Prehospital Phase of the Stroke Chain of Survival: A Prospective Observational Study

Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study

OBJECTIVES

Stroke prevalence is progressively increasing in developing countries due to increased vascular risk factors. This study aims to describe the epidemiology, prevalent risk factors, and outcomes of stroke in a multi-ethnic society of Qatar.

MATERIALS AND METHODS

We conducted a retrospective analysis of all patients with suspected stroke admitted to stroke services between January 2014 and September 2020.

RESULTS

A total of 11,892 patients were admitted during this period with suspected stroke. Of these, the diagnosis was ischemic stroke (48.8 %), transient ischemic attack (10.3 %), intracerebral hemorrhage (10.9 %), cerebral venous sinus thrombosis (1.3 %), and stroke mimics (28.6 %). The median age was 52 (43-62), with a male-female ratio of 3:1. The study population was predominantly Asian (56.8 %) and Arab (36 %). The majority of the patients were hypertensive (66.8 %), diabetic (47.9 %), and dyslipidemic (45.9 %). A history of prior stroke was observed in 11.7 %, while 0.9 % had prior transient ischemic attack. Among ischemic strokes, 31.7 % arrived within 4.5 h, 12.5 % received thrombolysis, and 4.6 % underwent thrombectomy. Median Door-to-Needle time was 51 (33-72) minutes. The average length of stay was 5.2 ± 9.0 days, with 71.5 % discharged home, 13.8 % transferred to rehabilitation, 9.3 % to other specialties, 3 % to long-term care, and 2.4 % suffered in-hospital mortality.

CONCLUSION

Stroke in Qatar is characterized by a younger, expatriate-dominant cohort, with notable prevalence of ischemic and hemorrhagic stroke and a distinct risk factor profile. Further analysis of epidemiological differences among different population groups can inform targeted policies for prevention and management to reduce the burden of disease.

Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals

INTRODUCTION

This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care.

METHODS

The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis.

RESULTS

The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients' utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups.

CONCLUSIONS

There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age.

Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.

METHODS

All cases of OHCA between 1 January 2016 and 31 December 2021 in the Helsinki University Hospital catchment area in which the ECPR protocol was activated were included in the study. The protocol involved patient transport from the emergency site with ongoing mechanical cardiopulmonary resuscitation (CPR) directly to the cardiac catheterisation laboratory where the implementation of extracorporeal membrane oxygenation (ECMO) was considered. Cases of hypothermic cardiac arrest were excluded. The main outcomes were the number of ECPR protocol activations, duration of prehospital and in-hospital time intervals, and whether the ECPR candidates were treated using ECMO or not.

RESULTS

The prehospital ECPR protocol was activated in 73 cases of normothermic OHCA. The mean patient age (SD) was 54 (±11) years and 67 (91.8%) of them were male. The arrest was witnessed in 67 (91.8%) and initial rhythm was shockable in 61 (83.6%) cases. The median ambulance response time (IQR) was 9 (7-11) min. All patients received mechanical CPR, epinephrine and/or amiodarone. Seventy (95.9%) patients were endotracheally intubated. The median (IQR) highest prehospital end-tidal CO2 was 5.5 (4.0-6.9) kPa.A total of 37 (50.7%) patients were treated with venoarterial ECMO within a median (IQR) of 84 (71-105) min after the arrest. Thirteen (35.1%) of them survived to discharge and 11 (29.7%) with a cerebral performance category (CPC) 1-2. In those ECPR candidates who did not receive ECMO, 8 (22.2%) received permanent return of spontaneuous circulation during transport or immediately after hospital arrival and 6 (16.7%) survived to discharge with a CPC 1-2.

CONCLUSIONS

Half of the ECPR protocol activations did not lead to ECMO treatment. However, every fourth ECPR candidate and every third patient who received ECMO-facilitated resuscitation at the hospital survived with a good neurological outcome.

Analysis of the Factors Intervening in the Prehospital Time in a Stroke Code

INTRODUCTION

Strokes continue to be considered public health problems due to the great social and health impact they entail. They are the second cause of death in the world, with a high incidence and prevalence. They are time-dependent diseases, and more than 80% of cases could be avoidable with greater management of risk factors.

