009 The ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithmic pre-hospital triage tool for endovascular thrombectomy: ongoing paramedic validation

IntroductionThe ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithm is a severity based 3-step paramedic triage tool for pre-hospital recognition of large vessel occlusion (LVO), designed to improve specificity and paramedic assessment reliability compared to existing triage scales. ACT-FAST sequentially assesses 1. Unilateral arm fall to stretcher <10 s; 2a. Severe language disturbance (right arm weak), or 2b. Severe gaze deviation/hemi-neglect assessed by shoulder tap (left arm weak); 3. Clinical eligibility questions. We present the results of the ongoing Ambulance Victoria paramedic validation study.MethodsAmbulance Victoria paramedics assessed ACT-FAST in all suspected stroke patients pre-hospital in metropolitan Melbourne, Australia, and in the Royal Melbourne Hospital Emergency Department since July 2017. Algorithm results were validated against a comparator of ICA/M1 occlusion on CT-angiography with NIHSS ≥6 (Class 1 indications for endovascular thrombectomy).ResultsData were available from n=119 assessments (ED n=68, pre-hospital n=51). Patient diagnoses were LVO n=20 (15.6%), non-LVO infarcts n=45 (38.5%), ICH n=10 (8.3%) and no stroke on imaging n=44 (37.6%). ACT-FAST showed 85% sensitivity, 88.9% specificity, 60.7% (72% excluding ICH) positive predictive value and 96.7% negative predictive value for LVO. Of 10 false-positives, 4 received thrombectomy for non-Class 1 indications (basilar/M2 occlusions/cervical dissection), 3 were ICH, and 1 was tumour. Three false-negatives were LVO with milder syndromes.DiscussionThe ongoing ACT-FAST algorithm validation study shows high accuracy for clinical recognition of LVO. The streamlined algorithmic approach with just two examination items provides a more practical option for implementation in large emergency service networks. Accurate pre-hospital recognition of LVO will allow bypass to endovascular centres and early activation of neuro-intervention services to expedite endovascular thrombectomy.

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Abstract TMP64: In-Field Paramedic Validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) Algorithm for Endovascular Thrombectomy

Stroke ◽

10.1161/str.50.suppl_1.tmp64 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Henry Zhao ◽

Karen Smith ◽

Stephen Bernard ◽

Michael Stephenson ◽

Mark Parsons ◽

...

Keyword(s):

Acute Stroke ◽

Fast Algorithm ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Acute Stroke Treatment

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Abstract TMP67: Prehospital Screening for Large Vessel Occlusion and Bypass to Endovascular Stroke Centers: Using the Ambulance Clinical Triage for Acute Stroke Treatment Scale With Adaptation From DAWN and DEFUSE-3 Trials

Stroke ◽

10.1161/str.50.suppl_1.tmp67 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Kyle L Ogle

Keyword(s):

Acute Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Acute Stroke Treatment

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Abstract 88: No Disparities in Acute Stroke Treatment in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.88 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Meghan Hatfield ◽

Lauren Klingman ◽

Benjamin Wilson ◽

Mai N Nguyen-Huynh ◽

...

Keyword(s):

Multivariate Analysis ◽

Acute Stroke ◽

Healthcare System ◽

Age Groups ◽

Stroke Care ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Iv Tpa

Background: Prior published studies reported disparities in timely treatment with tPA for stroke patients who were older, African American or female. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for the entire region, which included immediate evaluation by a stroke neurologist via video, an expedited IV tPA treatment program, rapid CT angiographic investigation, and expedited transfer of appropriate patients with large vessel occlusion (LVO) for endovascular stroke treatment (EST). We sought to evaluate whether disparities exist in acute stroke treatment within the redesigned process. Methods: KPNC is an integrated health care system with 21 certified stroke centers serving 3.9+ millions members. All centers implemented the new program by January 2016. Using clinical data from 1/1/16 to 7/10/16, we evaluated the frequency of IV tPA administration by gender, race, and age groups after implementation of the new process. We performed multivariate analysis with age, gender, race-ethnicity, Kaiser membership, mode of ED arrival (by ambulance vs. private transportation) to assess for any disparities in achieving DTN time. Results: Post implementation, we found no significant differences in the rates of IV t-pa administration in eligible patients based on race, gender, age category (<40 years, 40-64, 65-79, ≥80), Kaiser membership, or mode of ED arrival. In multivariate analysis for factors influencing DTN time, no differences were seen for DTN time <60 minutes. Age (OR=1.02, 95% CI 1.00-1.03, p=0.03) and arrival by ambulance (OR=5.01, 95% CI 3.01-8.60, p<0.001) were associated with a faster DTN time of <30 minutes. Conclusions: Thus far, we have found no disparities in the use of IV tPA or DTN time for a large integrated healthcare system after implementation of the Stroke EXPRESS program. A consistent standardized approach to acute stroke care may help to reduce disparities on the basis of race, gender, age, or even membership in healthcare system.

