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Background: Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown. Objective: To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with in-hospital and discharge disability outcomes. Design: Prospective observational study. Participants: AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina. Main Measures: National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24-h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0–5, 6–14, and ≥ 15, respectively). Key Results: Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference − 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02). Conclusions: The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/lifestyle in order to minimize post-stroke disability. [ABSTRACT FROM AUTHOR]

Treatment for acute ischemic stroke must be initiated within hours of stroke symptom onset, and the sooner it is administered, the better. In South Carolina, 76% of the population can access expert stroke care, and rural hospitals may provide specialized treatment using telemedicine, but many stroke sufferers seek care too late to achieve full benefit. Using a community‐engaged approach in a southern rural community, we explored barriers and facilitators to early stroke care and implications for improvement. The Community‐Engaged Assessment to facilitate Stroke Elimination (CEASE) study was guided by a community advisory group to ensure community centeredness and local relevance. In a qualitative descriptive study, eight focus groups were conducted including 52 individuals: recent stroke survivors, family members, emergency medical personnel, hospital emergency department staff, primary care providers, and community leaders. From analysis of focus group transcripts came six themes: lack of trust in healthcare system and providers; weak relationships fueled by poor communication; low health literacy; financial limitations related to health care; community‐based education; and faith as a message of hope. A hierarchy model for improving early community‐based stroke care was developed through consensus dialogue by community representatives and the research team. This model can be used to inform a community‐partnered, stakeholder‐informed intervention to improve stroke care in a rural southern community with the goal of improving stroke education, care, and outcome. © 2016 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Background: Patient selection for acute ischemic stroke has been largely driven by time-based criteria, although emerging data suggest that image-based criteria may be useful. The purpose of this study was to directly compare outcomes of patients treated within a traditional time window with those treated beyond this benchmark when CT perfusion (CTP) imaging was used as the primary selection tool. Methods: A prospectively collected database of all patients with acute ischemic stroke who received intraarterial therapy at the Medical University of South Carolina was retrospectively analyzed, regardless of time from symptom onset. At presentation, CTP maps were qualitatively assessed. Selected patients underwent intraarterial therapy. Functional outcome according to the modified Rankin scale (mRS) score at about 90 days was documented. Results: 140 patients were included in the study. The median time from symptom onset to groin access was 7.0 h. Overall, 28 patients (20%) had bleeding complications, but only 10 (7.1%) were symptomatic. The average National Institute of Health Stroke Scale (NIHSS) score for patients treated ≤7 h from symptom onset was 17.3 and 30.2% had a mRS score of 0–2 at 90 days. Patients treated >7 h from symptom onset had an average NIHSS score of 15.1 and 45.5% achieved a mRS score of 0–2 at 90 days ( p=0.104). Patients in the two groups had similar rates of symptomatic intracerebral hemorrhage (8.5% and 5.8%, respectively; p=0.745). Conclusions: No difference was found in the rates of good functional outcome between patients treated ≤7 h and those treated >7 h from symptom onset. These data suggest that imaging-based patient selection is a safe and viable methodology. [ABSTRACT FROM AUTHOR]

Background: Traditional treatment in acute ischemic stroke is based on time criteria when administering intravenous and intra-arterial therapies. However, recent evidence suggests that image-based criteria may be useful for selecting patients for intra-arterial interventions. The use of CT perfusion (CTP)-based criteria, regardless of time from symptom onset, in patient selection for intra-arterial treatment of ischemic stroke was assessed. Methods: Patients with ischemic stroke who presented to the emergency department at the Medical University of South Carolina with a National Institute of Health Stroke Scale score of ≥ 8, regardless of time from symptom onset, were assessed retrospectively. CTP maps were qualitatively assessed for the presence of penumbra and infarction. Selected patients underwent mechanical aspiration of their occlusion using the Penumbra system. Functional outcome was then recorded using the modified Rankin scale (mRS) at 90 days or the closest follow-up to 90 days. Results: 53 patients were included in the study. The median time from symptom onset to groin vascular access was 6.3 h. Eight patients (15%) had bleeding complications including subarachnoid hemorrhage, parenchymal hemorrhage and intraventricular hemorrhage. After CTP-based selection, the patients were divided into two groups for analysis: ≤6 h and >6 h from symptom onset to endovascular procedure. No difference was found in functional outcome between the two groups (38.5% and 40.7% achieved 90-day mRS ≤2, respectively (p=1.0) and 57.7% and 51.9% achieved 90-day mRS ≤3, respectively (p=0.785)). There was no difference in the rate of intracranial hemorrhage between the two groups (11.5 vs 18.5, p=0.704). Conclusion: This study demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CTP selection rather than time-guided selection. These findings suggest that endovascular reperfusion in ischemic stroke may be effective and safe, and may allow patient selection not solely based on time from symptom onset. [ABSTRACT FROM AUTHOR]