OBJECTIVE

to analyze the factors that influence prehospital time in a stroke code. Assess the population's knowledge of stroke symptoms and teach them how to act when a case is suspected. Document the continued training of health professionals for the early identification of patients with a suspected stroke. Demonstrate the importance of calling EMS as the first contact to reduce delays in prehospital time in a stroke.

METHODOLOGY

A bibliographic review was carried out focusing on articles published between December 2014 and August 2023. The following databases were consulted: Pubmed (Medline), Dialnet, Google Scholar, Web of Science (WOS), Scielo, Scopus, and ScienceDirect.

RESULTS

After applying the article selection criteria and evaluating the quality of the methodology, a total of 18 articles were obtained. The results affirm that the importance of achieving a reduction in prehospital time is based mainly on knowledge of the symptoms and the use of new technologies.

CONCLUSIONS

The evidence supports that the prehospital time of action in the stroke code is affected by numerous factors. These factors are determining factors in the time of action to achieve good effectiveness in the treatment of the pathology.

Recognition of visual symptoms in stroke: a challenge to patients, bystanders, and Emergency Medical Services

BACKGROUND

Identification of visual symptoms as a sign of acute stroke can be challenging for both first line healthcare professionals and lay persons. Failed recognition of visual symptoms by medical dispatchers at the Emergency Medical Dispatch Center (EMDC-112) or personnel at the Out-of-Hours Health Service (OOHS) may delay stroke revascularization. We aimed to identify correct system response to visual symptoms in emergency calls.

METHODS

Phone calls from patient or bystander to the EMDC-112 or OOHS, which included visual symptoms on patients later verified with stroke/Transient ischemic attack (TIA) diagnosis, were analyzed. Data were stratified according to hospitalization within and after 4.5 h from symptom onset. Descriptive and multiple logistic regression analysis were performed.

RESULTS

Of 517 calls identified, 290 calls fulfilled inclusion criteria. Only 30% of the patients received correct visitation by the medical dispatchers and referral to the hospital by a high-priority ambulance. Correct visitation was associated with early contact (adjusted OR: 2.37, 95% CI: 1.11, 5.03), contact to the EMDC-112 (adjusted OR: 3.18, 95% CI: 1.80, 5.62), and when the medical dispatcher asked additional questions on typical stroke symptoms (adjusted OR: 6.36, 95% CI: 3.01, 13.43). No specific visual symptom was associated with stroke recognition and fast hospitalization.

CONCLUSIONS

First line healthcare professionals had significant problems in identifying visual symptoms as a sign of acute stroke and eliciting correct response. This highlights an urgent need to improve knowledge of visual symptoms in acute stroke and emphasize correct response to stroke symptoms in general.

Different words for stroke: the same concept? an analysis of associated symptoms and intended reaction in Brazil

BACKGROUND

Different names for stroke might mislead physicians and emergency medical service workers. This study aimed to assess the different words for stroke in Brazil and both intended response and related symptoms associated with those names.

METHODS

Cross-sectional study enrolling healthy individuals from urban areas in Northeast of Brazil for an open-ended survey. We presented a typical clinical case of a stroke (an elderly who had sudden onset of hemiparalysis and slurred speech) and asked "what is happening?", "what would you do?" and "which other symptoms could happen in this condition?".

RESUTS

From 1,475 interviewed individuals, 1,220 (82,7%) recognized the scenario as a stroke. There were 3 words to correctly identify (based on correct intended response and spontaneously evoked associated symptoms) the stroke, which were "AVC" (acronym for cerebrovascular accident, in Portuguese), "derrame" (spillage) and "trombose" (thrombosis). There were significant differences among them concerning demographic, economic, educational and geographical aspects, but there was no difference according to the intended reaction among them. The most cited associated symptoms (excluding those present in the case) were impaired consciousness (10.6%), headache (8.9%) and dysesthesia (7.7%). "Aneurisma" (aneurism) was also cited, by 3 individuals.

