3 Building effective stroke systems of care through a regional emergency medical services (EMS) coalition and data transparency initiative: the south florida experience

IntroductionAdvances in acute stroke treatment of emergency large vessel occlusions (ELVO) have led to a transformation in the delivery of stroke care. Because of the importance of time to treatment with endovascular thrombectomy (EVT), there has been renewed emphasis on improving stroke systems of care. In south Florida, there has been a proliferation of stroke centers over the past decade claiming to offer EVT due to the practice of self-attestation by the Agency for Healthcare Administration (AHCA). Concurrently, there are over a dozen EMS agencies in the region, leading to variability in pre-hospital protocols.MethodsTo address the fragmented stroke landscape, in 2015 local EMS Medical Directors along with NeuroInterventionalists (NI) developed the South Florida Stroke Coalition (SFSC), and collaborated with the University of Miami Florida Stroke Registry (UM FSR) team. The core tenets were to: 1) Develop pre-hospital EMS stroke protocols; 2) Optimize in-hospital stroke processes to reduce times to treatment for ELVO; 3) Encourage all tri-county stroke centers to submit data to AHA/ASA Get with the Guidelines-Stroke (GWTG-S) program and participate in the UM FSR; 4) Develop a sustainable data transparency model for CSCs to allow EMS Medical Directors to understand quality of stroke care in their region; 5) Eliminate the practice of AHCA self-attestation of CSCs and require stroke centers to apply for Joint Commission certification.ResultsThe SFSC and the UM FSR analyzed AHCA criteria for Comprehensive Stroke Center (CSC) designation and compared them to those of the Joint Commission to better understand limitations of self-attestation. A sustainable mechanism for local hospitals to share stroke data with the EMS Medical Directors in their catchment areas was created through a regional dashboard initiative (figure 1). The following key variables were selected by the SFSC to provide a better understanding of the quality of care: 1) treatment rates for tPA and EVT, 2) door-to-needle time for tPA, 3) door-to-puncture time for EVT, 4) outcomes at 90 days using modified Rankin scale.Abstract 3 Figure 1ConclusionTo our knowledge, the Florida Stroke Registry Regional Dashboards developed as a grassroots effort between the SFSC and the UM FSR represents the first-of-its-kind, EMS-driven effort to improve stroke systems of care in a region that is comprised of a multitude of EMS agencies and numerous ELVO triage destinations within short distance of each other. Taken together, this data transparency initiative will be instrumental for EMS Medical Directors in future triage decision-making.DisclosuresB. Mehta: None. P. Antevy: None. R. Katz: None. J. Sessa: None. K. Scheppke: None. P. Pepe: None. R. Hanel: None. M. Mokin: None. C. Gutierrez: None. J. Romano: None. R. Nogueira: None. A. Jadhav: None. T. Leslie-Mazwi: None. R. Sacco: None

Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest

Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest. Design Setting and Patients: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival. Interventions: Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff. Measurements and Main Results: Compared with Cardiac Arrest Registry to Enhance Survival (n = 78,704), the cohorts from the 10 emergency medical services agencies examined (n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively). Conclusions: The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care