Innovative collaborations between a 911 emergency medical service (EMS) and local health care leaders helped foster a prehospital Mobile Integrated Health Care strategy that enhanced patient care while also mitigating the impact of Covid-19. Incorporating novel skill sets, alternate-destination pathways, safe and selective nontransport policies, and telehealth into upstream care has helped divert low-acuity patients from hospital EDs and optimally match patient need to location of care. In the City of Los Angeles, these strategies bought time for hospitals to stage for a patient surge, while the EMS bureau created the first Covid-19 testing sites for health care workers and, eventually, the public at large. Challenges such as cost, the need for increased medical oversight, EMS mission creep, and integrating this comprehensive EMS response into the community's health care system have led to broader discussions with health care executives about unlocking the upstream value of prehospital patient navigation.
Background: Ischemic conditioning, or endogenous protection of brain tissue, may be elicited by prior TIA or absent due to sudden cardioembolic occlusion in atrial fibrillation (AF). We hypothesized that such specific co-morbidities may be manifest by the extent of early ischemic changes, or ASPECTS score, on CT in the prehospital NINDS FAST-MAG trial. Methods: All FAST-MAG subjects with a final diagnosis of cerebral ischemia were included in these analyses of baseline clinical variables and ASPECTS, scored on the initial non-contrast CT acquired at ED arrival. The relationship between prior medical conditions and total ASPECTS score was determined by bivariate analyses, Mann-Whitney U, and Kruskal-Wallis tests. Results: 1,240 patients (mean age 69 SD 13; 45% women) had ASPECTS scored on initial imaging, CT in 1227 (97%), MRI in 42. ASPECTS (median 10, range 1-10) was notably higher, signifying less ischemic changes in those with history of prior TIA, median 10 (IQR 10-10) vs. 10 (8-10), p=0.012 by Mann-Whitney, whereas prior history of stroke revealed no difference. Conversely, substantially lower ASPECTS or greater ischemic changes were noted in those with history of AF, median 10 (7-10) vs. 10 (8-10), p=0.010) and presence of AF on EKG in ED, median 10 (6-10) vs. 10 (8-10), p=0.041. Interestingly, other cardiac history and all other co-morbidities demonstrated no relationship with ASPECTS. Elevated prehospital systolic blood pressure was linked with higher ASPECTS (r=0.098, p=0.001), as was the change in blood pressure from field to ED (ANOVA, p=0.049). Initial ASPECTS was linked with 90-day mRS outcomes (r=-.259, p<0.001). Conclusions: Prior TIA and AF exhibit striking, yet opposite relationships with the extent of early CT findings in this large cohort of patients enrolled in a prehospital stroke trial. These findings suggest that patient-specific factors, such as conditioning, may be pivotal in the course of cerebral ischemia.
Background: At over 45.5 million and growing, Hispanics are the United States’ fastest emerging ethnic group. Hispanics have a different prevalence of risk factors for stroke when compared with non-Hispanic whites, including increased frequency of hypertension, diabetes and obesity. Adequate ethnic representation in clinical trials is important to assure generalizability of results. Methods to enhance the Hispanic participants include Spanish language consent processes. We describe Hispanic participants in a prehospital clinical trial using Spanish as well as English consent forms. Methods: The NIH Field Administration of Stroke Therapy - Magnesium (FAST-MAG) Phase 3 Trial is a randomized study of prehospital initiated neuroprotection versus placebo in patients evaluated by paramedics less than two hours from symptom onset. After paramedics screened potential subjects, they dialed English or Spanish language enrollment lines, using voice-over-internet simulring numbers to directly connect to the cellphones of 4 Spanish-speaking or 4 English- speaking physician-investigators. Spanish speaking patients were able to learn about the study and be consented into the trial in their primary language. Results: There were 399 subjects enrolled in FAST-MAG who identified as Hispanic, 23% of the total cohort of 1700. Approximately half (48%) were enrolled using the Spanish- language consent process. Hispanic participants in FAST-MAG differed from non-Hispanic participants in several baseline characteristics, including being younger (65 vs. 71, p<0.001), more likely to have intracranial hemorrhage stroke subtype (33% vs. 20%, p<0.001), more often diabetic (32% vs. 19%, P<0.001), more severe baseline deficits (NIHSS 13 vs. 11, p=0.001) and higher systolic blood pressure (163 vs. 159, p=0.008). The two groups did not vary in gender, history of hypertension, time to paramedic evaluation, or rates of thrombolysis in cerebral ischemia. Conclusion: Better representation of Hispanics in clinical research is aided by availability of Spanish language consent processes. Dual language phone lines for consent elicitation are an effective strategy to increase enrollment of Hispanic participants in prehospital clinical research.
Background: Prehospital neuroprotective therapy aims to preserve penumbral tissue in anticipation of recanalization therapies. We describe the population receiving recanalization treatment upon hospital arrival after enrollment in a prehospital neuroprotective trial. Methods: The Field Administration of Stroke Therapy Magnesium (FAST-MAG) phase 3 clinical trial randomized subjects with stroke symptom onset within 2 hours to prehospital treatment with intravenous magnesium sulfate vs. placebo. Subjects were eligible for all FDA-approved/cleared therapies as concomitant treatment, including intravenous thrombolysis and mechanical neurothrombectomy. Results: Among the 1223 patients with acute cerebral ischemia enrolled in the trial, mean age was 71 [SD 13] , 45% were women, 78% White race, 14% Black race and 21% Hispanic ethnicity. Among the cerebral ischemia patients, 434 [36%] received IV thrombolysis and 72 [6%] received endovascular therapy, including 46 patients who received both IV and endovascular recanalization treatment.. Patients treated with IV TPA, compared to supportive care patients, had more severe deficits on ED arrival [median NIHSS 12.5 vs. 4.0, p<0.0001], were assessed by paramedics earlier [30 vs. 50 minutes, p<0.001], and arrived in the ED earlier [63 vs. 84 minutes, p<0.001], but were of similar age and ethnicity. Those who were taken for endovascular therapy had more severe strokes [NIHSS 16, IQR 9.5-23] but were no different in race-ethnicity or time to evaluation. Conclusions: Concomitant intravenous thrombolysis and endovascular recanalization were administered at high rates in the FAST-MAG study, reflecting expanding reperfusion practice in Los Angeles and Orange Counties during the study period. The FAST-MAG population has a sufficient volume of patients concomitantly treated with recanalization therapy to explore with good power the potential benefit of neuroprotection prior to recanalization therapy.
Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.
