scholarly journals Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

2018 ◽  
Vol 10 (1) ◽  
pp. 57-62 ◽  
Author(s):  
Tapan Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Gilbert Fortunato ◽  
Ilene Staff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Acute Stroke ◽  
Simulation Training ◽  
Stroke Registry ◽  
Practice Experience ◽  
Intravenous Tissue Plasminogen Activator ◽  
Simulation Based ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ABSTRACT Background  Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective  To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods  Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results  We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions  Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

Abstract P689: Do Cyclic Patterns of Stroke Code Activation Occur in a Comprehensive Stroke Center?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Edward Labin ◽  
Dawn M Meyer ◽  
Benjamin Shifflett ◽  
Brett C Meyer ◽  
Royya F Modir
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Circadian Rhythm ◽  
Time Of Day ◽  
Stroke Registry ◽  
Changing Practice ◽  
Cyclic Patterns ◽  
Chi Squared ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The effects of circadian rhythm on stroke can include increases in morning heart rate, blood pressure, catecholamines, platelet aggregation, and hypercoagulability and might correlate with higher numbers of morning strokes. We assessed time of day and frequency of stroke code activation for a potential role of circadian rhythm in stroke risk. Methods: A retrospective analysis of prospectively collected data from an IRB approved stroke registry, from July 2004 to July 2020, was performed. Codes were included where stroke codes were activated with last known well (LKW) <6 hours to limit the effect of wake-up strokes and equalize changing practice patterns over time. Subjects were divided into four epochs based on code activation: Night (00:00-05:59), Morning (06:00-11:59), Afternoon (12:00-17:59), and Evening (18:00-23:59). Confirmed diagnosis of stroke, baseline blood pressure (SBP & DBP), heart rate (HR), and PTT were compared. Chi squared was used to compare categorical data and t test for continuous. Results: A total of 5,366 subjects were identified. Stroke code activations differed across epochs (Night n=312, 5.81%; Morning n=1439, 26.82%; Afternoon n=2207, 41.13%; Evening n=1408, 26.24%: p<0.0001). In the subset analysis of true strokes, activations also differed across epochs (Night n=125, 5.26%; Morning n= 831, 34.95%; Afternoon n=934, 39.28%; Evening n=488, 20.52%: p<0.0001). Overall, SBP was different with Evening highest and Morning lowest (x 151.6, x 148.2;p=0.01). Overall DBP showed Night highest and Afternoon lowest (x 83.9, x 81;p=0.002). Heart rate showed Night highest and Morning lowest (x 84.9, x 81.6;p=0.002). Conclusions: This study found that most stroke code activations occur in Afternoons at this CSC. This may be due to patient level characteristics, bystander availability, or other factors. Future studies should assess multi-center data and include other circadian rhythm biomarkers.

Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Noah Grose ◽  
Cassandra Forrest ◽  
Sharon Heaton ◽  
Vivien Lee
Keyword(s):  
Acute Stroke ◽  
Nurse Practitioners ◽  
Final Diagnosis ◽  
Reperfusion Therapy ◽  
National Institutes Of Health ◽  
Advanced Practice ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Hours ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at <0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

Abstract WMP87: Simulation Based Medical Education Improves Door to Needle Times in Acute Ischemic Stroke Management

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tapan V Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Ilene Staff ◽  
Gilbert Fortunato ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Simulation Training ◽  
Linear Regression Analysis ◽  
Univariate Analysis ◽  
Multivariate Linear Regression Analysis ◽  
Simulation Based ◽  
Iv Tpa

Introduction: Literature on the effectiveness of simulation based medical education programs used in acute ischemic stroke (AIS) care is scant. In an effort to improve coordination and door to needle time (DNT) for AIS care, a stroke simulation education training program for neurology nursing staff and neurology residents was implemented in a comprehensive stroke center. Methods: Hospital stroke registry was used for retrospective analysis. The study population was defined as all patients treated with IV-tPA for AIS in the emergency room from October 2008 to September 2014. Simulation training was implemented yearly, for a three month period starting from July 2011. All neurology residents and a group of nurses trained to respond to all AIS cases participated. Simulations were standardized, using deliberate practice with a trained live actor portraying stroke vignettes in the presence of a board certified vascular neurologist. During the period of study, there were no changes in Emergency Department stroke triage protocol, or changes in first provider response to AIS. The data was analyzed using IBM SPSS24 software. Results: We identified 448 patients admitted with AIS who were treated with IV-tPA. The average DNT on univariate analysis before and after intervention was 67.9 and 58.3 minutes [p <0.001]. A multivariate linear regression analysis was performed controlling for age, night/day shift, weekday/weekend, and blood pressure at presentation (>185/110). After controlling for confounders we found that simulation training independently reduced the DNT by 9.64 minutes [95% confidence interval (CI) 4.01 - 15.28, p=0.001]. Amongst other co-variates, only the systolic blood pressure >185 was associated with 14.27 minutes of delay in DNT [95% CI 3.36 - 25.191, p=0.011]. Conclusion: Time to thrombolysis from symptom onset is a critical factor in AIS management and evidence shows improving the DNT could improve patient outcomes. In our six year study, integration of simulation based medical education for AIS reduced the average DNT by 9.64 minutes in multivariate analysis. Simulation based medical education therefore should be considered as a standard process for providers involved in the care of AIS patients receiving thrombolytic treatment.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Poor Functional Outcome ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kerrin Connelly ◽  
Rishi Gupta ◽  
Raul Nogueira ◽  
Arthur Yancey ◽  
Alexander Isakov ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Transport Protocol ◽  
Stroke Patients ◽  
Stroke Registry ◽  
The Public ◽  
State Office ◽  
Stroke Center ◽  
Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Abstract WP240: Ultra-acute Diagnostics for Stroke: Large-scale Implementation of Prehospital Biomarker Sampling

