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Legal Exposure if EMS Are Noncompliant with Stroke Guidelines

If clinicians miss a stroke diagnosis or delay care for that condition, plaintiff attorneys are going to scrutinize everything ED providers could have done differently. However, whatever problems there are or were all could have started well before the patient arrived at the facility. In fact, most patients receive prehospital stroke care from EMS that is noncompliant with American Stroke Association (ASA) guidelines.1

“The focus tends to be on treatments once a patient is diagnosed with a stroke and admitted to a stroke team. We neglect to account for the potential impact that a prehospital and ED provider can have,” says Layne Dylla, MD, PhD, assistant professor in the department of emergency medicine at University of Colorado School of Medicine.

EMS crews care for critically ill patients without the benefit of diagnostic imaging and labs that are available in the ED. Regardless, EMS still must provide critical information to ED clinicians and neurologists, such as “last time normal.” That information can mean the difference in a patient receiving tPA upon arrival at the ED. “EMS are instrumental in the chain of survival for stroke,” Dylla says.

Dylla and colleagues were curious about nationwide EMS practices for suspected stroke. Using the 2019-2020 National Emergency Medical Services Information System database, they analyzed 693,177 EMS encounters with a primary impression of stroke. The authors assessed compliance with eight metrics for “guideline-concordant” care. Compliance ranged from 18% (for providing supplemental oxygen to patients whose pulse oximetry was less than 94%) to 76% (for dispatching EMS in less than 90 seconds from the incoming call). Notably, almost none of the EMS encounters (0.39%) were fully compliant with the ASA guidelines. “This points to how difficult their job is and the limited training EMS may receive with regard to advances in stroke,” Dylla says.

EMS providers are taught to prioritize airway, breathing, and circulation; only then do they address other conditions, such as neurological changes. “ED clinicians have a role in educating EMS crews about guidelines and working as a team to ensure that key interventions occur in the prehospital setting,” Dylla says.

Dylla suggests administrators improve their operations by looking closer at other metrics that indicated low compliance with ASA guidelines. Only 24% of EMS prenotified receiving hospitals about the stroke patient’s arrival. Only 22% of EMS administered a 12-lead ECG. Also, 18% of EMS administered oxygen only to hypoxic patients.

“This may mean a significant practice change for some providers who have been practicing longer. Many were previously told that supplemental oxygen was harmless and potentially beneficial in stroke,” Dylla explains.

When the patient arrives, the burden quickly shifts to ED clinicians, who need to immediately obtain vital information that was missed in the prehospital setting (e.g., the “last known well” time). Clinicians also must obtain blood glucose if EMS did not and wean patients off supplemental oxygen as soon as possible. All these components of stroke evaluation, if not handled by EMS, can delay time-sensitive interventions, such as tPA, once the patient arrives at the facility.

“The emphasis should be on the team dynamics, with full realization that the EMS providers can make a significant impact on patients, even influencing the care and potential interventions that a patient receives after they part with EMS,” Dylla says.

Where the EMS transport the suspected stroke patient is another medical/legal concern. If EMS transport this patient to the wrong ED, it might necessitate transfer to a higher-level facility. That additional delay could put a patient outside the treatment window for tPA or other life-saving interventions. “EMS delays, as well as noncompliance with EMS treatment guidelines on destination decisions, can have serious risk management implications. If a stroke center is available, a suspected stroke patient should be transported there without delay,” says W. Ann Maggiore, JD, a practicing paramedic and an attorney at Butt Thornton & Baehr in Albuquerque, NM.

Delays in offloading patients (“ambulance parking”) also are problematic. “It backs up the EMS system when ambulances are waiting in the ED parking lot to unload when there are emergency calls holding,” Maggiore explains.

If a bad outcome happens and someone sues, the first question is going to be, “Who is legally responsible for the delay?” It could be EMS, ED providers, the hospital, or all three. “Delay in patient care implicates all aspects of the EMS system, from dispatch to patient destination. Any entity bearing a portion of the responsibility for the delay in care is potentially a target in a lawsuit,” Maggiore warns.

Some attorneys prefer to name multiple defendants, creating the chance for collecting damages from deep pockets. “But others realize that each defendant brings another defense attorney — and we do tend to gang up on them,” Maggiore notes.

The defendant with the deepest pocket also depends on the individual situation, particularly with respect to tort reform placing caps on damages that can be awarded. “In general, government EMS agencies, such as fire departments, are under a ‘cap,’ which may make them less attractive to sue,” Maggiore observes.

If it is unclear who is responsible for a delay in stroke care, the ED and EMS probably would be named. This prevents a situation known as the “empty chair.” In such cases, explains Maggiore, “when there is a responsible party who has not been sued, the defendants in the lawsuit will point there.” It is tempting for multiple defendants to place blame on the others. Plaintiff attorneys elicit that kind of finger-pointing with deposition questions such as, “Who is responsible for getting a blood glucose level?” to induce one defendant to admit their own responsibility or lay it on another defendant. “ED providers might also be asked what they ‘expected’ of EMS,” Maggiore says.

For example, plaintiff attorneys might ask, “Would you have expected EMS to provide you with that information?” or “Does EMS generally provide you with that information?”

The strongest defense is a unified approach. Ideally, each defendant “stays in their lane” and emphasizes he or she did the best they could do with the available resources. Naming multiple defendants and eliciting finger-pointing between the emergency physician and EMS is a strategy to raise the value of the case. “The defendants who incriminate each other — the more the price of settlement increases, not to mention ill will among the defendants, who will continue to work together in the medical system,” Maggiore says.


  1. Dylla L, Rice JD, Poisson SN, et al. Analysis of stroke care among 2019-2020 national emergency medical services information system encounters. J Stroke Cerebrovasc Dis 2022;31:106278.