Papers by Michael Redlener
Stroke, Feb 1, 2023
Introduction: There has been a shift in prehospital systems of care to prioritize transporting ac... more Introduction: There has been a shift in prehospital systems of care to prioritize transporting acute ischemic stroke (AIS) patients with suspected emergent large vessel occlusion (ELVO) stroke to thrombectomy capable stroke centers (TSCs), as opposed to primary stroke centers (PSCs) which may be closer and offer intravenous thrombolysis faster. Large scale data on clinical outcomes in direct triage are lacking. Methods: We conducted a systematic review and meta-analysis using PRISMA guidelines with the Nested Knowledge AutoLit platform to search PubMed for relevant terms from 01/2015 to 05/2022. Our primary endpoint was proportion of patients with a good clinical outcome [modified Rankin Score (mRS) 0-2] at 90 days. Results: We identified 390 studies, 16 of which compared direct triage to various models and were included. Amongst these, Mobile Stroke Unit (MSU; n=1), Mothership only (n=1), Drip-and-Ship only (n=3), and Mothership + Drip-and-Ship (n=11) were compared to Direct Triage. Among the eleven that reported 90-day functional status outcomes, there were no discernible trends. Four studies that compared 90-day functional outcomes amongst patients who received EVT and compared Direct Triage to Drip-and-Ship + Mothership models were analyzed. Baseline age, sex, and presenting NIHSS were similar. Patients who underwent Direct Triage were more likely to have a good outcome (mRS 0-2) at 90-days (OR 1.35, 95% CI 1.03-1.76). Conclusions: Amongst patients who received EVT, patients who underwent Direct Triage were more likely to have better functional outcomes at 90 days. Direct Triage of AIS patients is a promising strategy to improve clinical outcomes in patients who undergo EVT. More research is needed in patients who do not receive EVT.
Journal of the American College of Cardiology, Mar 1, 2023
Annals of Emergency Medicine, Oct 1, 2020
Elongator protein 3 (ELP3) acetylates histones in the nucleus but also plays a role in the cytopl... more Elongator protein 3 (ELP3) acetylates histones in the nucleus but also plays a role in the cytoplasm. Here, we report that in Drosophila neurons, ELP3 is necessary and sufficient to acetylate the ELKS family member Bruchpilot, an integral component of the presynaptic density where neurotransmitters are released. We find that in elp3 mutants, presynaptic densities assemble normally, but they show morphological defects such that their cytoplasmic extensions cover a larger area, resulting in increased vesicle tethering as well as a more proficient neurotransmitter release. We propose a model where ELP3dependent acetylation of Bruchpilot at synapses regulates the structure of individual presynaptic densities and neurotransmitter release efficiency. Neuron ELP3 Acetylates BRP
Annals of Emergency Medicine, Oct 1, 2015
Journal of the American College of Cardiology
Stroke
Introduction: There has been a shift in prehospital systems of care to prioritize transporting ac... more Introduction: There has been a shift in prehospital systems of care to prioritize transporting acute ischemic stroke (AIS) patients with suspected emergent large vessel occlusion (ELVO) stroke to thrombectomy capable stroke centers (TSCs), as opposed to primary stroke centers (PSCs) which may be closer and offer intravenous thrombolysis faster. Large scale data on clinical outcomes in direct triage are lacking. Methods: We conducted a systematic review and meta-analysis using PRISMA guidelines with the Nested Knowledge AutoLit platform to search PubMed for relevant terms from 01/2015 to 05/2022. Our primary endpoint was proportion of patients with a good clinical outcome [modified Rankin Score (mRS) 0-2] at 90 days. Results: We identified 390 studies, 16 of which compared direct triage to various models and were included. Amongst these, Mobile Stroke Unit (MSU; n=1), Mothership only (n=1), Drip-and-Ship only (n=3), and Mothership + Drip-and-Ship (n=11) were compared to Direct Triage...
