From the Department of Emergency Medicine, Harbor-UCLA Medical Center and The Lundquist Institute, Torrance, CA (N.B., M.G.-H.).
Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA (N.B., M.G.-H., R.T., C.C., L.P., M.W., S.R., P.L.-N.).
Stroke. 2020 Mar;51(3):908-913. doi: 10.1161/STROKEAHA.119.027756. Epub 2020 Jan 28.
Background and Purpose- We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods- In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results- With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services-transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05-1.3]; =0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0-5] =0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0-2.9]; <0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, -4 to 20] =0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2-0.5]; <0.0001). Conclusions- After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.
背景与目的-我们在洛杉矶县实施两级路由的区域卒中护理系统之前和之后，量化了人群进入血管内治疗能力中心的情况、时间和接受取栓术的比例。方法-2018 年，洛杉矶县紧急医疗服务机构实施了将洛杉矶电机量表评分≥4 的疑似大血管闭塞患者直接转运至指定的血管内治疗能力中心的方案。我们计算了在 30 分钟内进入指定血管内治疗能力中心的人群比例，比较了 2016 年（两级系统规划开始前）和 2018 年（实施后）的数据。我们分析了该地区卒中中心实施前后一年的数据，以描绘 tPA（组织型纤溶酶原激活剂）和取栓术给药速度和频率以及医院间转院的变化。结果-实施两级系统后，认证的血管内治疗能力医院从 4 家增加到 19 家，洛杉矶县公众在 30 分钟内获得血管内治疗的比例从 2016 年的 40%增加到 2018 年的 93%。将实施后第一年（N=3303）转运的卒中患者与实施前最后一年（N=3008）转运的患者进行比较，发现患者年龄、性别和就诊时的严重程度相似。溶栓治疗的频率从 23.8%增加到 26.9%（比值比，1.2[95%CI，1.05-1.3]；=0.006），急救人员至开始溶栓的中位数时间减少了 3 分钟（95%CI，0-5；=0.03）。取栓术的频率从 6.8%增加到 15.1%（比值比，2.4[95%CI，2.0-2.9]；<0.0001），尽管首次医疗接触至穿刺时间没有显著变化，但中位数下降了 8 分钟（95%CI，-4 至 20；=0.2）。医院间转院的频率从 3.2%下降到 1.0%（比值比，0.3[95%CI，0.2-0.5]；<0.0001）。结论-在美国人口最多的县实施两级卒中转运方案后，93%的人群可获得取栓术治疗，取栓术的频率增加了一倍以上，而医院间转院的比例下降。
