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Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches

Abstract

Intravenous thrombolysis and endovascular thrombectomy are the only approved reperfusion treatments available for patients with acute ischemic stroke. Despite the advances in reperfusion therapy, time continues to be a critical factor in the delivery of reperfusion treatment in acute stroke settings. In recent years, some systems-based approaches have been pursued with considerable success. However, approaches aimed at optimising and reducing treatment delays specifically in the prehospital settings are limited. A systems-based approach aimed at improving the process of care in the prehospital setting may result in the reduction of treatment delays and potentially improve clinical outcomes. In this article, we present an overview of the current prehospital acute stroke pathway. Areas to reduce treatment delays are identified and optimisations to the prehospital workflow addressing the identified gaps in acute stroke settings are proposed. Improving process and system gaps would translate to improved post-stroke outcomes following reperfusion therapy.

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Availability of Data and Material

All data generated or analysed during this study are included in this published article and Supplementary Information (SI) attached.

Abbreviations

ABCD-E2:

Ataxia, Blindness, Consciousness, Dysphagia, Eye 1 (Diplopia), Eye 2 (Pupillary abnormalities)

ACT-FAST:

Ambulance clinical triage for acute stroke treatment

AIS:

Acute ischemic stroke

aPPT:

Activated partial thromboplastin time

BEFAST:

Balance Eyes Face Arms Speech Test

BP:

Blood pressure

CALD:

Culturally and linguistically diverse communities

CI:

Confidence interval

CPSS:

Cincinnati Prehospital Stroke Scale

CSC:

Comprehensive Stroke Centre

C-STAT:

Cincinnati Stroke Triage Assessment Tool

CT:

Computed tomography scan

CTN:

Call to needle time

ED:

Emergency department

EMD:

Emergency medical dispatcher

EMS:

Emergency medical services

EMSA:

Emergency Medical Stroke Assessment

EVT:

Endovascular thrombectomy

FAST:

Face Arms Speech Test

FAST-ED:

Field Assessment Stroke Triage for Emergency Destination

GFAP:

Glial fibrillary acidic protein

G-FAST:

Gaze Face Arm Speech Test

GP:

General practitioner

ICH:

Intracerebral haemorrhage

INR:

International normalised ratio

iTREAT:

Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine

IV:

Intravenous

IVT:

Intravenous thrombolysis

LAMS:

Los Angeles Motor Scale

LAPSS:

Los Angeles Prehospital Stroke Scale

LMWH:

Low molecular weight heparin

LVO:

Large vessel occlusion

MASS:

Melbourne Ambulance Stroke Scale

MedPACS:

Medic Prehospital Assessment for Code Stroke

MPDS:

Medical Priority Dispatch System

mRS:

Modified Rankin Scale

MSU:

Mobile Stroke Unit

NIH:

National Institute of Health

NIHSS:

National Institute of Health Stroke Scale

NPV:

Negative predictive value

OPSST:

Ontario Prehospital Stroke Screening Tool

OR:

Odds ratio

OST:

On scene time

PASS:

Prehospital Acute Stroke Severity Scale

ParaNASPP:

Paramedic—Norwegian Acute Stroke Prehospital Project

PCS:

Posterior circulation stroke

POC:

Point of care

PPV:

Positive predictive value

PreHAST:

PreHospital Ambulance Stroke Test

PRESTO:

Pre-hospital Triage of Patients with Suspected Stroke Symptoms

PSC:

Primary Stroke Centre

RACE:

Rapid Arterial Occlusion Evaluation

RACECAT:

Transfer to the Local Stroke Center Versus Direct Transfer to Endovascular Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory

RCT:

Randomised control trial

ROSIER:

Recognition of Stroke in the Emergency Room

SSTS:

Stockholm Stroke Triage System

STRATIS:

Systematic Evaluation of Patients Treated with Stroke Devices for Acute Ischemic Stroke

tPA:

Tissue plasminogen activator

TRIAGE:

Treatment Strategy in Acute Large Vessel Occlusion

VAN:

Stroke Vision Aphasia Neglect Assessment

VES:

Ventura Emergent Large Vessel Occlusion Score

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Acknowledgements

We would like to acknowledge the support from the administrative staff and our NSW-wide clinician and investigator partners.

Funding

Seed funding from the UNSW Medicine Mindgardens CAG funding 2017 for the Thrombolysis and Endovascular FLow Network (TEFLON) trial (Chief Investigator: Dr Sonu Bhaskar) and funding for the NSW Brain Clot Bank (Chief Investigator: Dr Sonu Bhaskar) from the NSW Ministry of Health (2019–2022) is acknowledged. The funding body has no role in the study design, data collection, analysis, interpretation of findings and manuscript preparation.

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SMMB conceived the study, contributed to the planning, draft and revision of the manuscript; supervision of the students and the conduct of the trial; towards ethics submission and statewide leadership and networking development. SMMB and SC wrote the first draft of the manuscript. SC contributed to the literature review, writing and revision of the manuscript. All authors contributed to the revision of the manuscript. All authors approved the final draft of the manuscript.

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Correspondence to Sonu Menachem Maimonides Bhaskar.

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Chowdhury, S.Z., Wardman, D., Cordato, D.J. et al. Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches. SN Compr. Clin. Med. 3, 2558–2575 (2021). https://doi.org/10.1007/s42399-021-01069-x

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Keywords

  • Stroke
  • Reperfusion therapy
  • Health systems
  • Prehospital workflow
  • Ambulatory
  • Prehospital screening
  • Cerebrovascular diseases