Regional Access to Acute Ischemic Stroke Intervention

Abstract

Background and Purpose-Benefit-risk ratios from recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke demonstrate lack of efficacy if intravenous administration is commenced beyond 3 hours of symptom onset. We undertook to enhance therapeutic effectiveness by ensuring equitable access to rtPA for patients affected by acute ischemic stroke within a 20 000 km 2 population referral base served by a tertiary facility. Methods-Representatives of all provider groups involved in emergency medical services developed a Regional Acute Stroke Protocol (RASP), a coordinated regional system response by dispatch personnel, paramedics, physicians, community service providers, emergency and inpatient staff in community hospitals, and the tertiary facility acute stroke team. Results-As of July 26, 1999, all ambulance services in Southeastern Ontario began bypassing the closest hospital to deliver patients meeting the criteria for the RASP to the Kingston General Hospital. At 12 months, approximately 403 ischemic strokes have occurred in the region, the RASP has been activated 191 times, and 42 patients have received rtPA. Conclusions-We conclude that (1) acute stroke patients in Southeastern Ontario have improved access to interventions for stroke care; (2) geography of the region is not a barrier to access to interventions for patients with acute stroke; and (3) acute ischemic stroke patients treated with rtPA account for 5% of all acute strokes and 10% of all ischemic strokes in this region. (Stroke. 2001;32:652-655.)

A Citywide Prehospital Protocol Increases Access to Stroke Thrombolysis in Toronto

“…[7][8][9][10][11][12][13][14][15] We suspect that the increased proportion of patients arriving Ͻ2.5 hours resulted from a combination of more patients being transported to our center (rather than to a community hospital) plus patients being identified and transported faster by paramedics, although we cannot determine the relative contributions of these factors from the available data. For the tPA-treated patients, onset-to-arrival times were actually longer after implementation of the protocol, probably reflecting the transport of more patients from farther distances.…”

Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care

“…Currently, 1 important benefit for patients of the close collaboration between EMS responders and ED providers is the ability of EMS responders to facilitate rapid treatment at the hospital through prearrival notification. 35,74 Prearrival hospital notification by EMS responders who are known to accurately recognize stroke patients can increase the likelihood that hospitals quickly receive and treat stroke patients. 36 Physicians, nurses, computed tomography/magnetic resonance technologists, pharmacists, and others are able to use early notification to mobilize necessary resources for the patient.…”

Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care

“…7 Data from the Registry of the Canadian Stroke Network, which included information from 21 hospitals in 8 provinces from June 2001 to February 2002, indicated variations in the time from stroke onset to hospital arrival, administration of acute thrombolysis, admission to units specializing in stroke care and use of anticoagulants in patients with atrial fibrillation. 7 Populationbased chart audits from across Canada [8][9][10][11][12] indicated considerable variations in stroke care across geographic regions and across hospitals based on their size and designation as a "stroke centre." The 2006 National Stroke Audit in the United Kingdom, the Get With The Guidelines program in the United States and a pilot analysis of stroke indicators in Germany also reported performance differences across sites on several similar stroke indicators.…”