Massachusetts Updates Stroke Triage Protocol to Severity-Based Standard

Massachusetts is the latest state to revamp its EMS stroke triage protocol to a severity-based model. Under this model, stroke victims who seem likely to need thrombectomies may be directed to the nearest medical center capable of administering them, rather than the center closest to the responding ambulance.

During a thrombectomy procedure, an incision is made into the victim’s leg or wrist to access an artery. The doctor then inserts a catheter into the artery and uses a tiny tool within the catheter to reach the clot within the brain and take it out.

The reason fast access to thrombectomies matters is because nearly two million brain cells die within a severe stroke victim’s brain every minute that their stroke goes untreated.

This is why moving to a severity-based stroke triage protocol is “a big win for stroke patients in Massachusetts,” said Dr. Mahesh Jayaraman, an interventional neuroradiologist at Rhode Island Hospital and president of the Society of NeuroInterventional Surgery (SNIS). “This will significantly improve their odds of surviving a severe stroke.”

The Impact of Severity-Based Stroke Triage

According to Dr. Jayaraman, the State of Rhode Island moved to a severity-based stroke triage protocol in 2015. The improvement in patient treatment times between then and 2020 has been impressive.

“What we found in Rhode Island is — when we adjust for distance to the nearest designated medical center — severe stroke patients spend an average of an extra eight minutes in the ambulance under the severity-based stroke protocol,” he said. “At the same time, this change in destination resulted in nearly an hour reduction in time to the start of the thrombectomy procedure, which is very significant. It's about a 40% reduction in time to treatment. In contrast, in Massachusetts, there was literally zero minute improvement in time to treatment from 2015 to 2020. As a result, the stroke patients that were in Rhode Island had better outcomes than similar patients in Massachusetts.”

Implementing this new protocol in Massachusetts will not be instantaneous.

“What this 2024 State Budget that passed this measure does is to direct the Massachusetts Department of Public Health to appoint a task force of subject matter experts,” said Dr. Jayaraman. “They will then work with EMS providers to determine what the most appropriate stroke triage protocol for each region of the state looks like. For instance, the right version of the protocol for Metro Boston may look different from rural western Massachusetts, but that’s okay. The concept is to identify what is right for the local region and then implement that severity-based triage protocol.”

State Budget Impacts on New Protocol

Dr. Jayaraman’s only concern is the tight deadline imposed by the 2024 state budget, which was passed on July 31, 2023.

“The legislation says that we have 180 days to develop the protocol, and I suspect there may be a phased implementation,” he said. “I think it is unreasonable to expect EMS to flip a switch and instantly go to this. It may be a situation where, as we did in Rhode Island, it was optional for a period of time and then mandatory. Or it may be something else. We will have to wait and see.” 

However this plays out, Dr. Jayaraman is delighted to see Massachusetts adopt the severity-based stroke triage protocol. “Rhode Island actually was the first state to implement this concept back in 2016,” he said. “Over the course of seven years, we've gone from one state having a severity-based stroke triage protocol to nearly 40 states having some form of either total state or regional severity-based stroke protocol. So, we've really reached a tipping point, and this is really exciting because this will really impact patients' lives and, save patients from long-term disability.”