Background: Patients with acute ischemic stroke (AIS) who use emergency medical services (EMS) receive quicker reperfusion treatment which, in turn, mitigates post-stroke disability. However, nationally only 59% use EMS. We examined why AIS patients use or do not use EMS.Methods: During 2016-2018, a convenience sample of AIS patients admitted to a primary stroke center in South Carolina were surveyed during hospitalization if they were medically fit, available for survey when contacted, and consented to participate. The survey was programed into EpiInfo with skip patterns to minimize survey burden and self-administered on a touchscreen computer. Survey questions covered symptom characteristics, knowledge of stroke and EMS importance, subjective reactions, role of bystanders and financial factors. Descriptive and multiple regression analyses were performed.Results: Of 108 inpatients surveyed (out of 1179 AIS admissions), 49% were male, 44% African American, mean age 63.5 years, 59% mild strokes, 75 (69%) arrived by EMS, 33% were unaware of any stroke symptom prior to stroke, and 75% were unaware of the importance of EMS use for good outcome. Significant factors that influenced EMS use decisions (identified by regression analysis adjusting for stroke severity) were: prior familiarity with stroke (self or family/friend with stroke) adjusted odds ratio, 5.0 (95% confidence interval, 1.6, 15.1), perceiving symptoms as relevant for self and indicating possible stroke, 26.3 (7.6, 91.1), and bystander discouragement to call 911, 0.1 (0.01,0.7). Further, all 27 patients who knew the importance of EMS had used EMS. All patients whose physician office advised actions other than calling EMS at symptom onset, did not use EMS.Conclusion: Systematic stroke education of patients with stroke-relevant comorbidities and life-style risk factors, and public health educational programs may increase EMS use and mitigate post-stroke disability. [ABSTRACT FROM AUTHOR]

Objectives: Sudden cardiac arrest (SCA) remains a significant cause of morbidity and mortality, and the key to increased survival is emergent bystander intervention. A growing body of evidence has shown that timely bystander-initiated cardiopulmonary resuscitation (CPR) and defibrillation are significantly correlated with an increased likelihood of survival. Despite these demonstrated benefits, bystanders perform these interventions in less than half of witnessed SCA cases. We hypothesized that the level of public CPR and automated external defibrillator (AED) knowledge may be limited and may play a role in the likelihood of intervening.Methods: A convenience survey of potential bystanders to SCA was conducted in a high-traffic shopping center to estimate the overall knowledge level of CPR and AED usage and determine general attitudes toward intervening in the setting of SCA. Concurrently with the survey, professional emergency responders offered free bystander compression-only CPR and AED training on location.Results: The majority of survey respondents expressed a willingness to perform the aforementioned interventions when asked directly. Results, however, indicate that although 69% of respondents consider themselves to have a general knowledge of CPR, only 18% spontaneously mentioned CPR when presented with a hypothetical SCA scenario. In addition, only 2.2% mentioned defibrillation, and 63% indicated that they would not know how to locate a public access AED when needed. Of the individuals who participated in both the survey and the training, all of them indicated that they were more likely to intervene in an SCA after receiving the training.Conclusions: Our findings suggest that future public outreach efforts should target the current CPR and AED knowledge gap. They also indicate that free, brief trainings offered at public events are a feasible way to increase the knowledge and skills of potential bystanders to SCA. [ABSTRACT FROM AUTHOR]

Objectives: Telesimulation, in which learners and evaluators use technology to connect remotely to simulation-based learning activities, is effective for skills and decision-making review. Historical models in which learners are colocated with the simulation equipment have inherent issues, especially for emergency medical services (EMS) providers. This feasibility study placed the evaluators in the simulation center, whereas the learners were at a distance steering the scenario evolution through telehealth technologies.Methods: Volunteer EMS providers across South Carolina with varying levels of training and experience completed difficult airway management scenarios focused on clinical decision making. The program consisted of pre- and postexperience examinations, a lecture, and increasingly complicated simulations using high-fidelity mannequins that were facilitated by local trainers under the direction of remote trainees. Audio and video content, including vital signs and cardiac monitoring, were live streamed. Participants worked in two-person teams with lead providers on each scenario clinically assessing and managing cases of anaphylaxis. Data were collected from the simulations using Laerdal software, as well as examination and survey results.Results: A total of 24 participants completed all of the elements of the training. Trends toward improvement in times to bag-mask ventilation and initial epinephrine administration were noted. Average cognitive test scores increased by 9.6%, and learners reported improved comfort with simulation (75%, P ≥ 0.0001) and videoconferencing (83%, P ≥ 0.0001). They also reported high degrees of comfort with intubation (73.3%) following the training.Conclusions: This method of telesimulation appears to be a viable addition to continuing EMS education and may address access issues for some providers. [ABSTRACT FROM AUTHOR]

Background: Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown., Objective: To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with in-hospital and discharge disability outcomes., Design: Prospective observational study., Participants: AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina., Main Measures: National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24-h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0-5, 6-14, and ≥ 15, respectively)., Key Results: Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference - 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02)., Conclusions: The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/lifestyle in order to minimize post-stroke disability.

Background: The administration of thrombolysis to eligible patients is often limited to centers with expertise. This study was intended to report on the safety and efficacy (in increasing thrombolysis availability) of telemedicine in the acute assessment and treatment of stroke patients presenting to hospitals in distant locations from a designated stroke center., Methods: A web-based telestroke tool (remote evaluation of acute ischemic stroke at Medical University of South Carolina [REACH-MUSC]), was implemented to provide acute stroke care 24 hours per day, 7 days per week to 12 community hospitals in South Carolina., Results: Nine hundred sixty-five consults were performed. Among the 525 patients with a National Institutes of Health Stroke Score >3, 185 (35.7%) were treated with intravenous tissue plasminogen activator (t-PA) alone, 15 (2.9%) received combination of intravenous and intra-arterial thrombolysis/thrombectomy, and 11 (2.1%) were treated with intra-arterial therapy alone. Of those who received intravenous t-PA, 119 (64.3%) were transferred to the hub; the medians (interquartile range) for onset to treatment for the intravenous t-PA and the intravenous t-PA and intra-arterial groups were 152 (range 115-193) minutes and 147 (range 107-179) minutes, respectively. Three patients (1.6%) who received intravenous t-PA alone experienced symptomatic intracerebral hemorrhage. The most common reason for not receiving thrombolysis was patient presentation outside the time window for treatment., Conclusions: Telestroke can have a major impact in increasing thrombolysis rates in remote areas from specialized centers, and in particular in areas where t-PA is underutilized., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)