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Measured In Minutes

Battling to reduce their on-scene time when attending to stroke, Madrid’s SUMMA 112 undertook research about the impact of prenotification management in their complex city. The results yielded insights about old problems – and suggested new solutions.
Angels team 04 September 2023
The Air ambulance team SUMMA 112. From left, Adela Muñoz, Antonio Castñé, Lucía Benavent and Nico Riera.

BORN of the need to introduce quality monitoring into prehospital stroke care, the EMS Angels Awards were always about more than celebrating good performance. Important as it was to recognise EMS teams that excelled in stroke care, the awards were also intended to be a tool for improving performance by highlighting weaknesses that could be addressed through targeted actions.

“The awards are not about past work but about future performance,” said Petr Jaššo, EMS chief in the Czech Republic’s Moravian Silesian region, ahead of the inaugural awards in Lisbon in October 2021. Their impact, he predicted, would be “measured in minutes”.

Future performance was on emergency physician Dr Nicolas Riera’s mind in Lisbon where he collected an award on behalf of Madrid’s medical emergency service SUMMA 112. The Covid pandemic had taken a heavy toll on frontline medics in his city and the gold award would go some way towards restoring morale.

But winning gold also signalled there was room to improve, and the awards criteria held the key to where they should focus their attention. SUMMA 112 had delivered a near impeccable performance in every category but one. To reach platinum or diamond status, it would be necessary to reduce their on-scene time (OST), which meant overcoming among others the challenge of vertical urban design in the tall, densely populated Spanish capital.

In 2022, the SUMA 112 team scored 100% for prenotification (identifying and prenotifying the right hospital) for the second year running. They had also shaved 4,5 minutes off their OST, but it was still almost twice as long as the maximum 15 minutes recommended by international guidelines. When they received another gold award in Berlin that October, they began to consider why, besides Madrid’s large number of high-rise residential apartments, their efforts to improve were having such a muted effect.

A meeting to analyse their performance raised the possibility that managing prenotification was adding a significant number of minutes to the time between on-scene arrival and departure. To test this hypothesis, they analysed the hospital prenotification process for all cases where stroke code was activated during December 2022, a month during which the median OST was 22 minutes.

The analysis (the results of which are being presented as a poster at EUSEM 2023) showed that the median prenotification management time (PMT) was 8 minutes when, as in most cases, only one call to a hospital was made, and reached 16 minutes when calls had to be made to four hospitals. Overall the median PMT was 9 minutes, accounting for almost 45 percent of OST. The researchers concluded that efforts to reduce OST would entail changes to the hospital prenotification protocol.

Angels consultant Alicia Arjona explains that a location-specific set of conditions impacts prenotification management in Madrid. The EMS service uses a unique prehospital scale, the Madrid-Direct Referral to Endovascular Centre (M-DIRECT), which is highly accurate in identifying thrombectomy candidates for direct transfer to thrombectomy-capable centres. Unlike in most Spanish cities, mechanical thrombectomy is available at 10 hospitals in the capital, but the duty to treat patients with thrombectomy is rotated among these hospitals on a previously agreed schedule. A hospital on the schedule may however decline to accept a patient if they have reached their capacity. This accounts for the worst- case scenario where, before they can depart the scene, the EMS have to make up to four calls to locate a hospital that will accept their patient.

Dr. Alicia Villar, Medical Subdirector SUMMA 112 and Dr. Manuel Guiote (General Manager SUMMA 112)

SERVING as a checklist for providers of pre-hospital stroke care, the EMS Angels Awards have helped EMS teams across Europe identify and act on opportunities for intervention and improvement. Their efforts have not gone unrecognised: from nine awards in 2021, there are 63 this year, including 19 for Spain.

Although SUMMA 112 will collect their first platinum award, they attribute this to a chance occurrence: the difficulties underlying on-scene delays as confirmed by their research, have yet to be addressed.

But a problem well-defined is a problem half-solved, at least according to Albert Einstein. In all participating countries the awards have done more than pinpoint weaknesses: they have changed the conversation around prehospital stroke care, and trained a light on systemic problems that have long been left in the dark.

They have also suggested new solutions to old problems.

The analysis of the audio files for December 2022 revealed problems that won’t be solved by revision of the hospital prenotification protocol alone. Minutes were being lost to inefficient interactions between hospitals and EMS, particularly where these conversations were drawn out as the result of time-wasting questions arising from a lack of trust.

One important insight was that they were conducting advanced prenotification with the tools of the last century. In the offing is a digitalised process that will eliminate human error or bias, and which could provide realtime information about the capacity of thrombectomy centres on the schedule. A digital process in other words that will be equal both to the complexity of Madrid’s stroke network and to the sophistication of diagnostic tools like M-DIRECT.

Whether SUMMA 112 will finally be among the diamond winners at EUSEM 2024 matters less than the prospect that stroke patients in their city will reach the right hospitals faster. Their PMT-related interventions are, like the EMS Angels Awards, aimed at preserving life. And as Petr Jaššo suggested, when it comes to stroke, life is measured in minutes.


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