CONCLUSION

There are at least three words for stroke in Portuguese ("AVC", "derrame" and "trombose"); they were similar in terms of correct intended responses and spontaneously cited accompanying symptoms. Stroke campaigns should apply different names to reach a broader audience and to improve stroke recognition.

Impact of the first response unit on prehospital on-scene time among paramedic-suspected stroke patients: a retrospective before-after cohort study in Finland

BACKGROUND

Revascularization of an occluded artery by either thrombolysis or mechanical thrombectomy is a time-critical intervention in ischaemic stroke. Each link in the stroke chain of survival should minimize the delay to definitive treatment in every possible way. In this study, we investigated the effect of routine dispatch of a first response unit (FRU) on prehospital on-scene time (OST) on stroke missions.

METHODS

Medical dispatch of FRU together with an emergency medical service (EMS) ambulance was a routine strategy in the Tampere University Hospital area before 3 October 2018, after which the FRU has only been dispatched to medical emergencies on the decision of an EMS field commander. This study presents a retrospective before-after analysis of 2,228 paramedic-suspected strokes transported by EMSs to Tampere University Hospital. We collected data from EMS medical records from April 2016 to March 2021, and used statistical tests and binary logistic regression to detect the associations between the variables and the shorter and longer half of OSTs.

RESULTS

The median OST of stroke missions was 19 min, IQR [14-25] min. The OST decreased when the routine use of the FRU was discontinued (19 [14-26] min vs. 18 [13-24] min, p < 0.001). The median OST with the FRU being the first at the scene (n = 256, 11%) was shorter than in cases where the FRU arrived after the ambulance (16 [12-22] min vs. 19 [15-25] min, p < 0.001). The OST with a stroke dispatch code was shorter than with non-stroke dispatches (18 [13-23] min vs. 22 [15-30] min, p < 0.001). The OST for thrombectomy candidates was shorter than that for thrombolysis candidates (18 [13-23] min vs. 19 [14-25], p = 0.01). The shorter half of OSTs were associated with the FRU arriving first at the scene, stroke dispatch code, thrombectomy transportation and urban location.

CONCLUSION

The routine dispatch of the FRU to stroke missions did not decrease the OST unless the FRU was first to arrive at the scene. In addition, a correct stroke identification in the dispatch centre and thrombectomy candidate status decreased the OST.

Finnish emergency medical services managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues: a qualitative study

OBJECTIVES

This study aimed to describe emergency medical services (EMS) managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues in the EMS.

DESIGN

The study used a descriptive qualitative approach. Five focus groups and two individuals were interviewed using a semi-structured guide with open-ended questions. The data were analysed using reflexive thematic analysis. Consolidated criteria for Reporting Qualitative research was used to guide the reporting of this study.

SETTING

EMS organisations from Finland's five healthcare districts.

PARTICIPANTS

EMS medical directors (n=5) and EMS managers (n=14). Purposive sampling was used.

RESULTS

Two main themes, 'Patient safety considered an organisational responsibility' and 'EMS patients' opportunities and obstacles to speaking up', were generated from the data. Under the main theme, 'Patient safety considered an organisational responsibility', were three subthemes: patient safety considered part of the quality in EMS, system-level models for handling and observing patient safety in EMS, and management's ability to find a balance when using patients' feedback for patient safety development. Under the other main theme were four subthemes: 'social and feedback skills of EMS personnel and management', 'managements' assumptions of patients' reasons for not speaking up', 'EMS organisations' different but unsystematic ways of collecting feedback' and 'management's openness to develop patient participation'.

CONCLUSIONS

The nature of the EMS organisations and EMS assignments could affect a patient's participation in developing patient safety in EMS. However, EMS managers and medical directors are receptive to collaborating with patients concerning patient safety issues if they have sufficient resources and a coherent way to collect patient safety concerns. The management is open to collaborating with patients, but there is a need to develop a systematic method with enough resources to facilitate the management's collaborating with patients.