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Regular hours vs. on-call endovascular interventions for acute stroke treatment: initial single-center experience by interventional cardiologists

European Heart Journal ◽

10.1093/eurheartj/ehab724.2065 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

K Piayda ◽

M Hornung ◽

I Grunwald ◽

K Sievert ◽

S Bertog ◽

...

Keyword(s):

Endovascular Treatment ◽

Hospital Stay ◽

Acute Stroke ◽

Stent Retriever ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Dose Area Product ◽

Acute Stroke Treatment ◽

Area Product

Abstract Background Endovascular treatment for acute stroke with large vessel occlusion became the mainstay therapy but remains limited due to lack of trainees and specialized centers. To offer this therapeutical option to a vast population, interventional cardiologists joined interdisciplinary stroke teams. Because of limited experience, it remains unclear if the timing of the procedure (i.e., regular hours vs. on-call time) may influence quality, time-effectiveness and outcomes. Purpose To investigate if the timing of the procedure (i.e., regular hours vs. on-call time) significantly influences procedural parameters and outcomes of patients undergoing acute endovascular stroke treatment. Methods Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020, treated by cardiologists, were reviewed. Baseline characteristics, procedural aspects and clinical outcomes were retrospectively collected. Cases were divided into two groups, depending on the timing of the procedure: on-call time (OC, i.e., weekend days, public holidays and documented “call in” of the on-call service) vs. regular hours (RH, i.e., all other procedures) and outcomes subsequently compared. Results One-hundred-thirteen consecutive patients underwent endovascular treatment for acute stroke; of those 77 (68.1%) during regular hours and 36 (31.9%) during on-call time. Patients were in their early 70ies and risk factors such as arterial hypertension, diabetes mellitus, dyslipidemia and atrial fibrillation were evenly distributed. Modified Ranking Scale (mRS) at presentation was 5 in both groups and decreased to 3 at discharge. The anterior circulation was most often affected (RH: 90.9% vs. OC: 94.4%, p=0.518) and a stent retriever only strategy commonly chosen (RH: 42.8% vs. OC: 30.5%, p=0.211), followed by a combined approach of stent retriever use and aspiration (RH: 25.9% vs. OC: 27.7%, p=0.752). Door-to-needle time (RH: 0:55h IQR [0:45–1:22] vs. OC: 1:05h IQR [0:54–1:30], p=0.237) and procedure duration (RH: 0:48h IQR [0:30–1:25] vs. OC: 0:58h IQR [0:35–1:46], p=0.214) were comparable. Contrast agent use and radiation time (RH: 17.6 min IQR [11.7–29.3] vs. OC: 17.6 min IQR [12.1–33.6]) did not differ between groups, however patients in the OC group experienced a higher dose area product (RH: 4827mGy cm2 IQR [1567–14092] vs. 12727mGy cm2 [6732–18889], p<0.001). The combined quality endpoint, comprising of TICI IIb/III flow after the procedure, no embolization to new territory and no symptomatic intracranial bleeding during in hospital stay was met in 85.5% of patients in the RH group and 80.5% of the on-call group (p=0.485). Death during in-hospital stay was observed in 22% of patients in the RH group and 11.1% of the OC group (p=0.163). Conclusions Endovascular intervention for acute stroke treatment during on-call time is as effective and safe as if performed during regular hours but associated with a higher dose area product. FUNDunding Acknowledgement Type of funding sources: None.

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