A Citywide Prehospital Protocol Increases Access to Stroke Thrombolysis in Toronto

Abstract

Background and Purpose— Intravenous tissue plasminogen activator for ischemic stroke is approved for eligible patients who can be treated within a 3-hour window, but treatment rates remain disappointingly low, often <5%. To improve rapid access to stroke thrombolysis in Toronto, Canada, a citywide prehospital acute stroke activation protocol was implemented by the provincial government to transport acute stroke patients directly to one of 3 regional stroke centers, bypassing local hospitals. This comprised a paramedic screening tool, ambulance destination decision rule, and formal memorandum of understanding of system stakeholders. This report describes the initial impact of the activation protocol at our regional stroke center. Methods— We compared consecutive patients with stroke arriving to our stroke center during the first 4 months of this new triage protocol (February 14 to June 14, 2005) versus the same 4-month period in 2004. Results— The protocol resulted in an immediate doubling in the number of patients with acute stroke arriving to our regional stroke center within 2.5 hours of symptom onset. We observed a 4-fold increase in patients who were eligible for and treated with tissue plasminogen activator. The tissue plasminogen activator treatment rate for ischemic stroke patients increased from 9.5% to 23.4% ( P =0.01), and one in 2 patients with ischemic stroke arriving within 2.5 hours received thrombolysis during this period (one in 5 of patients with ischemic stroke overall). The median onset-to-needle time for tissue plasminogen activator-treated patients was significantly reduced. Many implementation challenges were identified and addressed. Conclusions— This prehospital triage was immediately successful in improving tissue plasminogen activator access for patients with ischemic stroke, enabling our center to achieve one of the highest tissue plasminogen activator treatment rates in North America and underscoring the need for coordinated systems of acute stroke care. Sustainability of such an initiative will be dependent on interdisciplinary teamwork, ongoing paramedic training, adequate hospital staffing, bed availability, and repatriation agreements with community hospitals.

Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke

“…14 Implementing these tools as part of a coordinated prehospital stroke strategy, including prehospital notification and targeted transport to dedicated stroke centers, results in shorter times to thrombolysis and increased proportions of stroke patients receiving thrombolytic therapy. 5,15 Prehospital protocols assigning stroke patients to the highest transport priority level do not appear to negatively influence transport times for other medical emergencies. 15 The use of such strategies is likely one of the core reasons for the observed decline in prehospital delays to accessing thrombolytic therapy over the past decade.…”

“…Evidence now shows that coordinated prehospital stroke strategies, including prehospital notification and targeted transport to dedicated stroke centers, results in shorter times to thrombolysis and increased proportions of stroke patients receiving thrombolytic therapy. 5 However, not all sites have this capability; administration of thrombolysis requires efficient ED systems, prompt 24-hour imaging capability, and access to clinicians with expertise in stroke. Integrated telestroke systems provide access to stroke expertise for those centers that do not have local resources.…”

“…Prehospital triage and transportation protocols should identify facilities locally or regionally designated to receive acute stroke patients and bypass more proximal facilities in favor of transporting to these sites, assuming the absence of other immediately life-threatening conditions (STRONG RECOMMENDATION, MODERATE QUALITY EVIDENCE). 5,7,10,11 2. Emergency departments that treat acute stroke patients should have "Code Stroke" protocols or stroke teams to rapidly assess, image and treat patients with the highest priority (STRONG RECOMMENDATION, MODERATE QUALITY EVIDENCE).…”

The Role of EMS in Regionalized Systems of Care

“…Ineffective bypass systems can lead to increased costs, inefficient use of both hospital-based and EMS resources, and over-crowding of regional-based centres. 32 Prehospital bypass activates a significant number of resources dedicated to the care of individual patients, decreasing the resources available to care for other patients. Each disease-specific system is unique, and it is therefore difficult to quantify a universal number of false-positives that would be deemed "acceptable."…”

“…28,29 A recent study by Gomez et al concluded that prehospital bypass was associated with a 3.5 hour (IQR 1.7 to 4.5 hours) reduction in time to arrival at a trauma centre, compared to transport and subsequent transfer from a non-trauma centre; 30 this reduction in time is important, considering that the majority of deaths from trauma occur within the first 24 hours after injury. 31 Similarly, prehospital stroke bypass has improved patient access to thrombolytics, 32 and STEMI bypass programs have significantly reduced the time from initial medical contact to percutaneous coronary intervention (PCI), compared to initial transportation to the nearest ED 9,33 . These cardiac programs have been shown to be associated with a decrease in short-term mortality.…”