Assessment of stroke knowledge and awareness among primary healthcare providers: A cross-sectional survey from the Kezhou quality improvement in acute stroke care project

Objective

Acute stroke care is a highly complex type of emergency medical service (EMS) involving patient-centered care in a highly unpredictable and stressful environment with the help of several busy providers. The ability of primary healthcare providers (PHPs) to identify stroke onset early and further manage referrals to higher-level hospitals becomes critical.

Methods

We conducted a cross-sectional survey about stroke knowledge and awareness among PHPs in China from September 2021 to December 2021. A total of 289 PHPs were divided into two groups, the stroke treatment window (STW) Aware group vs. the STW Unaware group according to their knowledge on the time window for acute ischemic stroke (AIS) management. Logistic regression analysis was performed to explore the predictors associated with knowledge of the time window for acute stroke management.

Results

Of 289 PHPs surveyed during the study period, 115 (39.7%) participants were aware of the time window for stroke management and were in the STW Aware group, while 174 (60.2%) were in the STW Unaware group. Forty percent of PHPs in the STW Aware group were familiar with the secondary stroke prevention goal of &lt;140/90 mmHg, compared with 27.01% in the Unaware group (P &lt; 0.05). PHPs were not sufficiently aware of loss of consciousness also a symptom of stroke in two groups (75.7 vs. 62.6%, P &lt; 0.05). A higher proportion of PHPs in the STW Aware group believed that thrombolysis was an effective treatment for AIS (96.5 vs. 79.9%, P &lt; 0.01). Endovascular therapy is indicated for AIS was perceived by a higher proportion of PHPs in the STW Aware group than that in the Unaware group (62.6 vs. 6.9%, P &lt; 0.01). Eighty percent of PHPs in the STW Aware group reported attending training on stroke management compared with 58.1% in the Unaware group (P &lt; 0.01). Logistic regression results showed that the predictors of stroke knowledge and awareness among PHPs included sex (OR: 2.3, 95% CI, 1.2–4.6), received training (OR: 2.9, 95% CI, 1.60–5.1), and times of training per year (OR: 0.70, 95% CI, 0.6–0.9).

Conclusions

PHPs present with a mild to moderate level of stroke management knowledge in northwest China. Strategies to help increase stroke knowledge and awareness among PHPs should be considered in order to help improve the stroke related health service system.

Differences between the dispatch priority assessments of emergency medical dispatchers and emergency medical services: a prospective register-based study in Finland

BACKGROUND

Responsive and efficient emergency medical services (EMS) require accurate telephone triage. In Finland, such services are provided by Emergency Response Centre Agency (ERC Agency). In 2018, a new Finnish computer-assisted emergency dispatch system was introduced: the Emergency Response Integrated Common Authorities (ERICA). After the introduction of ERICA, the appropriateness of EMS dispatch has not been investigated yet. The study´s objective is to determine the consistency between the priority triage of the emergency medical dispatcher (EMD) and the on-scene priority assessment of the EMS, and whether the priority assessment consistency varied among the dispatch categories.

METHODS

This was a prospective register-based study. All EMS dispatches registered in the Tampere University Hospital area from 1 August 2021 to 31 August 2021 were analysed. The EMD's mission priority triaged during the emergency call was compared with the on-scene EMS's assessment of the priority, derived from the pre-set criteria. The test performance levels were measured from the crosstabulation of true or false positive and negative values of the priority assessment. Statistical significance was analysed using the chi-square test and the Kruskal-Wallis H test, and p-values < 0.05 were considered significant.

RESULTS

Of the 6416 EMS dispatches analysed in this study, 36% (2341) were urgent according to the EMD's dispatch priority, and of these, only 29% (688) were urgent according to the EMS criteria. On the other hand, 64% (4075) of the dispatches were non-urgent according to the EMD's dispatch priority, of which 97% (3949) were non-urgent according to the EMS criteria. Moreover, there were differences between the EMD and EMS priority assessments among the dispatch categories (p < 0.001). The overall efficiency was 72%, sensitivity 85%, specificity 71%, positive predictive value 29%, and negative predictive value 97%.

