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Prehospital Phase of the Stroke Chain of Survival: A Prospective Observational Study.

ABSTRACT: Few studies have discussed the emergency call and prehospital care as a continuous process to decrease the prehospital and in-hospital delays for acute stroke. To identify features associated with early hospital arrival (<90 minutes) and treatment (<120 minutes), we analyzed the operation of current dispatch protocol and emergency medical services and compared stroke recognition by dispatchers and ambulance crews.This was a 2-year prospective observational study. All stroke patients who were transported to the hospital by emergency medical services and received recanalization therapy were recruited for the study. For a sample of 308 patients, the stroke code was activated in 206 (67%) and high priority was used in 258 (84%) of the emergency calls. Emergency medical services transported 285 (93%) of the patients using the stroke code and 269 (87%) using high priority. In the univariate analysis, the most dominant predictors of early hospital arrival were transport using stroke code (P=0.001) and high priority (P=0.002) and onset-to-call (P<0.0001) and on-scene times (P=0.052). In the regression analysis, the influences of high-priority transport (P<0.01) and onset-to-call time (P<0.001) prevailed as significant in both dichotomies of early arrival and treatment. The on-scene time was found to be surprisingly long (>23.5 minutes) for both early and late-arriving patients.Fast emergency medical services activation and ambulance transport promoted early hospital arrival and treatment. Although patient-dependent delays still dominate the prehospital process, it should be ensured that the minutes on the scene are well spent.

SUBMITTER: Puolakka T

PROVIDER: S-EPMC4889170 | biostudies-other | 2016 May

REPOSITORIES: biostudies-other

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Project description:IntroductionThe efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting.Methods and analysisPrehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve.Ethics and disseminationThe Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients.Trial registration numberNTR7595.

Project description:BACKGROUND:Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS:Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS:Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. CONCLUSION:Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. LEVEL OF EVIDENCE:Level II.

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Prehospital Phase of the Stroke Chain of Survival: A Prospective Observational Study.

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