Background Recent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient. Aim To develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients. Methods Building on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

Background: Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally. Methods: A survey was distributed via email to the World Stroke Organisation (WSO) members. Information was sought on the current status of stroke prehospital delay globally including 1) ambulance availability and whether payment for use is required, 2) ambulance response times and the proportion of patients arriving at hospital by ambulance, 3) the proportion of patients arriving within 3 hours and more than 24 hours after symptom, 4) whether stroke care training of paramedics, call handlers and primary care staff, 5) availability of specialist centers, and 6) the proportion of patients taken to specialist centers. Respondents were also asked to identify the top three changes in prehospital care that would benefit their population. Data were analysed descriptively at both country and continent level. Results: Responses were received from 116 individuals in 43 countries, with a response rate of 4.7%. Most respondents (90%) reported access to ambulances but 40% of respondents reported payment was required by the patient. Where an ambulance service was available (105 respondents) 37% of respondents reported that less than 50% of patients used an ambulance and 12% less than 20% of patients used an ambulance. Large variations in ambulance response times were reported both within and between countries. Most of the participating High-Income Countries (HIC) offered a service used by patients, but this was rarely the case for the Low and Middle Income Countries (LMIC). Time to admission was often much longer in LMIC and there was less access to stroke training for EMS and primary care staff. Conclusions: Significant deficiencies in stroke prehospital care exist globally especially in LMIC. In all countries there are opportunities to improve the quality of the service in ways that would likely result in improved outcomes after acute stroke.

Aims:To explore the association between nurses' perceptions of their nurse manager's transformational leadership style and nurses' organisational commitment.Design: Narrative systematic review.

Background A spontaneous breathing trial (SBT) is recommended to help patients to liberate themselves from mechanical ventilation as soon as possible in the ICU. The respiratory workload in SBT, which depends on being with or without respiratory support and a specific time, is more accurate to reflect how much support the weaning patients need compared with only considering SBT technologies. Aim To compare and rank the effectiveness of different respiratory workloads during SBT via differing technologies (Pressure Support Ventilation and T‐piece) and differing duration (30 and 120 min) in SBTs. Study design A comprehensive literature search was performed in six English electronic databases to identify eligible randomized controlled trials (RCTs) published before September 2020. The pooled risk ratio (RR) with 95% confidence interval (CI) was calculated by Markov chain Monte Carlo methods. A Bayesian network meta‐analysis was conducted using “gemtc” version 0.8.2 of R software. Each intervention's ranking possibilities were calculated using the surface under the cumulative ranking analysis (SUCRA). Results A total of nine RCTs including 3115 participants were eligible for this network meta‐analysis involving four different commonly used SBT strategies and four outcomes. The only statistically significant difference was between Pressure Support Ventilation (PSV) 30 min and T‐piece 120 min in the outcome of the rate of success in SBTs (RR = 0.91; 95% CI, 0.84–0.98). The cumulative rank probability showed that the rate of success in SBT from best to worst was PSV 30 min, PSV 120 min, T‐piece 30 min and T‐piece 120 min. PSV 30 min and PSV 120 min are more likely to have a higher rate of extubation (SUCRA values of 82.5% for 30 min PSV, 70.7% for 120 min PSV, 36.4% for T‐piece 30 min, 10.4% for T‐piece 120). Meanwhile, T‐piece 120 min (SUCRA, 62.9%) and PSV 120 min (SUCRA, 60.9%) may result in lower reintubation rates, followed by T‐piece 30 min (SUCRA, 41.8%) and PSV 30 min (SUCRA, 34.4%). Conclusions and relevance to clinical practice In comprehensive consideration of four outcomes, regarding SBT strategies, 30‐min PSV was superior in simple‐to‐wean patients. Besides, 120‐min T‐piece and 120‐min PSV are more likely to achieve a lower reintubation rate. Thus, the impact of duration is more significant among patients who have a high risk of reintubation. It is still unclear whether the SBTs affect the outcome of mortality; further studies may need to explore the underlying mechanism.