Prehospital Stroke Management Research Articles

Telemedicine-Enabled Ambulances for Prehospital Acute Stroke Management: A Pilot Study

ObjectiveTo assess the feasibility and potential scalability of telemedicine-enabled ambulances for the prehospital evaluation of patients with suspected acute stroke symptoms. Patients and MethodsA pilot study of telemedicine-enabled ambulances for evaluating patients with suspected acute stroke symptoms en route at 2 tertiary academic comprehensive stroke centers from January 1, 2018, to February 5, 2024. Charts of included patients were reviewed for demographic data, vascular risk factors, final diagnosis, time from arrival to neuroimaging, door-to–needle and door-to-puncture times in patients eligible for acute treatment, and any reported technical challenges during audio-video consultations. ResultsForty-seven patients (mean age, 68.0 years; 62% men) were evaluated via telemedicine-enabled ambulances, of which 35 (74%) where for hospital-to-hospital transferred patients. Mean time from arrival to neuroimaging was 11.8 minutes. Twenty-nine patients (62%) were diagnosed with acute ischemic stroke, and the remainder were diagnosed with intracranial hemorrhage (n=13), seizure (n=2), brain mass (n=1), or other diagnoses (n=3). Four patients (9%) received intravenous thrombolysis with alteplase (mean door to needle, 30.3 minutes), and 15 patients (32%) underwent mechanical thrombectomy (mean door to puncture, 72 minutes). Technical challenges were reported in 15 of the 42 (36%) cases, of which 10 (67%) were related to poor internet connectivity. ConclusionTelemedicine-enabled ambulances in emergency medical services systems are novel, feasible, and potentially scalable options for evaluating patients with suspected acute stroke in the prehospital setting. However, optimization of infrastructure, staffing models, and internet connectivity is necessary, and larger studies evaluating the clinical and cost effectiveness of this approach are needed before widespread implementation.

Analysis of Dominant Factors Affecting Pre-Hospital Stroke Management in Kupang City

The incidence of stroke is increasing every year, and effective management comprises both pre-hospital and hospital care. The key to successful management is for families to recognise the clinical symptoms and promptly seek medical attention. Delayed assistance frequently leads to complications, underscoring the importance of timely intervention to save lives and prevent long-term disabilities. The key to successful management is identifying a stroke and prompt transportation to a medical facility. This study used a quantitative approach with a cross-sectional design, and the total sample was 300 people, while data analysis was performed using the Chi-Square test and logistic regression. The results showed that the family decision-making time in taking a stroke patient to the hospital, individually or collectively, significantly affected the Accuracy of Pre-Hospital Stroke Patient Management with a value of P (Sig) < 0.05. The magnitude of the influence was indicated by the value of EXP (B), also known as ODDS RATIO (OR). Specifically, the Decision-Making Time by the family to take stroke patients to the hospital exhibited an OR of 20.714. This implied that respondents capable of making the right decision to take stroke patients to the hospital were 20.714 times more likely to be accurate in pre-hospital stroke patient management. Based on the results, it can be concluded that the dominant factor influencing pre-hospital stroke attack management is the family decision-making time to take the stroke patient to the hospital. Therefore, the Kupang City government needs to improve ambulance facilities for the public, making it easier to access services, specifically in emergencies.

The Effect Of Integrated Emergency Management System Education In Stroke Emergency Using Booklets On Community Knowledge

Background : Pre-hospital stroke management is a service provided at the time and during the first time the victim is found, during the transportation process until the patient arrives home Sick. Pre- hospital stroke treatment can be determinants of condition and treatment furthermore. Public must own knowledge in do action pre-hospital strokes. Efforts that can be made to increase public knowledge are wrong One way is to provide health education. Method: This type of research is analytic descriptive research by collecting data using a questionnaire, and data analysis Which done is analysis univariate And bivariate, participant in activity research This as many as 25 respondents, with the variable Integrated Emergency Management System Education On Emergency Strokes Use booklet To Knowledge Public. This research was conducted in the working area of the Tanjung Enim Public Health Center in April - May 2023, Results: The results showed that there were significant differences in anxiety between before and after the intervention on health education The Effect of Education System Countermeasures bad Emergency Integrated On Emergency Strokes Use booklet To Knowledge Public, Obtained mark p <0.05. Discussion : Research which includes interpretation and discussion of research results as described in the previous chapter. The explanation is based on research objectives and hypotheses, research limitations related to the process of implementing research on nursing services, nursing science and education as well as the objectives of research interests and the implications of research results for services and research in the nursing area

Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke

To investigate the association between the Emergency Medical Service dispatcher’s initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017–2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1–76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was − 33.2 min (95% CI − 44.4; − 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI − 18.9; − 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.

