How Prehospital Severe Stroke Screening Impacts Patients and Systems of Care: A Debate (Neurologic EM and Emergency Medical Services Interest Group Sponsored)

This session co-sponsored by the Neurologic Emergencies Interest Group and the EMS Interest Group will address controversies with prehospital screening and transport of patients with severe stroke syndromes. Recent attention has been focused on how emergency medical services (EMS) practitioners can identify patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) who may benefit from direct transport to stroke centers capable of providing endovascular therapy. However, severe stroke screening carries important patient-level considerations, including how to best screen for severe stroke and its impact on outcomes of patients with and without LVO AIS. Additionally, direct transport carries important systems of care considerations for receiving emergency departments. Low specificity screens can lead to over-triage to thrombectomy-capable and comprehensive stroke centers, which in turn can negatively affect emergency department operations at higher level stroke centers and reduce appropriate patient encounters at primary stroke centers. In contrast, overly specific screens can lead to under-triage of LVO AIS, leading to the need for interfacility transfer and delays in definitive treatment. This session will present a debate among experts in the field about the advantages and disadvantages of prehospital severe stroke screening. The session will begin by describing severe stroke screening and an example from a large urban EMS system, followed by a debate of the patient-level pros and cons of prehospital severe stroke screening. Next, speakers will discuss how severe stroke screening affects emergency department operations at both referring and receiving stroke centers. Lastly, the session will discuss innovations to optimize stroke systems of care. Upon completion, attendees will define severe stroke screening and direct transport for suspected stroke patients, specify the advantages and disadvantages to severe stroke screening for patients and emergency departments, and identify future innovations to optimize stroke systems of care for severe stroke patients.

Presenters:

Christopher T. Richards, MD, MS
Craig Cooley, MD, MPH, EMT-P, FACEP, FAAEM, FAEMS
Lauren E. Mamer, MD, PhD
Peter D. Panagos, MD
Lauren M. Nentwich, MD
Cemal B. Sozener, MD, M. Eng., FACEP, FAHA
Latha Ganti, MD

Authors

Christopher T. Richards, MD, MS

University of Cincinnati

Dr. Richards is an Associate Professor of Emergency Medicine at the University of Cincinnati and has an expertise in prehospital stroke care. He is a board-certified EMS physician and is the medical director of the UCHealth Mobile Stroke Unit as well as for several Fire-EMS agencies in Greater Cincinnati. He is also Co-Director and clinical faculty of the UC Stroke Team which provides acute stroke reperfusion consultation to over 30 emergency departments and hospitals in the Greater Cincinnati region. He has been on several national workgroups focusing on prehospital stroke care, including the NIH’s Brain Attack Coalition Symposium on Inequities in Access and Delivery of Acute Stroke Care and as the chair of the Acute Care Subcommittee of the American Stroke Association Advisory Committee.
Craig Cooley, MD, MPH, EMT-P, FACEP, FAAEM, FAEMS

UT Health San Antonio

Craig Cooley MD, MPH, EMT-P is the EMS Division Chief and EMS Fellowship Director for UT Health San Antonio Department of Emergency Medicine, Deputy Medical Director for San Antonio Fire Department, and a Medical Director for the Texas Emergency Medical Task Force (EMTF) – Region 8. In these roles, Dr. Cooley provides radio/phone and on-scene medical control for SAFD, provides medical oversight during state disaster responses, and educates fellows, residents, and medical students through the different programs and rotations he helped develop that are offered at UT Health San Antonio. He is also part of the Office of the Medical Director that provides EMT and Paramedic continuing education to 1500 personnel per year. Among his involvement in several regional, state and national organizations, Dr. Cooley is a member of the Texas Governor’s EMS and Trauma Advisory Council (GETAC) Cardiac Subcommittee and is Chair of the Council of EMS Fellowship Directors with the National Association of EMS Physicians (NAEMSP). In addition to speaking frequently at the program and local level on several EMS topics, Dr. Cooley continues to speak regionally, nationally and internationally about EMS and EMS system development.
Lauren E. Mamer, MD, PhD

University of Michigan

Lauren Mamer, MD, PhD is a Clinical Assistant Professor in Emergency Medicine at University of Michigan and Hurley Medical Center. She completed a NINDS StrokeNet Fellowship, during which she focused on the composition of stroke teams. She has an enduring interest in cerebrovascular disease in the ED that has spanned projects across multiple modalities including large national data set analysis, health services research, quality improvement and medical education. She is currently a K12 scholar studying the application of blood-based biomarkers to risk stratification of TIA in the emergency department. Her current research interest is in optimizing the care of patients presenting to the emergency department with transient neurologic deficits, specifically the application of blood-based biomarker assays to the diagnosis of clinically silent ischemic stroke in these patients with the goal of optimizing secondary prevention and streamlining the diagnostic workup of neurologic complaints.
Peter D. Panagos, MD

