clot-busting therapy.”

“A stroke is a brain attack, kind of equivalent to a heart attack, and must be evaluated promptly,” he said.

A separate study (Abstract P27) by researchers in Portland, Oregon, investigated which patients were most likely to receive a computed tomography (CT) scan within 25 minutes of hospital arrival.  

CT scans help determine whether a stroke is caused by a blockage (ischemic stroke) or by bleeding in the brain (hemorrhagic stroke).   Only ischemic strokes can be treated with the clot-busting drug.

“CT scan is usually the first imaging test done for stroke patients in the acute treatment phase and often occurs in the emergency room,” said lead author C. Ken House, M.S. of Providence Health System in Portland.  “National guidelines recommend conducting a CT scan within 25 minutes of stroke patients arrival at the hospital.”

Analyzing data from 493 stroke and transient ischemic attack patients who arrived at the hospital within three hours of symptom onset, researchers found that only 36.1 percent received a head CT within the recommended time.

Among the factors that made patients more likely to received CT promptly were that they:

• arrived by ambulance with lights and sirens on,
• had a neurologist involved in their care,
• had commercial insurance,
• were treated at an urban hospital, and
• were of “normal” weight.

Factors related to the hospital, the patient and the patient’s arrival mode may impact the likelihood of receiving a head CT quickly.

House echoed Mohammed’s assessment of the implications of the findings.

“If a person thinks they may be having a stroke, they need to call 9-1-1 immediately.  Let an ambulance take you to the hospital – you get there faster, safer and you may be treated more rapidly when you get there,” he said.  “On the other hand, emergency room and radiology personnel must consider stroke patients a top priority and avoid delays in getting brain images – whether the patient arrives by ambulance or not.”

He also noted that ambulance personnel should be aware of which of the nearest hospitals can provide a brain CT or MRI within 25 minutes, “that might be especially challenging on the weekends or late at night,” he said.

The warning signs of stroke are:

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body,
• Sudden confusion, trouble speaking or understanding,
• Sudden trouble seeing in one or both eyes,
• Sudden trouble walking, dizziness, loss of balance or coordination, and
• Sudden, severe headache with no known cause.

Mohammad’s co-authors are Abu Nasar, M.Sc.; Victoria Shekhman, M.D.; Pansy Harris-Lane, M.S.N.; Mustapha A Ezzeddine, M.D.; and M. Fareed K Suri, M.D.

House’s co-authors are Valerie Stewart, Ph.D.; Ted J. Lowenkopf, M.D.; Allen J. Brown, B.S. and Jenny Richardson, R.N., M.S.   This study was funded by the Centers for Disease Control and Prevention.

Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position.  The American Heart Association makes no representation or warranty as to their accuracy or reliability.

NR06-1014 (ISC06/Mohammad, House)

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