scholarly journals Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke

2021 ◽  
pp. neurintsurg-2021-017863
Author(s):  
Hayato Araki ◽  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Kaoru Kurisu ◽  
Nobuaki Shime ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Success Rate ◽  
Preparation Time ◽  
Transport Time ◽  
Multicenter Cohort Study ◽  
Vessel Occlusion ◽  
Multicenter Cohort ◽  
Prehospital Management ◽  
Suspected Stroke ◽  
Time Of Intervention

BackgroundPrehospital stroke triage scales help with the decision to transport patients with suspected stroke to suitable hospitals.ObjectiveTo explore the effect of the region-wide use of the Japan Urgent Stroke Triage (JUST) score, which can predict several types of stroke: large vessel occlusion (LVO), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral infarction other than LVO (CI).MethodsWe implemented the JUST score and conducted a retrospective and prospective multicenter cohort study at 13 centers in Hiroshima from April 1, 2018, to March 31, 2020. We investigated the success rate of the first request to the hospital, on-scene time, and transport time to hospital. We evaluated the door-to-puncture time, puncture-to-reperfusion time, and 90-day outcome among patients with final diagnoses of LVO.ResultsThe cohort included 5141 patients (2735 before and 2406 after JUST score implementation). Before JUST score implementation, 1269 strokes (46.4%) occurred, including 140 LVO (5.1%), 394 ICH (14.4%), 120 SAH (4.4%), and 615 CI (22.5%). The JUST score was used in 1484 (61.7%) of the 2406 patients after implementation, which included 1267 (52.7%) cases of stroke (186 LVO (7.7%), 405 ICH (16.8%), 109 SAH (4.5%), and 567 CI (23.6%)). Success rate of the first request to the hospital significantly increased after JUST score implementation (76.3% vs 79.7%, p=0.004). JUST score implementation significantly shortened the door-to-puncture time (84 vs 73 min, p=0.03), but the prognosis remained unaltered among patients with acute LVO.ConclusionsUse of prehospital stroke triage scales improved prehospital management and preparation time of intervention among patients with acute stroke.

scholarly journals Prehospital Stroke Triage

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S25-S33
Author(s):  
Anna Ramos ◽  
Waldo R. Guerrero ◽  
Natalia Pérez de la Ossa
Keyword(s):  
Acute Stroke ◽  
Randomized Clinical Trials ◽  
Vessel Occlusion ◽  
Novel Technologies ◽  
Maximum Benefit ◽  
Prehospital Management ◽  
Prehospital Triage ◽  
Clinical Tools ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

Abstract P186: New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michal Bar ◽  
Martin Cabal ◽  
Ondrej Volny ◽  
Petr Jaššo ◽  
David Holeš ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT, and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a prospective interventional multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion, and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015, and 142 min in 2018; and median TT was 118 min in 2015, and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015, and 109 min in 2018; and median TT was 41 min in 2015, and 48 min in 2018. Clinical outcome did not significantly change. The median mRS at 3 months after stroke onset in both 2015 and 2018 was 2 among tPA patients, and 3 among EVT patients. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60% vs 59% in tPA patients, and 40% vs 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter onset-to-groin times for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Taylor Haight ◽  
Burton Tabaac ◽  
Kelly-Ann Patrice ◽  
Michael S. Phipps ◽  
Jaime Butler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Emergency Medical Services ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Emergency Medical ◽  
Suspected Stroke

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

scholarly journals New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

2021 ◽  
Vol 12 ◽  
Author(s):  
Martin Cabal ◽  
Linda Machova ◽  
Daniel Vaclavik ◽  
Petr Jasso ◽  
David Holes ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes.Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian–Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database.Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0–2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients.Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

Abstract WP279: Evaluation of a Novel Point-of-care Neuromonitoring Device to Detect Large Vessel Occlusion in Suspected Acute Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Madeleine R Wilcox ◽  
Liam Berti ◽  
Andrew Maza ◽  
Matthew Kesinger
Keyword(s):  
Acute Stroke ◽  
Point Of Care ◽  
Normal Subjects ◽  
Large Vessel ◽  
Neurological Deficits ◽  
Device Performance ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Convenience Sample ◽  
Suspected Stroke