CONCLUSION

While the EMD recognised the non-urgent dispatches with high consistency with the EMS criteria, most of the EMD's urgent dispatches were not urgent according to the same criteria. This may diminish the availability of the EMS for more urgent missions. Thus, measures are needed to ensure more accurate and therefore, more efficient use of EMS resources in the future.

Evaluation of stroke pre-hospital management in Lebanon from symptoms onset to hospital arrival and impact on patients' status at discharge: a pilot study

BACKGROUND

Hospital arrival time after acute ischemic stroke onset is the major factor limiting the eligibility of patients to receive intravenous thrombolysis. Shortening the prehospital delay is crucial to reducing morbidity and mortality for stroke patients. The study was conducted to investigate the factors that influence hospital arrival time after acute stroke onset in the Lebanese population and to assess the effect of the prehospital phase on patients' prognosis at discharge.

METHOD

A prospective cross-sectional study was performed in eleven hospitals from April to July 2021 including 100 patients having stroke symptoms or transient ischemic attack (TIA). Two questionnaires were used to collect data addressing patient management in the pre-hospital phase and the in-hospital phase. Descriptive and bivariate analyses were done to evaluate the potential associations between prognosis, pre-hospital characteristics, and other factors.

RESULTS

The patients' mean age was 70.36 ± 12.25 years, 43 (53.8%) of them were females, and 79 (85%) arrived within 3 hours after symptoms onset. Diabetic patients had a significant delay in hospital arrival compared with non-diabetics (27.0%vs.7.1%, p-value = 0.009). Moreover, 37 (75.5%) of school-level education patients arrived early at the hospital compared to 7 (100%) of university-level education (p-value = 0.009). The modified Rankin Scale (mRS) at discharge in patients with hemorrhagic stroke (10 (90%)) was worse than that in patients with ischemic stroke (38 (80%)) or TIA (3 (15%)) (p-value< 0.001).

CONCLUSION

The study findings make it imperative to raise awareness about stroke symptoms among the Lebanese population. Emergency Medical Services should be utilized appropriately in the transportation of stroke patients to achieve optimal patient outcomes.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms

Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.

Comparison of large vessel occlusion scales using prehospital patient reports

BACKGROUND

Prehospital identification of large vessel occlusion (LVO) holds significant potential to decrease the onset-to-treatment time. Several prehospital scales have been developed to identify LVO but data on their comparison has been limited. The aim of this study was to review the currently available prehospital LVO scales and compare their performance using prehospital data.

METHODS

All patients transported by ambulance using stroke code on a six-month period were enrolled into the study. The prehospital patient reports were retrospectively evaluated by two investigators using sixteen LVO scales identified by literature search and expert opinion. After the evaluation, the computed tomography angiography results were reviewed by a neuroradiologist to confirm or exclude LVO.

RESULTS

Sixteen different LVO scales met the predetermined study criteria and were selected for further comparison. Using them, a total of 610 evaluations were registered. The sensitivity of the scales varied between 8%-73%, specificity between 71%-97% and overall accuracy between 71%-87%. The areas under curve (AUC) varied between 0.61-0.80 for the whole scale range and 0.53%-0.74 for the scales' binary cut-offs. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was the only scale with AUC > 0.8. Regarding scales' binary cut-offs, The FAST-ED (0.70), Gaze - Face Arm Speech Time (G-FAST) (0.74) and Emergency Medical Stroke Assessment (EMSA) (0.72) were the only scales with AUC > 0.7.

CONCLUSIONS

In a comparison of 16 different LVO scales, the FAST-ED, G-FAST and EMSA achieved the highest overall performance.

Association between dispatch complaint and critical prehospital time intervals in suspected stroke 911 activations in the National Emergency Medical Services Information System, 2012-2016

OBJECTIVE

Emergency Medical Services can help improve stroke outcomes by recognizing stroke symptoms, establishing response priority for 911 calls, and minimizing prehospital delays. This study examines 911 stroke events and evaluates associations between events dispatched as stroke and critical EMS time intervals.