Prehospital stroke-scale machine-learning model predicts the need for surgical intervention

While the development of prehospital diagnosis scales has been reported in various regions, we have also developed a scale to predict stroke type using machine learning. In the present study, we aimed to assess for the first time a scale that predicts the need for surgical intervention across stroke types, including subarachnoid haemorrhage and intracerebral haemorrhage. A multicentre retrospective study was conducted within a secondary medical care area. Twenty-three items, including vitals and neurological symptoms, were analysed in adult patients suspected of having a stroke by paramedics. The primary outcome was a binary classification model for predicting surgical intervention based on eXtreme Gradient Boosting (XGBoost). Of the 1143 patients enrolled, 765 (70%) were used as the training cohort, and 378 (30%) were used as the test cohort. The XGBoost model predicted stroke requiring surgical intervention with high accuracy in the test cohort, with an area under the receiver operating characteristic curve of 0.802 (sensitivity 0.748, specificity 0.853). We found that simple survey items, such as the level of consciousness, vital signs, sudden headache, and speech abnormalities were the most significant variables for accurate prediction. This algorithm can be useful for prehospital stroke management, which is crucial for better patient outcomes.

Abstract Number: LBA3 Head Pulse For Ischemic Stroke Detection Prehospital Study During COVID‐19 Pandemic (EPISODE‐PS‐COVID): Initial Trial Results

Introduction Prehospital identification of large vessel occlusion (LVO) ischemic stroke using stroke scoring tools based upon physical exam findings is highly user‐dependent and associated with poor specificity. Measurement of the “headpulse” by cranial accelerometry has been previously shown to reliably identify LVO in a hospitalized group of suspected stroke patients, but the utility of this technology in the prehospital environment remains unclear. The EPISODE‐PS‐COVID study was designed to evaluate the use of a novel triaxial cranial accelerometry device (Harmony, MindRhythm, Inc.) for predicting LVO using prehospital data. Methods Paramedics from multiple emergency medical services (EMS) agencies were trained in placement of the Harmony device. Patients suspected of LVO stroke by EMS personnel received placement of the non‐invasive headband device in the field, and prehospital data were collected over a 3‐minute period prior to hospital arrival. Headpulse data were then compared to clinical data collected during a subsequent emergency department (ED) and hospital visit, including results of brain computed tomography angiogram (CTA) as the gold standard for LVO diagnosis. Patients were consented for inclusion in the study after hospital arrival, utilizing a delayed consent model, as approved by the local institutional review board (IRB). Los Angeles Motor Scale (LAMS) scores were also calculated by prehospital providers for comparison with headpulse measurements. Results A total of 377 enrollments were made at six participating hospitals over a period of 18 months (April 2021 – September 2022), including 92 subjects with recordings free of technical recording errors who were able to provide informed consent for use of their data. Nine (9.8%) subjects were confirmed to have LVO by subsequent CTA, while 15 (16.3%) were diagnosed with non‐LVO ischemic stroke, seven (7.6%) with intracranial hemorrhage, and 61 (66.3%) with stroke mimics. The Harmony device algorithm correctly identified seven of nine LVO strokes, resulting in 78% sensitivity, as well as 82 of 83 non‐LVO diagnoses (99% specificity, p < 0.0001). In this data set, contemporaneous LAMS score demonstrated 44% sensitivity and 82% specificity (p = 0.087). Device innovation during the trial significantly reduced the number of technical errors. Device performance numerically exceeded the LAMS score, with p = 0.099. Conclusions Data from this pilot study suggest that the Harmony device has a sensitivity and specificity that may be non‐inferior to the LAMS score when tested in an undifferentiated population of suspected stroke patients. Although the sample size is underpowered to test for superiority, enrollment in the trial is ongoing. A blinded, pivotal trial will begin soon. The use of a non‐invasive device to detect LVO has substantial implications for prehospital LVO stroke management, including the potential for improved triage and improved outcomes for patients with LVO stroke, without delaying care for non‐LVO stroke patients.

Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms.

Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.

PERBEDAAN PENGETAHUAN KELUARGA TERHADAP PENGETAHUAN PREHOSPITAL STROKE KELUARGA

The high death rate makes the stroke as the second leading cause of death globally after heart disease. The biggest factor for the delay in prehospital stroke management is the lack of knowledge. Cost-effective case handling will be optimal if the emergency handling cases are well organized and well-prepared. Online health education during the COVID-19 pandemic is the right choice to increase family understanding regarding prehospital stroke which leads to the optimization of prompt and precise emergency services. Objective: To determine the effect of online method health education on family stroke prehospital knowledge in Makassar city. Methods: The study was a quasy experiment using two group pretest-posttest design with a control group design. The sample was the community in the working area of the public health center in Makassar, amounting to 15 samples from the intervention group as same with the control group based on the rule of thumb using accidental sampling technique. Result: The mean change in the intervention group was 2.067 and the control group was -0.2. The difference test after treatment was 0.018 (p <0.05). Conclusion: There was an effect of online method health education after intervention.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management.