Washington University in St. Louis

My primary research, clinical and administrative interest is in acute neurological emergencies and emergency systems of care. From 2003-2009, I was faculty at The Warren Alpert School of Medicine of Brown University Emergency Medicine Program in Providence, RI and served as Associate Director of the Rhode Island Hospital, The Miriam Hospital Stroke Center and Chaired the RI Stroke Task Force. I have served on numerous leadership positions at the state, regional and national level in the field of stroke and systems of care development. I have delivered over 450 lectures providing me a tremendous perspective on the limitations and barriers of emergency services care across various healthcare settings. At Washington University, I’ve served as PI for the several NIH-funded trials: IMS III trial, EXTEND, STOP IT, MOST, FASTEST and Rhapsody II. I served on the Executive Leadership Committee of our NINDS-funded SPOTRIAS program. I currently or have held several national leadership positions: ACEP Research Committee, AHA ACLS/BLS Committees, AHA ECC Stroke Council Liaison, AHA Emergency Neurovascular Care Committee (ENCC), ASA Scientific Operations Committee (SOC), Chair, AHA Mission: Lifeline Stroke, AHA Stroke EMS Routing Subcommittee and recent past-Chair of the ASA Stroke Leadership Council. These organizations are focused on the coordinating of prehospital and hospital based stroke care nationally. As PI on numerous NIH/NINDS and industry sponsored multi-center clinical trials, I understand the complexity of patient enrollment and have successfully enrolled numerous patients. Currently, I serve as Co-PI at Washington University Emergency Medicine (MARCC-RCC 28) overseeing our network structure and enrollment of patients in a wide-variety of NIH clinical trials and protocols.
Lauren M. Nentwich, MD

Harvard Medical School/Massachusetts General Hospital

Dr. Lauren Nentwich is Vice Chair for Clinical Affairs for the Department of Emergency Medicine at Massachusetts General Hospital in Boston, Massachusetts. She is an Assistant Professor of Emergency Medicine at Harvard Medical School. Dr. Nentwich earned her undergraduate degree in mathematics from the University of Chicago and her medical degree from Harvard Medical School. She completed her residency in emergency medicine at Boston Medical Center followed by an NIH research fellowship in neurology at Massachusetts General Hospital and Brigham and Women’s Hospital. Dr. Nentwich’s professional interests are in optimizing ED and hospital flow and capacity and developing processes to support emergency physicians and ED staff in the care of their patients.
Cemal B. Sozener, MD, M. Eng., FACEP, FAHA

University of Michigan

As a physician experienced in both prehospital and hospital education on acute stroke care, Dr. Sozener has worked with the INSTINCT research team at the University of Michigan and led past efforts in both qualitative and quantitative interventions and analysis for that study in addition to working with the numerous physicians, nurses, and other staff personnel throughout the entire INSTINCT network. Dr. Sozener is active in the NINDS StrokeNet Training Program and is co-director of the University of Michigan Comprehensive Stroke Program.
Latha Ganti, MD, MS, MBA

University of Central Florida College of Medicine

Dr. Ganti is Professor of Neurology and Emergency Medicine at the University of Central Florida and Vice Chair for Research and Academic Affairs. She is one of the members of the inaugural class of the American Academy of Neurology’s Women Leaders in Neurology program.

Dr. Ganti is a prolific writer. Her small book empire comprises over a dozen textbooks, including the best-selling First Aid for the Clinical Clerkship series. Recently, she has started to write for a non-technical audience, as a first-time blogger for Neurology Now.

She has published extensively in neurologic emergencies, with high impact. Her Google scholar citations reveal an H index of 35, with more than 6000 citations to her work just in the last few years and over 650 published manuscripts and abstracts, focusing on her areas of research, acute stroke and traumatic brain injury. Her early work on hypotension in the setting of hyperacute ischemic stroke was instrumental in changing our thinking of BP and stroke as being a U-shaped rather than J-shaped curve, and referenced in all the stroke guidelines. Similarly, her work in mild TBI demonstrated that there is nothing “mild” about mild TBI. Her dedication to the field of neurologic emergencies was has been recognized by the Mayo Clinic Lifetime Achievement Award for Outstanding Contributions in EM Research, and the Toral Family Foundation Endowed Professorship in Traumatic Brain injury. Dr. Ganti has won over 18 national awards, and is a Fulbright Scholar.