Emergency medical services in stroke care: a Rhode Island perspective.

retains a physician medical consultant to oversee clinical aspects of the system including the Rhode Island Prehospital Care Protocols and Standing Orders. The most unique characteristic of Rhode Island emergency medical services is the absence of a mandate requiring individual agencies to have a medical director. While the most visible component of the system is the nearly 400 licensed ambulances that are positioned in local communities, the State is comprised of 95 separate EMS agencies. The fire service makes up the majority of the EMS service in Rhode Island followed by third party municipal and commercial agencies. The volume and variety of agencies creates a complexity as we look at stroke care because each service has different resources, motivations, education, and experience. In addition to the breakdown of agency type, we must also analyze the type of provider functioning within the agencies. Currently, there are 4200 licensed EMS personnel in the State, broken down into the following categories: emergency medical technician (EMT)-Basic, EMT-Cardiac, and EMTParamedic. Predominately, the prehospital provider is the EMT-Cardiac, which is a provider level unique to Rhode Island. There are also 91 licensed EMTinstructor/coordinators. PrehosPItAl cAre stroke Protocol The current prehospital stroke care protocol was developed in December of 2002, prior to the recognition of the importance of EMS in stroke care. Ironically, it was not just hospitals that did not realize the importance of EMS; prehospital providers themselves did not realize that their care had such a profound affect on stroke patient outcomes. The Cincinnati Prehospital Stroke Scale is used as an assessment tool in addition to recognition criteria of monocular blindness, vertigo, or ataxia, without impaired consciousness. In patients who are impaired, providers are referred to the Impaired Consciousness Protocol. Current treatment protocols include: determination of when the patient was last known without symptoms, withholding the administration of oral medications, and administration of oxygen at the highest concentration tolerated. The protocol directs the use of the prehospital stroke scale to determine the treatment priority yet there is no reference to transport the stroke patient to a primary stroke center. The protocol is a good foundation but must be updated and reorganized to reflect current recommendations for prehospital stroke care and the provisions of the Stroke Prevention and Treatment Act of 2009.9  ADvAnces over the PAst DecADe In Acute stroke care, including the introduction of fibrinolytic and other short-term therapies, have highlighted the critical role of emergency medical services (EMS) agencies in optimizing stroke care. Statistics show 29-65% of all stroke patients are treated by EMS. In order to ensure the greatest outcomes for stroke patients, EMS must be considered an integral part of the stroke care system. The goal of prehospital care must be to deliver the greatest number of stroke patients to a primary stroke center within established timelines to provide for the best outcomes.