The Quality Encompassing Stroke Team (QuEST) Project: Defining Stroke Quality Care within the Inter-Hospital Setting for Air Medical Providers

Introduction

Emergency Medical Services (EMS) first integrated into the stroke notification system in the mid-90s by using 911 telephone triggers to respond to strokes as an acute emergency. EMS systems have different performance metrics compared to hospitals that define success and quality in caring for stroke patients. Examples of these metrics are documentation of a stroke scale, pre-arrival notification, and determining a blood glucose level. Primary Stroke Centers (PSC) were developed in 2004, and Comprehensive Stroke Centers (CSC) developed in 2012. To become a PSC or CSC, the American Heart Association/American Stroke Association and The Joint Commission have defined eligibility requirements and quality metrics to measure success and quality care. Despite established quality metrics for stroke centers, no clear recommendations or guidelines exist for quality metrics and comprehensive quality stroke care within the air medical industry.

Methods

A literature review was completed in PubMed with articles from 2012-2022 and included all countries, military, combat, and natural disasters. Retrieved articles surrounding stroke quality metrics focused on ground transport or in-hospital care. There are no published metrics that define quality stroke care in the inter-hospital setting for air medical providers. We completed a retrospective data analysis of stroke patient transfers from January 1, 2019 – June 2, 2023, excluding pediatric patients and ground transports. Metrics from pre-hospital and in-hospital care areas included blood glucose, last known well, FAST, LAMS, and bedside times.

Results

A sample size (n=2041) transported patients with hemorrhagic and ischemic strokes were evaluated. The volume of patients was equivocal year over year, and quarter over quarter. Bedside times were consistent; scene calls (10 mins) and interfacility transports (20 mins). Glucose documentation was compliant at 98.24%. FAST documentation was lacking at 45.56%, and LAMS documentation at 38.18%, revealing opportunities for education and quality improvement. Our KPIs address operational, educational, clinical and regulatory requirements allowing us to shift our focus to critical care metrics that promote better patient outcomes.

Conclusion

While some of the quality metrics from the pre-hospital and in-hospital areas can be applied to the inter-hospital space, they don’t take account for the unique HEMS environment. More research is required to establish formal recommendations that consider the complexities of the air medical transport. Our analysis reveals that documentation of pre-hospital quality metrics such as FAST and LAMS was less frequent. Until better evidenced based quality metrics are established, air medical programs should consider extrapolating pre-hospital and in-hospital metrics and tracking compliance.