Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki

Puolakka, Tuukka; Kuisma, Markku; Länkimäki, Sami; Puolakka, Jyrki; Hallikainen, Juhana; Rantanen, Kirsi; Lindsberg, Perttu J.

doi:10.1161/strokeaha.116.014531

Cited by 21 publications

(27 citation statements)

References 8 publications

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“…Our finding of a median OST of 21 min is comparable to earlier Finnish and Danish studies, which report OSTs between 18 and 25 min, [7, 18] while an American study has reported OSTs as low as 15 min [12]. Various studies of Mobile Stroke Units (MSUs) have also reported on on-scene time consumption [19–21].…”

Section: Discussionsupporting

confidence: 84%

“…Establishing the first IV access during transport was shown to reduce OST by almost 20% and demonstrates and important opportunity of time reduction. It could be argued that cannulation during transport is more difficult and may also pose a risk to both patient and ambulance personnel [18]. Nonetheless, balancing potential risks and rewards, it should at least be considered to establish IV accesses during transport if possible in order to reduce OST and alarm-to-treatment time.…”

Section: Discussionmentioning

confidence: 99%

“…A recent Finnish study aiming to reduce OST employed a training programme to enhance ambulance personnel performance [18]. The training programme specified that emergency medical technicians and paramedic students should not examine nor practice procedures on suspected thrombolysis candidates.…”

Section: Discussionmentioning

confidence: 99%

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Pre-hospital management of acute stroke patients eligible for thrombolysis – an evaluation of ambulance on-scene time

Drenck

Viereck

Baekgaard

et al. 2019

Scand J Trauma Resusc Emerg Med

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BackgroundStroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. While door-to-needle time in hospital has been optimized for many years, little is known about the ambulance on-scene time (OST). OST has been reported to account for 44% of total alarm-to-door time, thereby being a major time component. We aimed to analyse ambulance OST in stroke patients eligible for thrombolysis and identify potential areas of time optimization.MethodsA study-specific registration form was developed to record detailed information about OST consumption in cases where the Emergency Medical Services (EMS) suspected a stroke from July 2014–May 2015. Registration forms were completed by ambulance personnel and included details on estimated time spent: 1) localising patient, 2) clinical examination, 3) consulting with the on-call neurologist, 4) mobilising patient to the ambulance, 5) treatment in ambulance before departure. Additionally, estimated total OST was noted. For patients found eligible for further evaluation at a stroke centre, time points were analysed using multivariate Poisson regressions.ResultsA total of 520 cases were included. The median OST was 21 min (Interquartile Range (IQR) 16–27). Time consumption was significantly lower (17 vs 21 min, p = 0.0015) when electrocardiography (ECG) was obtained in-hospital instead of on-scene, when intravenous (IV) access was established during transportation instead of before transportation (17 vs 21 min, p < 0.0001), and when the quality of communication with the stroke centres was rated as “good” as opposed to “acceptable/poor” (21 vs 23 min, p = 0.014). Neither the presence of relatives nor ambulance trainees had a significant effect on OST.ConclusionsIn-hospital ECG recording and IV cannulation during transport were found to reduce OST, while “acceptable/poor” communication was found to prolong OST relative to “good” communication. These components of pre-hospital stroke management represent potential opportunities for lowering OST with relatively simple changes, which could ultimately lead to earlier treatment and better patient outcome.Trial registrationUnique identifier: NCT02191514.Electronic supplementary materialThe online version of this article (10.1186/s13049-018-0580-4) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

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Pre-hospital management of acute stroke patients eligible for thrombolysis – an evaluation of ambulance on-scene time

Drenck

Viereck

Baekgaard

et al. 2019

Scand J Trauma Resusc Emerg Med

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“…Intravenous tissue plasminogen activator (IV tPA) needs to be administered within 4.5 hrs of the last known well time, and earlier treatmentis associated with improved patient outcomes 2–8. Early recognition, accurate emergency medical services (EMS) dispatch, rapid EMS transport,9 and stroke team activation have helped shorten door-to-IV tPA time, but EMS prenotification of stroke still remains crucial in saving time to treat a stroke patient. EMS prenotification allows the emergency department (ED) and hospital staff to prepare for the patient’s arrival so that appropriate care can be initiated promptly.…”

Section: Introductionmentioning

confidence: 99%

<p>Emergency Medical Services Providers’ Knowledge, Practices, And Barriers To Stroke Management</p>