Annals of Emergency Medicine, 2020
Elongator protein 3 (ELP3) acetylates histones in the nucleus but also plays a role in the cytopl... more Elongator protein 3 (ELP3) acetylates histones in the nucleus but also plays a role in the cytoplasm. Here, we report that in Drosophila neurons, ELP3 is necessary and sufficient to acetylate the ELKS family member Bruchpilot, an integral component of the presynaptic density where neurotransmitters are released. We find that in elp3 mutants, presynaptic densities assemble normally, but they show morphological defects such that their cytoplasmic extensions cover a larger area, resulting in increased vesicle tethering as well as a more proficient neurotransmitter release. We propose a model where ELP3dependent acetylation of Bruchpilot at synapses regulates the structure of individual presynaptic densities and neurotransmitter release efficiency. Neuron ELP3 Acetylates BRP
Annals of Emergency Medicine, 2015
Disaster Medicine and Public Health Preparedness
Objective: The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an... more Objective: The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an unprecedented response. The US military deployed active-duty medical professionals and equipment to NYC in a first of its kind response to a “medical” domestic disaster. Transitions of care for patients surfaced as a key challenge. Uniformed Services University and the Icahn School of Medicine at Mount Sinai hosted a consensus conference of civilian and military healthcare professionals to identify care transition best practices for future military-civilian responses. Methods: We performed individual interviews followed by a modified Delphi technique during a two-day virtual conference. Patient transitions of care emerged as a key theme from pre-conference interviews. Twelve participants attended the two-day virtual conference and generated best practice recommendations from an iterative process. Results: Participants identified 19 recommendations in 10 “sub-themes” related to patient t...
Stroke: Vascular and Interventional Neurology
BACKGROUND New York City Emergency Medical Services implemented a prehospital triage protocol usi... more BACKGROUND New York City Emergency Medical Services implemented a prehospital triage protocol using a modified Speech–Los Angeles Motor Scale to identify patients with large‐vessel occlusion. Patients with Speech–Los Angeles Motor Scale ≥4 and last known well within 5 hours were routed to the nearest thrombectomy‐capable stroke center. Our aim was to describe the Speech–Los Angeles Motor Scale Triage Positive (STP) cohort and compare to a cohort that ultimately underwent endovascular thrombectomy (EVT) but were missed by the protocol (not triaged as Speech–Los Angeles Motor Scale positive [NSTP]). METHODS A prospectively collected database identified patients arriving within 5 hours from last known well between April 2019 and March 2020. STP patients (N=145) were assessed for medical history, acute stroke time metrics, and clinical accuracy. NSTP (N=65) was subdivided into those who arrived directly to a thrombectomy‐capable stroke center (direct NSTP, N=30), and those transferred t...
Despite studies suggesting that 15% of patients treated by Emergency Medical Services (EMS) can b... more Despite studies suggesting that 15% of patients treated by Emergency Medical Services (EMS) can be effectively managed at alternate destinations, most patients continue to be transported to an Emergency Department (ED). As reliable triage algorithms are lacking, we studied and iterated upon a locally developed protocol to help identify EMS patients that might be appropriate to receive care in an urgent care center (UCC). Eligible patients were those that arrived by 911 EMS and were triaged with an Emergency Severity Index (ESI) of 4 (less urgent) or 5 (nonurgent) from July to August of 2014. Prehospital data was used to determine if patients met protocol selection criteria. In-hospital data such as ED disposition, use of advanced diagnostics and interventions was also gathered. Three independent, blinded physicians determined if cases were appropriate for treatment at an UCC. In this retrospective cohort analysis of 273 low acuity ED patients, 121 (44.32%) patients met protocol sel...
