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.
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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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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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DOI: https://doi.org/10.1007/s42399-021-01069-x