Background: Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often charac-terized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS techni-cians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. Methods: Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in per-son and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. Results: Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P< .001. Conclusions: EMS techni-cians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

April 23, 2018April 10, 2018Free AccessSafety and Feasibility of Telestroke in the Prehospital Emergency Medical Services Setting – The REACHOUT Project (P2.251)Muhammad Adeel Saleemi, Chris Hackett, Rahul Rahangdale, Ashis Tayal, Sandeep Rana, Robert Fishman, Jack Protetch, David Wright, Eric Schmidt, and Rebekah PrattAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement)https://doi.org/10.1212/WNL.90.15_supplement.P2.251 Letters to the Editor

April 22, 2018April 10, 2018Free AccessRapid Arterial Occlusion Evaluation Score Agreement Between Emergency Medical Services Providers and Stroke Specialized Neurologists (P1.211)Rahul Rahangdale, M.D., M. Adeel Saleemi, M.D., Christopher Hackett, M.A., Jack Protetch, Sandeep Rana, M.D., David Wright, M.D., Robert Fishman, M.D., and Ashis Tayal, M.D.Authors Info & AffiliationsApril 10, 2018 issue90 (15_supplement)https://doi.org/10.1212/WNL.90.15_supplement.P1.211 Letters to the Editor

Introduction: Implementation of telestroke in community hospitals and primary stroke centers has resulted in reduced door to needle times. Mobile stroke units equipped with CT scanners, also utilizing telestroke have demonstrated a further reduction in door to needle times. Despite the benefits of mobile stroke units, the cost of producing and maintaining these units may be a limiting factor in system-wide adoption of the concept. There is little data examining continuous telestroke support provided by neurologists in the EMS setting. We tested this lower-cost alternative, by providing 24/7 telestroke access to two local EMS providers. We hypothesized that telestroke in the EMS setting would be safe, feasible and reduce door to needle times. Methods: Stroke-specialized neurologists provided continuous (24/7) video-based telestroke access to two local EMS agencies from December 2015 through May 2017 as part of the REACHOUT project. Data were prospectively collected and retrospectively analyzed. Intravenous (IV) tPA door to needle times were compared between patients who were assessed via EMS telestroke to patients assessed by hospital based telestroke in one of the nine hospitals within our telestroke network, during the same time period. Results: Fifty-eight telestroke requests were registered with 52 (89.7%) successful consultations during the study period. The initial telestroke impression in 42/52 (80.8%) cases was a possible acute stroke or TIA. There were 142 patients treated with IV tPA via hospital based telestroke encounters and 4 patients were treated with IV tPA after being evaluated via EMS telestroke. A comparison of door to needle times suggested shorter door to needle times in the EMS telestroke group (mean rank 12.8; median 39.5 min) compared to the hospital based telestroke group (mean rank 74.2; median 65.5 min), U = 41, p = .004, r = .24. Conclusions: Despite isolated connectivity issues, we found EMS based telestroke encounters to be safe and feasible. Pre-hospital evaluation of patients by a stroke-specialized neurologist provided a comprehensive clinical picture to emergency department physicians upon arrival to the hospital. Reduced door to needle times were reported in EMS based telestroke compared to hospital based telestroke.

Introduction: Recent data from the Get with the Guidelines (GWTG-Stroke) registry showed improved in-hospital outcomes in relation to shorter onset-to-treatment (OTT) time. The effect size of OTT time on in-hospital outcomes is presumed to be clinically significant.Hypothesis: We hypothesize that the effect of OTT on in-hospital clinical and radiographic outcomes could be demonstrated in a single center cohort.Methods: We reviewed 368 consecutive acute ischemic stroke patients treated with IV tPA ≤ 4.5 hours from onset (2006-2013). Patients were identified in an acute stroke data registry, maintained independently of the GWTG-Stroke registry. Patients who underwent treatment by telemedicine/telephone decision support and endovascular therapy were excluded. Patient demographics and clinical variables including initial NIHSS, OTT time, DTN time, mortality, discharge disposition, parenchymal hematomas (PH) types 1 and 2, and total anterior cerebral infarction (TACI) were collected. OTT time (continuous variable) was examined in relation to in-hospital outcome variables; 1) mortality, 2) discharge to home, 3) PH 1-2 and 4) TACI using multivariable logistic regressions.Results: Mean age was 71.5±14.5 years, median NIHSS was 12 (IQR, 6-17), mean DTN time was 72.3±30.6 minutes and mean OTT time was 148.4±42.9 minutes. In-hospital deaths were 75 (20.4%), discharges to home were 107 (29.1%), PH 1-2 were 23 (6.3%) and TACI were 61 (16.6%). OTT time was not associated with in-hospital mortality (adjusted odds ratio (OR), 1.01 [95%CI 1.00-1.02]; p=0.114), discharge to home (OR, 0.99 [95%CI 0.99-1.00]; p=0.070), PH-1/2 (OR, 1.01 [95%CI 1.00-1.02]; p=0.121) and TACI (OR, 1.00 [95%CI 1.00-1.01]; p=0.266). The number of patients needed to treat with IV tPA to demonstrate the effect of OTT time in one patient outcome would be; death (n=667), discharge home (n=700), PH 1-2 (n=542) and TACI (n=932).Conclusion: The impact of OTT time on clinical and radiographic in-hospital outcomes was not detectable with prolonged experience at a single center. Disclosure: Dr. Malhotra has nothing to disclose. Dr. Ramanathan has nothing to disclose. Dr. Hackett has nothing to disclose. Dr. Quigley has nothing to disclose. Dr. Tian has nothing to disclose. Dr. Protetch has nothing to disclose. Dr. Wong has nothing to disclose. Dr. Wright has nothing to disclose. Dr. Tayal has nothing to disclose.

