New Jersey Adopts RACE Scale for EMS Stroke Detection

With a goal of faster detection of possible strokes and quicker care leading to better outcomes, the New Jersey Department of Health this summer adopted the Rapid Arterial Occlusion Evaluation (RACE) scale as the standardized stroke triage assessment tool for New Jersey EMS providers. Judith Persichilli, commissioner of the New Jersey Department of Health, issued an executive directive establishing the use of the scale as a result of legislation enacted in January 2020 to improve stroke care in the state.

New Jersey established a Stroke Advisory Panel under its Office of EMS, and the panel recommended the RACE scale for statewide adoption. Members used data from the American Heart Association’s “Get With The Guidelines–Stroke” (GWTG) program and the 76% of New Jersey hospitals that participate in it to arrive at their decision. GWTG is an “in-hospital program for improving stroke care by promoting consistent adherence to the latest scientific treatment guidelines,” according to the American Heart Association’s website.

According to 2018 GWTG data, New Jersey recorded 18,217 strokes, up from 15,835 in 2013. Nationally in 2018 there were 640,946 strokes recorded in the GWTG data.1 Approximately 51% of these patients in New Jersey (and 44% nationally) arrived at hospitals via EMS. Of these New Jersey patients, 12.1% received IV tPA therapy in hospitals, and 4.3% received catheter-based reperfusion. Further, in New Jersey in 2018, 40% of patients had tPA on board in under 45 minutes, which is slightly lower than the national average.

The American Heart Association set a target of achieving “door-to-needle” for tPA administration within 45 minutes for 75% or more of acute ischemic stroke patients. The New Jersey panel recommended the RACE scale be used universally by EMS to help achieve that goal. While research has shown no one stroke scale is superior to another, the panel selected the RACE scale based on “specificity, [the] scale agencies are currently using, and ease of adding [the] scale to current stroke identification processes.”2

The RACE scale looks at five signs and their level of severity. They include:

• Facial palsy: Can the patient show their teeth or smile?
• Arm motor function: If sitting, can the patient extend their arms to 90 degrees?
• Leg motor function: Can the patient separately raise their legs 30 degrees from the supine position?
• Head and gaze deviation: Can the patient look to the left and then to the right?
• Aphasia/agnosia: If right hemiparesis, ask the patient to close their eyes and make a fist with the left hand. If left hemiparesis, show the patient their left arm and ask, “Whose arm is this?” Next, ask the patient to move their arm and clap their hands.

Patients are given a score (see chart) based on responses. A score of 5 or more indicates a greater probability of a large vessel occlusion.

EMS considerations also include the time the patient was last seen at their normal baseline, proximity to a designated stroke center, and if the patient is hemodynamically stable. In New Jersey, once a potential stroke differential diagnosis is made based on the RACE scale, ALS modalities begin, transport is initiated (preferably to a designated stroke center), and a stroke team is activated via dispatch or medical control.

All New Jersey providers are provided training in the RACE scale via a free online continuing education program. Additionally, all New Jersey agencies are expected to incorporate RACE stroke assessments into their ePCRs.

References

1. American Heart Association. Get With the Guidelines Stroke, www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke.

2. Merlin M. State Stroke Systems of Care Updates: NJ Breakout Session. NorthEast Cerebrovascular Consortium, 2019, http://thenecc.org/wp-content/uploads/2019/11/NJ-Breakout-NECC-2019_v2.pdf.

Barry Bachenheimer, EdD, NREMT/FF, has been involved in EMS for over 35 years and is a frequent contributor to EMS World.