Munder

Chaudhry

et al. 2019

OAEM

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PurposeMany strokes are not recognized by emergency medical services (EMS) providers and many providers do not prenotify emergency departments (EDs) of incoming stroke patients. The objectives of this project were to survey EMS providers to (1) assess knowledge of prehospital care related to stroke identification, time window for intravenous tissue plasminogen activator (IV tPA) administration, and comprehensive stroke centers in our health system, (2) gain insight from EMS providers regarding barriers to providing prenotification, information they provide for a prenotification, and optimal methods of providing feedback, and (3) provide EMS providers with stroke care and management information.MethodsA survey was administered to EMS providers at four hospital EDs. The survey included questions related to knowledge of prehospital stroke care and barriers to providing prenotification. EMS providers were also provided a one-page flyer with information related to prehospital stroke care. Descriptive statistics were used to describe results.ResultsOf 301 EMS providers surveyed, 96.0% report that they use the Cincinnati Prehospital Stroke Scale to identify stroke, and 11.0% correctly identified the time window for IV tPA administration for acute ischemic stroke as within 4.5 hrs from the last known well time. The majority (82.7%) correctly identified the comprehensive stroke center in our health system. Barriers to providing prenotification included short transport time (40.5%), information being lost in dispatch (39.5%), and not having direct communication with ED staff (30.2%). Most reported wanting to receive feedback on the stroke patients they transported (93.7%), and 49.5% reported that the optimal method of providing feedback is via a mobile application.ConclusionDeficits in stroke care knowledge among EMS providers were identified. Short transport time, inability to communicate with ED staff, and information lost in dispatch were cited as barriers to providing prenotification. Most EMS providers desire real-time feedback regarding patients via a mobile application.

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“…A Swedish randomised trial showed that IV thrombolysis rates and hospital treatment delays significantly improved after paramedics were provided with training and the emergency status of stroke ambulance dispatch was raised [13]. An observational study in Helsinki collecting data before and after a simple training package for ambulance personnel showed that on-scene time reduced by an average of 2.5 min, but there was insufficient power to assess the impact on IV thrombolysis treatment rates [14]. An alternative model of ‘mobile stroke units’ (adapted ambulances with computerised tomography (CT) scanner and neurologist on board or video link to a stroke specialist) has been shown to reduce service-level call to needle times (CTNTs) by 15 min in dense urban areas, but the impact on outcomes must be balanced against the additional costs and technical challenges [15–17].…”

Section: Introductionmentioning

confidence: 99%

Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial

Price

Shaw

Dodd

et al. 2019

Trials

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BackgroundDespite evidence from clinical trials that intravenous (IV) thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. This study is evaluating whether an enhanced care pathway delivered by paramedics (the Paramedic Acute Stroke Treatment Assessment (PASTA)) could increase the number of patients who receive IV thrombolysis treatment.MethodsStudy design: Cluster randomised trial with economic analysis and parallel process evaluation.Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales.Randomisation: Ambulance stations within each region are the units of randomisation. According to station allocation, paramedics based at a station deliver the PASTA pathway (intervention) or continue with standard stroke care (control).Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment. Study-trained intervention group paramedics deliver this pathway to adults within 4 h of suspected stroke onset.Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke.Participants: Participants enrolled in the study are adults with confirmed stroke who were assessed by a study paramedic within 4 h of symptom onset.Primary outcome: Proportion of participants receiving IV thrombolysis.Sample size: 1297 participants provide 90% power to detect a 10% difference in the proportion of patients receiving IV thrombolysis.DiscussionThe results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates.Trial registrationISRCTN registry, ISRCTN12418919. Registered on 5 November 2015.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-3144-z) contains supplementary material, which is available to authorized users.

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Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki

Abstract: Implementation of the emergency medical services training program successfully decreased the OST of thrombolysis candidates by 10%. Higher expertise level of the ambulance crew was associated with shorter OST, and decisions to consult a physician via telephone were reflected by longer OST.

Cited by 21 publications

References 8 publications

Pre-hospital management of acute stroke patients eligible for thrombolysis – an evaluation of ambulance on-scene time

Pre-hospital management of acute stroke patients eligible for thrombolysis – an evaluation of ambulance on-scene time

<p>Emergency Medical Services Providers’ Knowledge, Practices, And Barriers To Stroke Management</p>

Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial

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