Improving access to acute stroke therapies: a controlled trial of organised pre‐hospital and emergency care

Abstract

Objective: To assess the effectiveness of the PAST (Pre‐hospital Acute Stroke Triage) protocol in reducing pre‐hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy. Design: Prospective cohort study using historical controls. Setting: Hunter Region of New South Wales, September 2005 to March 2006 (pre‐intervention) and September 2006 to March 2007 (post‐intervention). Participants: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital. Intervention: PAST protocol, comprising a pre‐hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis‐eligible patients, and pre‐hospital notification of the acute stroke team. Main outcome measures: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA. Results: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre‐intervention) to 21.4% (post‐intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months. Conclusions: Organised pre‐hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke‐related disability.

Stroke thrombolysis in England, Wales and Northern Ireland: how much do we do and how much do we need?

“…It has been shown that where the FAST22 is being used patients are more likely to be thrombolysed but this may simply reflect services organising themselves to deliver care effectively. An Australian randomised controlled trial has shown that a prehospital protocol increases access to treatment23 and this has also been demonstrated in the USA 24. Improving public awareness of the symptoms of stroke and how to respond when they happen is being addressed in England with a major advertising campaign funded by the Department of Health and ongoing awareness raising by the Stroke Association, although the efficacy of such campaigns remains unproven.…”

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

“…Careful delineation of the phases of care was carried out by the research team on the basis of earlier work at a single site [40], beginning at the point of seeking emergency medical care (hospital or paramedic). The situational analysis follows the journey of a stroke patient including pre-hospital assessment, triage, clinical assessment, imaging, final clinical assessment, preparation and delivery of thrombolysis.…”

“…The TIPS website also contains scientific literature relating to thrombolysis, and tools and resources such as those from the PAST trial [40]. In addition to training in decision making skills, training in the skills of being a champion will be provided.…”

“…A description of the series of tasks involved in the delivery of timely thrombolysis (see Table 1) illustrates the number of tasks, complexity, multidisciplinary nature, and time urgency involved in successful delivery of thrombolysis for acute stroke. An Australian study at a single large teaching hospital (Pre-hospital Acute Stroke Triage [PAST]) developed and implemented a pre-hospital stroke assessment tool for ambulance officers and a pre-hospital notification system following assessment of system barriers [40]. The PAST study demonstrated an increase in tPA rates from 4.7% to 21.4% [40].…”

“…An Australian study at a single large teaching hospital (Pre-hospital Acute Stroke Triage [PAST]) developed and implemented a pre-hospital stroke assessment tool for ambulance officers and a pre-hospital notification system following assessment of system barriers [40]. The PAST study demonstrated an increase in tPA rates from 4.7% to 21.4% [40]. …”