Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset

Almqvist, Tove; Berglund, Annika; Sjöstrand, Christina; Eriksson, Einar E.; Mazya, Michael V.

doi:10.1161/strokeaha.120.033676

Cited by 8 publications

(8 citation statements)

References 14 publications

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“…This system combines prehospital assessment of hemiparesis with ambulance-to-hospital teleconsultation, to triage cases with high likelihood of EVT-eligible LAO to CSC. 15,16 During the first year after implementation, onset to puncture time for EVT was reduced from 206 to 137 minutes. The triage system's accuracy for LAO stroke was 87% and for treatment with EVT, 91%.…”

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confidence: 99%

The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation

Keselman

Berglund

Ahmed

et al. 2022

Stroke

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Background and Purpose: The Stockholm Stroke Triage System (SSTS) is a prehospital algorithm for detection of endovascular thrombectomy (EVT)-eligible patients, combining symptom severity assessment and ambulance-to-hospital teleconsultation, leading to a decision on primary stroke center bypass. In the Stockholm Region (6 primary stroke centers, 1 EVT center), SSTS implementation in October 2017 reduced onset-to-EVT time by 69 minutes. We compared clinical outcomes before and after implementation of SSTS in an observational study. Methods: We prospectively recruited patients transported by Code Stroke ambulance within the Stockholm region under the SSTS, treated with EVT during October 2017 to October 2019, and compared to EVT patients from 2 previous years. Outcomes: shift in modified Rankin Scale (mRS) scores, mRS score 0 to 1, mRS score 0 to 2, and death (all 3 months), National Institutes of Health Stroke Scale (NIHSS) score change 24-hour post-EVT, recanalization (Thrombolysis in Cerebral Infarction 2b-3), and symptomatic intracranial hemorrhage. mRS outcomes were adjusted for age and baseline NIHSS. Results: Patients with EVT in the SSTS group (n=244) were older and had higher baseline NIHSS versus historical controls (n=187): median age 74 (interquartile range, 63–81) versus 71 (61–78); NIHSS score 17 (11.5–21) versus 15 (10–20). During SSTS, median onset-to-puncture time was 136 versus 205 minutes ( P <0.001). Adjusted common odds ratio for lower mRS in SSTS patients was 1.7 (95% CI, 1.2–2.3) versus controls. During SSTS, 83/240 (34.6%) versus 44/186 (23.7%) reached 3-month mRS score 0 to 1 ( P =0.014), adjusted common odds ratio 2.3 (95% CI, 1.4–3.6). Median NIHSS change 24-hour post-EVT was 6 versus 4 ( P =0.005). Differences in Thrombolysis in Cerebral Infarction, symptomatic intracranial hemorrhage, and death were nonsignificant. Conclusions: With an onset to arterial puncture time reduction by 69 minutes, outcomes in thrombectomy-treated patients improved significantly after region-wide large artery occlusion triage system implementation. These results warrant replication studies in other geographic and organizational circumstances.

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confidence: 99%

The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation

Keselman

Berglund

Ahmed

et al. 2022

Stroke

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“…It is important to note that a review of currently existing triage scales for ELVO supported that different scales may have a different sensitivity and/or specificity in different settings (field, emergency department) [ 20 ]. The Stockholm Stroke Triage System (SSTS), which includes a physical exam for hemiparesis, real-time screen by a nurse, and a telehealth assessment by a stroke expert, achieved 95% specificity in both detecting ELVO and the need for MT [ 21 ]. In addition, specificity and overall accuracy were statistically significantly higher in the patient group that presented within 6 h after symptoms onset [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

“…The Stockholm Stroke Triage System (SSTS), which includes a physical exam for hemiparesis, real-time screen by a nurse, and a telehealth assessment by a stroke expert, achieved 95% specificity in both detecting ELVO and the need for MT [ 21 ]. In addition, specificity and overall accuracy were statistically significantly higher in the patient group that presented within 6 h after symptoms onset [ 21 ]. In a case-control study, triaging stroke patients with SSTS in the field resulted in faster MT times without delaying IV thrombolysis [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

Matsoukas

Giovanni

Rubinstein

et al. 2021

Cerebrovasc Dis Extra

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Objective: The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system. Methods: We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients’ initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort. Results: Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with p = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (p < 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (p < 0.001) for the DS versus BM cohort, respectively. Conclusions: Modeled EMS prehospital triage of ELVO patients’ results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

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“…The SSTS combines a test for moderate-to-severe hemiparesis with ambulance-hospital teleconsultation, to identify patients with a high likelihood of LAO with EVT indication, for PSC bypass. The SSTS predicts LAO and EVT with high accuracy both within 6 and 6-24 h from onset or last known well, and has reduced regional median onset-to-puncture time in EVT by 69 min, without delaying IVT (2,3). Studies on AIS have found that, unlike greater mortality, the lower poststroke functional level and quality of life in women remains significant after adjustment for prestroke mRS and age (4-6).…”

Section: Introductionmentioning

confidence: 99%

Sex Equitable Prehospital Stroke Triage Using Symptom Severity and Teleconsultation

et al. 2021

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Objectives: We aimed to determine whether there are sex differences in prehospital accuracy of the Stockholm Stroke Triage System (SSTS) to predict large artery occlusion (LAO) stroke, and endovascular thrombectomy (EVT), and whether clinical characteristics differ between men and women undergoing “code stroke” ambulance transport.Materials and Methods: This prospective observational study collected data between October 2017 and October 2018. We included 2,905 patients, transported as “code stroke,” by nurse-staffed ground ambulance, to a Stockholm Region hospital. Exclusion criteria were private or helicopter transport, onset outside Stockholm, and in-hospital stroke. We compared overall accuracy, sensitivity, specificity, positive and negative predictive values, and clinical characteristics between sexes.Results: No significant sex differences in SSTS predictive performance for LAO or EVT were found, overall accuracy for LAO 87.3% in women vs. 86.7% in men. Women were median 4 years older and more frequently had stroke mimics (46.2 vs. 41.8%). Women more commonly had decreased level of consciousness (14.0 vs. 10.2%) and moderate-to-severe motor symptoms (by 2.7–3.8 percentage points), and less commonly limb ataxia (7.2 vs. 9.7%).Conclusions: The SSTS had equal predictive performance for LAO and EVT among men and women, despite minor sex differences in the clinical characteristics in patients undergoing ambulance transport for suspected stroke.

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Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset

Cited by 8 publications

References 14 publications

The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation

The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation

Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

Sex Equitable Prehospital Stroke Triage Using Symptom Severity and Teleconsultation

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