Abstract
BackgroundStroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. While door-to-needle time in hospital has been optimized for many years, little is known about the ambulance on-scene time (OST). OST has been reported to account for 44% of total alarm-to-door time, thereby being a major time component. We aimed to analyse ambulance OST in stroke patients eligible for thrombolysis and identify potential areas of time optimization.MethodsA study-specific registration form was developed to record detailed information about OST consumption in cases where the Emergency Medical Services (EMS) suspected a stroke from July 2014–May 2015. Registration forms were completed by ambulance personnel and included details on estimated time spent: 1) localising patient, 2) clinical examination, 3) consulting with the on-call neurologist, 4) mobilising patient to the ambulance, 5) treatment in ambulance before departure. Additionally, estimated total OST was noted. For patients found eligible for further evaluation at a stroke centre, time points were analysed using multivariate Poisson regressions.ResultsA total of 520 cases were included. The median OST was 21 min (Interquartile Range (IQR) 16–27). Time consumption was significantly lower (17 vs 21 min, p = 0.0015) when electrocardiography (ECG) was obtained in-hospital instead of on-scene, when intravenous (IV) access was established during transportation instead of before transportation (17 vs 21 min, p < 0.0001), and when the quality of communication with the stroke centres was rated as “good” as opposed to “acceptable/poor” (21 vs 23 min, p = 0.014). Neither the presence of relatives nor ambulance trainees had a significant effect on OST.ConclusionsIn-hospital ECG recording and IV cannulation during transport were found to reduce OST, while “acceptable/poor” communication was found to prolong OST relative to “good” communication. These components of pre-hospital stroke management represent potential opportunities for lowering OST with relatively simple changes, which could ultimately lead to earlier treatment and better patient outcome.Trial registrationUnique identifier: NCT02191514.
Highlights
Stroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes
After the removal of duplicates, incomplete forms, and patients who were not considered eligible for further evaluation at a stroke centre, 520 registration forms were included for analysis (Fig. 2)
Total on-scene time We found in-hospital ECG to significantly reduce total OST compared with ECG obtained on-scene
Summary
Stroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. For haemorrhagic strokes direct treatment of the underlying cause is often not readily available in contrast to ischemic strokes It is well-known that time is of the essence in ischemic stroke as the ischemic insult can progress to rapid and irreversible brain damage [4]. Treatment of ischemic stroke aims to preserve tissue in the ischemic penumbra, by restoring blood flow to the affected areas This is often accomplished through the administration of intravenous (IV) recombinant tissue-type plasminogen activator (rtPA), which must be initiated as early as possible, but within 4.5 h of symptom onset in order to maximize its effect while minimizing the risk of haemorrhage [5]. This is 4.5 h time frame is followed in recommendations in both American and Danish guidelines [3, 6]
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