Prehospital Triage of Patients with Suspected Stroke (PRESTO): A Prospective In-Field Validation of Eight Prehospital Stroke Scales to Detect Intracranial Large Vessel Occlusion

2020 ◽  
Author(s):  
Martijne Helene Catharina Duvekot ◽  
Esmee Venema ◽  
Anouk D. Rozeman ◽  
Walid Moudrous ◽  
Frédérique H. Vermeij ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Field Validation ◽  
Vessel Occlusion ◽  
Prehospital Triage ◽  
Suspected Stroke

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 Personalized Prehospital Triage in Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (2) ◽  
pp. 313-320 ◽  
Author(s):  
Esmee Venema ◽  
Hester F. Lingsma ◽  
Vicky Chalos ◽  
Maxim J.H.L. Mulder ◽  
Maarten M.H. Lahr ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Base Case ◽  
Large Vessel Occlusion ◽  
Case Scenario ◽  
Vessel Occlusion ◽  
Base Case Scenario ◽  
Primary Stroke Center ◽  
Prehospital Triage ◽  
Stroke Center

Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.

scholarly journals Large Vessel Occlusion Stroke Detection in the Prehospital Environment

2021 ◽  
Author(s):  
Lauren Patrick ◽  
Wade Smith ◽  
Kevin J. Keenan
Keyword(s):  
Endovascular Therapy ◽  
Ease Of Use ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Published Data ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Suspected Stroke

Abstract Purpose of Review Endovascular therapy for acute ischemic stroke secondary to large vessel occlusion (LVO) is time-dependent. Prehospital patients with suspected LVO stroke should be triaged directly to specialized stroke centers for endovascular therapy. This review describes advances in LVO detection among prehospital suspected stroke patients. Recent Findings Clinical prehospital stroke severity tools have been validated in the prehospital setting. Devices including EEG, SSEPs, TCD, cranial accelerometry, and volumetric impedance phase-shift-spectroscopy have recently published data regarding LVO detection in hospital settings. Mobile stroke units bring thrombolysis and vessel imaging to patients. Summary The use of a prehospital stroke severity tool for LVO triage is now widely supported. Ease of use should be prioritized as there are no meaningful differences in diagnostic performance amongst tools. LVO diagnostic devices are promising, but none have been validated in the prehospital setting. Mobile stroke units improve patient outcomes and cost-effectiveness analyses are underway.

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.

Abstract TP260: Reducing Time From Pre-Hospital to Arterial Puncture in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nobuyuki Ohara ◽  
Hirotoshi Imamura ◽  
Satoru Fujiwara ◽  
Yasutaka Murakami ◽  
Hiroyuki Ishiyama ◽  
...  
Keyword(s):  
Education Program ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Arterial Puncture ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Transport Distance ◽  
Time Component ◽  
Suspected Stroke ◽  
Ems Education

Background and Purpose: Efficacy of mechanical thrombectomy for acute cerebral large vessel occlusion depends on time from symptom onset to reperfusion. While time to treatment in hospital has been optimized in these days, it is not well-known about improving time in pre-hospital when suspected stroke. We sought to analyze time from emergency medical services (EMS) dispatch to arterial puncture in stroke patients eligible for mechanical thrombectomy. Methods: We analyzed time components from EMS dispatch to puncture in patients with acute large vessel occlusion within 6 hours from onset treated with mechanical thrombectomy between April 2015 and December 2018. We assessed the associated factors with each time component and patient outcomes. Results: Consecutive 195 patients were included in this analysis. The median EMS dispatch-to-scene, on-scene, transport, door-to-puncture (DTP), and scene-to-puncture (STP) times were 4, 16, 12, 40, and 70 minutes, respectively. Percentage of favorable outcomes were significantly higher in patients with STP within 60 minutes (57.5% vs 35.8%, p<0.05). Direct call from EMS, lower number of acceptance request times, shorter transport distance, and out-of-home onset were significantly associated with STP within 60 minutes (P<0.01). EMS education program shortened STP times and increased use of direct call which significantly reduced on-scene (15.9 vs 20.2), DTP (40.4 vs 57.8), and STP (68.9 vs 91.5) times (P<0.001). Conclusions: Reducing time in pre-hospital and in-hospital interact with each other. Education program and use of direct call from EMS contributed to reducing these times.

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