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Olli S Mattila ◽  
Heini Harve ◽  
Saana Pihlasviita ◽  
Juhani Ritvonen ◽  
Gerli Sibolt ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Large Scale ◽  
Biomarker Discovery ◽  
Cost Effective ◽  
Blood Sampling ◽  
Blood Samples ◽  
And Performance ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Acute Diagnostics

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

Abstract TP414: Support from a Comprehensive Stroke Center Improves Door to tPA Times at Primary Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie M Fussner ◽  
Kelly Montgomery ◽  
Tinatin Gumberidze ◽  
Erin Supan
Keyword(s):  
Gap Analysis ◽  
Heart Association ◽  
Measure Data ◽  
Quality Improvement Initiative ◽  
University Hospitals ◽  
Stroke Registry ◽  
National Quality ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
System Average

Target Stroke, a national quality improvement initiative of the American Heart Association /American Stroke Association (AHA/ASA) to improve the timeliness of administration of intravenous (IV) tissue plasminogen activator (tPA) to eligible stroke patients, was launched in 2010. The door-to-needle time goal is 60 minutes (mins) from hospital arrival. Earlier administration of IV t-PA is associated with greater functional recovery. Since 2009 University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) has meet quarterly with its 7 system community hospitals to share stroke core measure data, review clinical practice guidelines and address new system initiatives for the care of the stroke patient. The purpose of this project is to demonstrate how a comprehensive stroke center (CSC) can assist a primary stroke center (PSC) to improve their door to tPA treatment times. In 2010 to support the primary stroke centers, the UHCSCC developed standardized stroke education for nurses including an online course for tPA. In 2014 an additional online interactive module was created to assist nurses in programing the Alaris IV pump to improve their speed. In 2013 the quarterly system meetings started to include door to CT and door to tPA data with discussions about best practices and challenges. The AHA Target Stroke campaign recommendations and evidenced-based strategies were reviewed and a gap analysis at each hospital was completed to identify opportunities. Throughout 2012-2013 the stroke coordinator at UHCSCC led monthly conference calls with the community stroke coordinators. Since 2014 the stroke operations manager visits each community hospital monthly to work with the stroke coordinator and their teams reviewing TPA cases. Finally, a formal feedback took was developed and is sent to the PSC to provide patient outcomes and opportunities on all TPA cases that are transferred to the CSC. The AHA Get With The Guidelines stroke registry is used to monitor compliance. In 2012 the University Hospitals Health System average door to tPA in 60 mins was only 41%. January - June 2015, the system average has improved 86%. Community primary stroke centers benefit from the comprehensive stroke center interventions and support to improve door to tPA in 60 mins.

Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Vivien H Lee ◽  
Paul A Segerstrom ◽  
Ciarán J Powers ◽  
Sharon Heaton ◽  
Shahid M Nimjee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Transfer Model ◽  
Transfer Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Patients With Stroke

2017 ◽  
Vol 34 (11-12) ◽  
pp. 990-995 ◽  
Author(s):  
Teresa A. Allison ◽  
Stephanie Bowman ◽  
Brian Gulbis ◽  
Heather Hartman ◽  
Sara Schepcoff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Reduction ◽  
Group Versus ◽  
Pressure Control ◽  
Care Needs ◽  
Observational Cohort ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Time Standard ◽  
Mean Time

Objective: The aim of this study was to determine whether clevidipine (CLEV) achieved faster blood pressure control compared to nicardipine (NIC) in patients presenting with either an acute ischemic stroke (AIS) or a spontaneous intracerebral hemorrhage (ICH). Methods: This was a retrospective, observational, cohort study conducted in patients with AIS or ICH admitted to the emergency department of a Comprehensive Stroke Center from November 2011 to June 2013 who received CLEV or NIC continuous infusion for acute blood pressure management. Results: The study included 210 patients: 70 in the CLEV group and 140 in the NIC group. There was no difference in mean time (standard deviation [SD]) from initiation of the infusion to goal systolic blood pressure (SBP), CLEV: 50 (83) minutes versus NIC: 74 (103) minutes, P = .101. Comparison of the 2 agents within diagnosis showed no difference. Hypotension developed in 5 (7.1%) CLEV patients versus 14 (10%) NIC patients ( P = .003). There was no difference in the percentage change at 2 hours; CLEV: −20% (16%) versus NIC: −16% (16%), P = .058. Mean (SD) time to alteplase administration from admission was 56 (22) minutes in the CLEV group versus 59 (25) minutes in the NIC group ( P = .684). Conclusions: There was no difference in the mean time from initiation of the infusion to the SBP goal between agents or in the secondary outcomes. Due to the lack of differences observed, each agent should be considered based on the patient care needs of the institution.

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.

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