Study Objectives: Several prehospital stroke scales have been developed to provide quick and accurate triage to facilitate timely treatment. This study evaluated a portable, experimental EEG device using AI as a tool for detection of acute stroke and large vessel occlusion (LVO) among patients with neurological deficits. Both device performance and feasibility in the emergent setting were assessed. Methods: This observational study enrolled a convenience sample of emergency department (ED) patients evaluated for suspected stroke within 24 hours of symptom onset. LVO and stroke status were determined by local neuroradiologists blinded to device output. LVO was defined as an acute occlusion of any of the following arteries: ICA/MCA-(M1 or M2)/vertebral/ basilar. Controls were neurologically normal subjects (NIHSS=0). Results: From May 2018 to July 2019, eight urban US stroke centers enrolled 89 subjects being evaluated for stroke. In suspected stroke subjects, 68 had stroke (76%) and 23 had LVO (26%). Mean (± SD) age was 68 (± 14), 36% were female, and the median (IQR) NIH stroke score was 6 (3 - 12) among suspected stroke subjects. The median last known well time was 327 minutes (196 - 577). Device performance for detecting LVO is shown in Table 1. There were no severe adverse events related to use of the device. Conclusion: The neuromonitoring device performed well in identifying LVO in patients presenting with suspected stroke. The performance of the neuromonitoring device in the acute setting indicates that it may be able to support prehospital decision making when triaging suspected stroke subjects. Additional studies with larger sample sizes are needed to validate this study’s findings.

Paramedic and Emergency Department Care of Stroke: Baseline Data From a Citywide Performance Improvement Study

2003 ◽  
Vol 12 (5) ◽  
pp. 411-417 ◽  
Author(s):  
Anne W. Wojner ◽  
Lewis Morgenstern ◽  
Andrei V. Alexandrov ◽  
Diana Rodriguez ◽  
David Persse ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Performance Improvement ◽  
Thrombolytic Treatment ◽  
Treatment Rate ◽  
Community Based ◽  
Transport Time ◽  
Emergency Department Care ◽  
Total Transport ◽  
Suspected Stroke

• Background Rapid diagnosis and transport by paramedics and efficient, effective emergency management are essential to improving care of acute stroke patients. • Objectives To measure the performance of paramedics and emergency departments providing care for patients with suspected acute stroke. • Methods Two stroke centers and 4 other hospitals where most patients with acute stroke in Houston, Tex, are admitted participated. Hospital and paramedic performance data were collected prospectively on 446 patients with suspected acute stroke transported by paramedics between September 1999 and February 2000. • Results Paramedics had a sensitivity of 66%, specificity of 98%, and overall accuracy of 72% in diagnosing stroke. For patients with suspected stroke, 58.5% arrived in the emergency department within 120 minutes of symptom onset; in confirmed cases, that percentage was 67%. Mean total transport time was 42.2 minutes and was significantly longer (P < .001) to inner-city hospitals (44 minutes) than to suburban, community-based centers (39 minutes). Door to computed tomography times were significantly (P < .001) shorter for the 2 stroke centers than the other hospitals. Overall thrombolysis treatment rate among patients with confirmed ischemic stroke was 7.4% (range, 0–19.4%); treatment rates at the 2 stroke centers were 5.9% and 19.4%. • Conclusions More than half of patients with suspected stroke arrive at hospitals while thrombolytic treatment is still feasible. Although the current rate for thrombolytic treatment in Houston exceeds the national rate, performance of paramedics and hospitals in treating acute stroke can be improved by increasing efficiency and standardizing medical practices.

Prehospital Computed Tomography Angiography in Acute Stroke Management

2017 ◽  
Vol 44 (5-6) ◽  
pp. 338-343 ◽  
Author(s):  
Michael Kettner ◽  
Stefan Alexander Helwig ◽  
Andreas Ragoschke-Schumm ◽  
Lenka Schwindling ◽  
Safwan Roumia ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Point Of Care ◽  
Vascular Pathology ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Spot Sign ◽  
Specialized Treatment ◽  
Mobile Stroke Unit ◽  
Prehospital Management

Background: An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. Methods: Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. Results: Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.

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