The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90days, reduced onset to treatment times and increased proportion receiving IVT within 60min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.

Abstract 129: Electromagnetic Portable Brain Imaging For Stroke

Background: Electromagnetic imaging (EMI) is an emerging technology that transmits low energy electromagnetic waves from a ring of transceivers around the head, modified as they pass through abnormal tissue, providing unique signatures for brain pathology. It promises to provide portable, non-ionizing, rapid neuroimaging for prehospital and bedside evaluation of stroke, based on the dielectric properties of the tissue. We aimed to assess the clinical utility of EMI in stroke diagnosis in a pilot study. Methods: In a prospective, observational, open, non-interventional pilot study, patients with imaging-proven ischemic (IS) or haemorrhagic stroke (ICH) within the preceding 48 hours were recruited. Using the EMVision scanner, EMI was performed within 1-24 hours of diagnostic CT or MRI. Images were obtained by processing signals from encircling transceiver antennae contained in an instrumented 18 kg helmet which emit and detect low energy non-ionising signals in the microwave frequency spectrum (0.5-2.0 GHz). Localisation was assessed by determining whether fusion images resulted in target detection in the same quadrant as comparable CT or MRI. Electromagnetic (EM) images were reconstructed by creating maps of the EM wave scattering arising from contrast in electrical parameters between IS or ICH lesions and normal brain. A blinded clinician assessed agreement between regional abnormalities on EMI and CT or MRI scans. Algorithms for distinction between IS and ICH were based on differences in EM transmission, reflection and scattering through brain tissue. Results: Thirty patients were studied, 21 IS and 9 ICH. Mean age was 66.7 years (range 37-87), 57% were female. Mean NIHSS at presentation was 5. Mean time to routine imaging was 5.5 hrs (range 1-48) and to EMI 24 hrs (range 6-60). Nineteen patients (63%) had only CT performed; 11 (37%) had both CT and MRI. EMI differentiated ICH from IS with 93% accuracy and localised the stroke to the correct brain quadrant with 87% accuracy. Conclusion: In this early validation pilot study we show the ability to distinguish between IS and ICH and stroke location within a given brain quadrant. Further developments may produce a valuable imaging tool to assist in prehospital and bedside stroke diagnosis and management.

Telemedicine-enabled ambulances and mobile stroke units for prehospital stroke management

The recognition and management of stroke in the prehospital setting has become increasingly important to improve patient outcomes. Several strategies to advance prehospital stroke care have been developed, including the mobile stroke unit and the telemedicine-enabled ambulance—or “mini-MSU.” These strategies both incorporate ambulance-based audio-visual telemedicine evaluation with a vascular neurologist to facilitate faster treatment but differ in several areas including upfront and recurring costs, scalability or growth potential, ability to integrate into existing emergency medical services systems, and interoperability across multiple specialties or conditions. While both the mobile stroke unit and mini-mobile stroke unit model are valid approaches to improve stroke care, the authors aim to compare these models based on costs, scalability, integration, and interoperability in order to guide our prehospital leaders to find the best solutions for their communities.

Profile of practices and knowledge on stroke among Polish emergency medical service staff

BACKGROUND: Stroke is a leading cause of disability and death in both developed and developing countries. While hemorrhagic stroke often necessitates immediate neurosurgical intervention, ischemic stroke is treated with reperfusion therapies such as thrombolysis with intravenous recombinant tissue plasminogen activator (IV rtPA) and early endovascular thrombectomy for broad vessel occlusions. OBJECTIVES: Early diagnoses, accurate emergency medical services (EMS) dispatch, rapid EMS transfer, and stroke team activation have helped reduce door-to-IV tPA time and continue to be critical in saving time for stroke patients’ treatment. MATERIAL AND METHODS: One reason for prehospital delays may be incorrect qualification by emergency team members due to incomplete medical records and incorrect evaluation of symptoms by dispatchers or paramedics. The dispatcher’s precise identification of the report helps them decide on the patient’s priority disposal of the ambulance. In comparison, a correct initial diagnosis by paramedics allows the patient to be transported immediately to the destination hospital, i.e., the unit with a stroke unit. Extending the time it takes for the patient to enter the stroke facility due to the patient being moved through stages reduces the probability of successful treatment being introduced significantly. RESULTS: We hypothesized that paramedics’ knowledge of prehospital stroke management protocols would be linked to their clinical experience as well as their stroke preparation. CONCLUSION: A secondary goal of this study was to evaluate and compare the theoretical knowledge on stroke management among paramedics and identify factors associated with high knowledge. 468 EMS providers agreed to complete a questionnaire that included demographic questions, practical experience questions, and 14 theoretical information questions. Our research found that paramedics in Poland have significant awareness gaps in existing stroke treatment guidelines.