Journal of Stroke
Systems of care for emergent large vessel occlusion (ELVO) stroke patients have evolved from a so... more Systems of care for emergent large vessel occlusion (ELVO) stroke patients have evolved from a sole focus on intravenous thrombolysis (IVT) to also incorporate timely access to endovascular thrombectomy (EVT). 1,2 Prehospital Emergency Medical Services (EMS) triage has historically transported these patients to the closest stroke center for IVT, regardless of stroke center classification, with a subsequent transfer if the initial facility was not a Thrombectomy Capable Stroke Center (TSC). Triage of ELVO stroke patients directly to TSCs, possibly bypassing primary stroke centers (PSCs), has been modeled to improve treatment times and access to EVT. 3 These protocols have led to higher rates of EVT, improved time to EVT without delays to IVT, and potentially less disability at 3 months. 4-6 Our objective is to determine whether an updated New York City (NYC) EMS Acute Stroke Triage Protocol reduced the proportion of ELVO stroke patients requiring interfacility transfers and time to EVT. This is a retrospective observational study using prospectively collected data (IRB-20-03285) at our health system (Mount Sinai Health System, New York, NY, USA), which consists of six emergency departments with three additional covered through affiliate agreements. Written informed consent by the patients was waived due to the retrospective nature of our study. Of these nine hospitals, four were TSCs (Supplementary Figure 1). These four TSCs are a subset of the 22 total TSCs across NYC participating in the updated NYC EMS Acute Stroke Triage Pro
Stroke, 2021
Introduction: On April 1 2019, New York City EMS began a triage protocol using a modified Los Ang... more Introduction: On April 1 2019, New York City EMS began a triage protocol using a modified Los Angeles Motor Scale (S-LAMS for addition of speech) to identify potential endovascular thrombectomy (EVT) eligible patients in the field (S-LAMS 4-6 with last known well (LKW) <5 hours). These patients are routed to the nearest thrombectomy capable center, driving past potentially closer primary stroke centers. Methods: Patients brought by EMS to a large multicenter health system across NYC for the year following April 1, 2019 were extracted from a prospectively collected stroke database. S-LAMS triage positive (STP) patients were assessed for diagnostic accuracy and treatment times. They were compared with a cohort that underwent EVT during the same period, but triaged as S-LAMS triage negative (STN). Results: STP patients (N=145) were 56.6% women, mean age of 70, median baseline mRS of 0, S-LAMS score of 5, and arrival NIHSS of 13. Stroke was diagnosed in 110 (75.8%) patients, 32 intra...
Prehospital Emergency Care, 2022
Abstract Prehospital airway management encompasses a multitude of complex decision-making process... more Abstract Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care. It is the position of NAEMSP that: All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director. Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur. Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions. EMS systems should regularly measure and report process, outcome, and balancing airway management measures. Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians. Findings from quality management programs should be used to guide and develop initial education and continued training. Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
Circulation, 2019
Introduction: Since 2007, the American Heart Association Mission: Lifeline program has provided a... more Introduction: Since 2007, the American Heart Association Mission: Lifeline program has provided a framework for development of systems of care for ST-elevation myocardial infarct (STEMI) patients. ...
Journal of the American College of Cardiology, 2021
Annals of Emergency Medicine, 2021
MedEdPORTAL, 2021
Introduction: Emergency medicine resident physicians are required to complete observational ride-... more Introduction: Emergency medicine resident physicians are required to complete observational ride-alongs with emergency medical services (EMS) units as part of their curriculum as per the ACGME. We created this curriculum to expose emergency medicine residents to the equipment they will encounter in the prehospital setting, discuss basic EMS operations and the challenges of working in the prehospital environment, and review the limitations that restrict care provided by EMS professionals. Methods: We created a series of five simulation cases for resident physicians participating in an EMS ride-along rotation. Each case was implemented with three to four residents at a time. A critical action checklist was used to assess participants during the scenarios. Following each simulation, a debriefing was conducted to discuss EMS operations and the impact on providers. At the conclusion of the session, participants completed a course evaluation survey. Results: Thirteen emergency medicine resident physicians took part in this curriculum from October 2020 through January 2021. Results indicated that the participants gained insight into the prehospital environment, felt more prepared to complete their ride-alongs, and were engaged and satisfied with the introduction to EMS program. Discussion: Simulation allowed emergency medicine residents to be exposed to the complex nature of prehospital care and prepared them for their ride-along sessions. The five cases provided significant breadth and depth of potential prehospital care issues, and the residents were able to discuss the medical, policy, and operational challenges presented as part of each case.
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Papers by Michael Redlener