Background: Reduced time to administration of intravenous thrombolysis for acute ischemic stroke (AIS) is associated with improved functional outcomes. Less than one-third of AIS patients receive IV rt-PA with a door-to-needle (DTN) ≤ 60 minutes with only modest improvements reported over time. We investigated factors that may adversely prolong DTN time including reduced resident physician experience, low stroke severity on presentation, patient presentation time (day, evening, night) and day of week. Methods: A consecutive series of 258 patients with AIS received IV rt-PA at an academic comprehensive stroke center with a developed process for IV rt-PA administration and a neurology training program. Patient presentation times in the emergency department were divided into shifts defined as 07:00-14:59 (day), 15:00-22:59 (evening) and 23:00-06:59 (night). Neurology resident experience level was grouped as July-December (less experienced) vs. January-June (more experienced). Day of the week was grouped into weekday (Monday-Friday) and weekend (Saturday-Sunday). Variables associated with DTN time were assessed by t-test, ANOVA and by logistic regression. Results: The group had a mean age of 70.7±14.3 years, NIHSS score 13.3±6.8, DTN time 70.0±28.1 minutes, onset to ED arrival time 77.5±38.0 minutes. Patients presenting during evening and night hours had prolonged DTN times, day=65.5, evening=71.8 and night=78.3 minutes (p=0.05) by ANOVA. Patients arriving on weekends also had prolonged DTN times weekdays= 66.6 vs. weekends=77.2 minutes (p=.01). Increased time from onset to ED arrival was also associated with reduced DTN time (p<0.001). Age, gender, race, stroke severity on presentation, and resident experience level were not related to DTN time. Both presentation time by shift and day of week were predictive of prolonged DTN time by multivariable analysis (p<0.01). Conclusions: Presentation time during the evening and night hours and weekends is associated with prolonged DTN times. Reduced staffing and support on nights and weekends may adversely affect DTN time.

Prolonged intensive care unit lengths of stay (ICU LOS) for critical illness can have acceptable mortality rates and quality of life despite significant costs. Only a few studies have specifically addressed prolonged ICU LOS after trauma. Our goals were to examine characteristics and outcomes of trauma patients with LOS ≥ 30 days, predictors of prolonged stay and mortality.

Carlton, Chad J. MD; Elan, Jeremitsky MD; Ong, Adrian W. MD; Kao, Amy H. MD, MPH; Protetch, Jack BS; Rodriguez, Aurelio MD, FACS Author Information

The objective of the study was to determine if negative multidetector computed tomography (MDCT) and lateral radiography of the cervical spine effectively excludes patients with unstable cervical spine injuries. Over a period of 40 months, 6558 people were admitted to our trauma service with blunt injury and 447 (6.8%) were found to have cervical fractures. Fractures were identified by CT and/or lateral radiography. In order to rule out clinically significant instability in the absence of fracture, we identified nine patients who required any type of stabilization of the cervical spine including anterior fusion, posterior fusion and external orthosis. These patients also underwent MR of the cervical spine. Radiography, CT, and MR images and reports of these nine patients were reviewed. Nine patients without a fracture required cervical stabilization. These patients had the following abnormalities: disc herniation with canal stenosis in three, unilateral jumped facet in three, and various other soft tissue abnormalities in three, all of which were evident on CT or radiography. All nine patients had evidence for cervical spine injury or instability by MDCT. Normal MDCT and radiography appears adequate to ‘clear’ the cervical spine. We recommend that patients requiring cervical spine clearance undergo a complete MDCT and lateral radiograph of the cervical spine. If these studies are entirely normal, then the cervical spine may be cleared. If any abnormalities, including disc herniation, soft tissue swelling and bony malalignments are noted by radiography and/or MDCT, further studies, including MR, are indicated prior to clearance of the cervical spine.

The process of developing, implementing, and refining a registry data validation system is integral to optimal trauma registry operations. Describing registrar skill and proficiency in a manner that was once subjective can be replaced with objective assessment through the use of concrete rating guidelines and examples. The ability to standardize the evaluation of each registry abstract becomes the foundation for analyzing the overall accuracy of registry data. Key to the process is incorporating the validation rating tool as part of the data abstract. If properly implemented, the methodology described becomes a practical means for accuracy reporting, peer benchmarking, orientation and training, and performance management.

Sekula, Raymond F. Jr M.D.; Quigley, Matthew R. M.D.; Daffner, Richard H. M.D.; Protetch, Jack B.A.; McCrady, Christine S. B.S.; Rodriguez, A M.D.

Goodman, Brian M. MD; Ong, Adrian MD, FACS; Omert, Laurel MD, FACS; Jeremitsky, Elan MD; Protetch, Jack BS; Rodriguez, Aurelio MD, FACS Author Information

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 ± 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.