Prehospital stroke management in the thrombectomy era.

Acute stroke management has been revolutionised by evidence of the effectiveness of thrombectomy. Because time is brain in stroke care, the speed with which a patient with large vessel occlusion is transferred to a thrombectomy-capable centre determines outcome. Therefore, each link in the stroke rescue chain, starting with symptom onset and ending with recanalisation, should be streamlined. However, in contrast to inhospital delays, prehospital delays are unchanged despite substantial efforts in quality improvement. Furthermore, thrombectomy is offered by only a few, usually distant, specialised centres and not by the many other, usually nearer, hospitals. To take maximum advantage of the first so-called golden hours after stroke, and because of the difficulty of on-scene triage decision making with respect to the target hospital offering the required level of care, the focus of stroke research has shifted to the prehospital setting. Current research focuses on the effects of public education, implementation of protocols for emergency medical services for streamlining clinical investigations and accurate triage, use of preclinical scales for stroke recognition, and deployment of novel technical solutions such as smartphone applications, telemedicine, and mobile stroke units.

A review of mobile stroke units.

Mobile stroke units (MSUs) for prehospital treatment and management of patients with acute stroke have been developed more than a decade ago and is currently spreading worldwide. This review discusses the history of MSU and current operations and research. Multiple studies have shown that MSU can significantly reduce treatment time with a tenfold increase of patients treated within the first 60min of symptom onset. Recent preliminary results from the Berlin Prehospital or Usual Delivery of Acute Stroke Care trial (B-PROUD) showed a positive shift in modified Rankin Scale (mRS) scores at 3months for patients treated in MSUs. Two German studies indicate that the MSU model is cost effective by reducing disability and improving adjusted quality-life years after stroke. The MSU model for prehospital management of acute stroke is spreading worldwide. More research is needed, however, to establish cost-effectiveness, efficacy and best setting for prehospital stroke management.

Innovations in Prehospital Stroke Management Utilizing Mobile Stroke Units.

Using a representative case, this article discusses prehospital innovations for patients with acute large vessel occlusion ischemic stroke, including mobile stroke unit care supported by advanced field imaging.

Prehospital time intervals and management of ischemic stroke patients.

Quantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED). Acute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed. Data from 870 patients were analyzed. Median total prehospital time was 39min and comprised the following: chute time: 1min; response time: 9min; on-scene time: 15min; and transport time: 14min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene. On-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.

Significant Stroke Knowledge Deficiencies in Community Physician Improved with Stroke 120

Background and Purpose: In the existing model of community health service in China, community general practitioners play important roles in health promotion as well as prehospital stroke recognition and management. We recently engineered Stroke 120 based on FAST for China. This investigation aimed to investigate its acceptance in community physicians and promote their stroke related knowledge. Methods: We conducted an stroke education session to community physicians or family doctors (total of 435 participants), teaching both FAST and Stroke 120. Online survey was distributed to the participants before and after the education session to evaluate the awareness of stroke and the acceptance of the stroke recognition tool. Results: Significant stroke knowledge deficiencies were found in community physicians. After the education session, percent of the participants knew that the thrombolytic therapeutic window (<4.5 hours) was improved from 54.0% to 91.6% (P < .001). A total of 88.5% of them would send their patients who had stroke to the nearest hospital with stroke center by emergency medical service, compared to baseline (64.4%, P < .001). In total, 95.2% of them would recommend thrombolytic therapy in the treatment of acute ischemic stroke compared to 82.7% (baseline P < .001). Although majority mastered both FAST (95.5%) and Stroke 120 (98.0%) through our education session, 96.3% of them believe that Stroke 120 is the most suitable for Chinese in stroke education. Conclusions: Stroke 120 strategy was well accepted by the community physicians in China and in the meantime improved knowledge regarding stroke was observed.

Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke

Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. ClinicalTrials.gov identifier: NCT02465346.

Pre- and In-Hospital Management of Stroke

In pre-hospital stroke management, factors related to pre-hospital delays include demographic characteristics, social factors, clinical factors, behavioral factors, and cognitive factors. Great significance should be assigned to the implementation of stroke preparedness interventions, stroke assessment instruments, the use of emergency medical service (EMS), mobile stroke units (MSUs), and the Stroke Emergency Map.

Pre-hospital management of acute stroke patients eligible for thrombolysis \u2013 an evaluation of ambulance on-scene time

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.