Khan, Nadeem

Background: Timely and accurate triage of stroke patients in rural settings remains a critical challenge, especially for patients with large vessel occlusions (LVO) requiring rapid access to comprehensive stroke centers (CSCs). This project aimed to improve the efficiency and accuracy of transport decisions for EMS stroke care in rural Michigan by adapting American Heart Association (AHA) guidelines on prehospital management and EMS routing. Method: We established a novel database involving linking regional EMS records, regional hospital stroke code quality improvement data, and Get With The Guidelines–Stroke (GWTG-S) registry data for suspected and confirmed stroke cases originating from five counties within 60 minutes of an urban CSC in West Michigan. Using a stepped-wedge design, we adapted the model AHA Severity-Based Stroke Triage Algorithm and implemented it in four rural EMS agencies through a staged roll-out of educational programs delivered to EMS providers and regional ED staff. We analyzed pre- and post-intervention data to assess protocol compliance, bypass frequency, and time from EMS scene arrival to CT acquisition and reperfusion therapy delivery. Results: Among 949 (598 pre- and 351 post-intervention) stroke transports occurred between November 2021 to December 2024, guideline-compliant hospital destination selection improved from 62% to 71% (p=0.018). Stroke mimics saw the greatest improvement (72% to 88%, p<0.001) through reduced unnecessary bypass. LVO screening documentation increased (10% to 23%, p<0.001), and EMS scene arrival-to-CT time decreased by 7 minutes (95% CI: 3–11). Trends toward improved thrombolysis rates (18% to 26%, p=0.055) and faster EMS-to-needle times (99 to 87 min, p=0.059) were observed. Mechanical thrombectomy rates and transfer metrics remained unchanged. Conclusions: This project successfully implemented a rural stroke triage protocol aligned with AHA guidelines, improving EMS routing decisions and reducing time to imaging. The intervention enhanced access to thrombolysis, however did not expedite mechanical thrombectomy. Findings support the AHA protocol’s scalability and underscore the feasibility of rural stroke system optimization.

Background: Emergency medical services (EMS) routing of stroke patients is challenging in rural settings. To address this, the American Stroke Association (ASA) has developed a template severity-based EMS triage algorithm to direct EMS to either the nearest stroke-ready versus the nearest Comprehensive Stroke Center (CSC) hospital, but its real-world impact is uncertain. Methods: This is an interim analysis of a before-and-after quality improvement study examining the impact of implementation of a severity-based EMS stroke destination protocol by three medical control authorities (MCAs) covering 4 rural counties in western Michigan. We defined optimal destination according to the ASA algorithm, which recommends bypass for patients within 24 of last known well if large vessel occlusion suspected and bypass will not delay thrombolysis. Chi square tests were used to compare optimal destination selection before and after implementation among EMS suspected stroke cases originating from the target counties. We also compared the time from EMS scene arrival to ischemic stroke (IS) treatment (thrombolysis or endovascular therapy [EVT]) before and after implementation using Wilcoxon Rank Sum tests. Results: From November 2021 to May 2024, EMS transported 616 suspected stroke cases, 272 (44.2%) of which ultimately received a diagnosis of ischemic stroke (IS) or transient ischemic attack. The protocol was implemented by each MCA in random order at months 21, 23, and 29, resulting in 73 MCA-months before and 17 after implementation, excluding a one-month washout for each MCA. Optimal hospital destinations were selected for 310/499 (62.1%) patients prior to the protocol and 86/117 (73.5%) after (p=0.021). Thrombolytics were administered to 57 patients (48 before and 9 after) and 46 (42 before and 4 after) received EVT. Median times from first EMS contact to needle decreased from 98 (interquartile range [IQR]: 79-107) to 77 (IQR: 75-85) minutes (p=0.012); median times from EMS contact to groin puncture increased nonsignificantly from 165 (IQR: 132-216) to 196 (IQR: 191-228) minutes (p=0.110). Conclusions: Interim analysis of implementation of a rural EMS severity-based triage algorithm for suspected stroke cases resulted in improved destination selection and faster thrombolysis but did not improve EVT treatment times. This analysis will be repeated once follow-up is completed in 7 months.

Timed Up and Go test predicts one-year mortality among patients cardiovascular events after percutaneous coronary intervention Nadeem A. Khan, R. Jay Widmer, Amrit Kanwar, Mohammed A. Al-Hijji, Abdallah El Sabbagh, Ryan J. Lennon, Rajiv Gulati, Amir Lerman, Arashk Motiei, Mandeep Singh Background: Frailty is frequently seen in older adults and among patients with cardiovascular disease (CVD). Timed Up and Go Test (TUG) is a reliable and validated measure of frailty. We aim to assess 1-year mortality and stratify patients based on the performance on the test. Methods: Patients ≥55 years and referred to the cardiac catheterization laboratory underwent the TUG, a simple test to measure static and dynamic balance. We timed the patients while they were instructed to rise from the chair, walk 3 meters (or 10 feet), turn around, and walk back to the chair and sit down. Timing was divided in four categories [<7 sec (controls), 8-10 sec, 11-14 sec, and > 15 sec]. Mortality at one year was evaluated using a Cox proportional hazards model. Results: Those with TUG >15s were older (75.8 ±9.1years vs. 71.2±9.2 years in controls; P<0.001) and more women (42% vs. 29%) had TUG >15s, P=0.002. Patients with TUG >15 s had a significantly increased risk of mortality on follow-up (HR 3.88, 95% CI 1.97-7.66; P<0.001, Figure) which remained significant after adjusting for age and sex (HR 1.86, 95% CI 1.05, 3.30). Conclusions: The TUG test predicts one year mortality among patients referred to the cardiac catheterization laboratory. These data underscore the importance of frailty assessment in patients with CVD.