Once again you have to have the proper stroke with the correct presentations to be treated properly. This leaves vast numbers of strokes left behind. NOT ACCEPTABLE. Do you think you can accomplish that? No consequences to the doctors for not having prepared for all eventualities. But severe consequences to the stroke survivors, if they survive.
Pre-hospital Triage of Acute Ischemic Stroke Patients—Importance of Considering More Than Two Transport Options
Ludwig Schlemm
Eckhard Schlemm
Christian H. Nolte
Matthias Endres- 1Department of Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- 2Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- 3Berlin Institute of Health (BIH), Berlin, Germany
- 4Medizinische Fakultät, Universität Hamburg, Hamburg, Germany
- 5Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- 6DZHK (German Center for Cardiovascular Research), Partner Site, Berlin, Germany
- 7DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin, Germany
Background: Patients with acute
ischemic stroke (AIS) and large vessel occlusion benefit from rapid
access to mechanical thrombectomy in addition to intravenous
thrombolysis. Prehospital triage algorithms to determine the optimal
transport destination for AIS patients with unknown vessel status have
so far only considered two alternatives: the nearest comprehensive (CSC)
and the nearest primary stroke center (PSC).
Objective: This study explores the importance of considering a larger number of PSCs during pre-hospital triage of AIS patients.
Methods: Analysis was performed in
random two-dimensional abstract geographic stroke care infrastructure
environments and two models based on real-world geographic scenarios.
Transport times to CSCs and PSCs were calculated to define sub-regions
with specific triage properties. Possible transport destinations
included the nearest CSC, the nearest PSC, and any of the remaining PSCs
that are not closest to the scene, but transport to which would imply a
shorter total time-to-CSC-via-PSC.
Results: In abstract geographic
environments, the median relative size of the sub-region where a triage
decision is required ranged from 34 to 92%. The median relative size of
the sub-region where more than two triage options need to be considered
ranged from 0 to 56%. The achievable reduction in time-to-thrombectomy
(“benefit”) exceeded the increase in time-to-thrombolysis (“harm”) by a
factor of 2 in 30.5–37.0% of the sub-region where more than two triage
options need to be considered. Results were confirmed in geographic
environments based on real-world urban and rural stroke care
infrastructures.
Conclusion: Pre-hospital triage
algorithms for AIS patients that only take into account the nearest CSC
and the nearest PSC as transport destinations may be unable to identify
the optimal transport destination for a significant proportion of
patients.
Introduction
Background
International guidelines recommend early administration
of intravenous thrombolysis for eligible patients with acute ischemic
stroke (AIS); in addition, patients with proximal large vessel occlusion
(LVO) should receive mechanical thrombectomy (MT) as quickly as
possible (1). As the clinical benefit of both thrombolysis (2–4) and MT (5–7) diminishes over time, research efforts in recent years have focused on improving clinical outcome by reducing pre-hospital (8–10) and intra-hospital delays (11, 12).
With regard to pre-hospital delays, directly transporting AIS patients
to an MT-capable comprehensive stroke center (CSC) instead of a nearer
non-MT-capable primary stroke center (PSC) has been suggested as one
strategy to reduce time to MT for patients with LVO (13).
Given that information about the vessel status of patients is typically
not available to emergency medical personnel in the field, patients
that are likely to benefit from direct transportation to a CSC need to
be selected based on clinical and demographic variables. Several
clinical pre-hospital stroke severity scales with similar accuracies to
estimate the likelihood of LVO exist (14);
however, the optimal instruments as well as the most appropriate cutoff
values to inform pre-hospital triage decisions and to select patients
for direct transportation to a CSC are not currently known (1).
Previous studies that explored the impact of triage algorithms to
determine the most adequate transport destination for AIS patients only
allowed for a decision between two alternatives, namely transport to the
nearest CSC, bypassing all PSCs; and transport to the nearest PSC (15–17).
However, clinical experience as well as fundamental geographic
observations suggest that oftentimes a PSC that is not nearest to the
scene, but from which a patient could be transferred quickly to a CSC if
necessary, might be a better primary transport destination option than
the nearest PSC.
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