MATERIALS AND METHODS

Data from the National Emergency Medical Services Information System, 2012 to 2016, were analyzed. Activations from 911 calls with a primary or secondary provider impression of stroke were included for adult patients transported to a hospital destination. Three prehospital time intervals were evaluated: (1) response time (RT) ≤8 min, (2) on-scene time (OST) ≤15 min, and (3) transport time (TT) ≤12 min. Associations between stroke dispatch complaint and prehospital time intervals were assessed using multivariate regression to estimate adjusted risk ratios (ARR) and 95% confidence intervals (CIs).

RESULTS

Approximately 37% of stroke dispatch complaints were identified by EMS as a suspected stroke. Compared to stroke events without a stroke dispatch complaint, median OST was shorter for events with a stroke dispatch (16 min vs. 14 min, respectively). In adjusted analyses, events dispatched as stroke were more likely to meet the EMS time benchmark for OST ≤15 min (OST, 1.20 [1.20-1.21]), but not RT or TT (RT, [1.00-1.01]; TT, 0.95 [0.94-0.95]).

CONCLUSIONS

Our results indicate that dispatcher recognition of stroke symptoms reduces the time spent on-scene by EMS personnel. These findings can inform future EMS stroke education and quality improvement efforts to emphasize dispatcher recognition of stroke signs and symptoms, as EMS dispatchers play a crucial role in optimizing the prehospital response.

Prehospital identification of large vessel occlusion using the FAST-ED score

OBJECTIVES

The prehospital identification of stroke patients with large vessel occlusion (LVO) enables appropriate hospital selection and reduces the onset-to-treatment time. The aim of this study was to investigate whether the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale could be reconstructed from existing prehospital patient reports and to compare its performance with neurologist's clinical judgement using the same prehospital data.

MATERIALS & METHODS

All patients transported by ambulance using stroke code on a six-month period were registered for the study. The prehospital patient reports were retrospectively evaluated using the FAST-ED scale by two investigators. The performance of FAST-ED score (≥4 points) in LVO identification was compared to neurologist's clinical judgement ('LVO or not'). The presence of LVO was verified using computed tomography angiography imaging.

RESULTS

A total of 610 FAST-ED scores were obtained. The FAST-ED had a sensitivity of 57.8%, specificity of 87.2%, positive predictive value (PPV) of 37.3%, negative predictive value (NPV) of 93.4% and area under curve (AUC) of 0.724. Interclass correlation coefficient for both raters over the entire range of FAST-ED was 0.92 (0.88-0.94). The neurologist's clinical judgement raised sensitivity to 79.4%, NPV to 97.1% and PPV to 45.0% with an AUC of 0.837 (p < .05).

CONCLUSIONS

The existing patient report data could be feasibly used to reconstruct FAST-ED scores to identify LVO. The binary FAST-ED score had a moderate sensitivity and good specificity for prehospital LVO identification. However, the FAST-ED was surpassed by neurologist's clinical judgement which further increased the sensitivity of identification.

Patient-reported factors associated with early arrival for stroke treatment

OBJECTIVE

Timely evaluation and initiation of treatment is the key for improving stroke outcomes, although minimizing the time from symptom onset to the first contact with healthcare professionals remains a challenge. We aimed to identify patient-related factors associated with early hospital arrival.

MATERIALS AND METHODS

In this cross-sectional survey, we included patients with stroke or transient ischemic attack admitted directly to one of two noncomprehensive stroke units or transferred to the units from comprehensive stroke centers in the Capital Region of Denmark. Patient-reported factors associated with early hospital arrival were analyzed using multivariable logistic regression analysis adjusted for age, sex, education, living arrangement, brain location of the stroke, stroke severity, patient-perceived symptom severity, history of prior stroke, stroke risk factors, and knowledge of stroke symptoms.

RESULTS

In total, 479 patients with acute stroke were included (median age 74 (25th-75th percentile, 64-80), 40% women), of whom 46.4% arrived within 180 min of symptom onset. Factors associated with early hospital arrival were patients or bystanders choosing emergency medical service (EMS) for the first contact with a medical professional (adjusted odds ratio (OR), 3.41; 95% confidence interval, CI [1.57, 7.35]) or the patient's perceived symptom severity above the median score of 25 on a 100-point verbal scale (adjusted OR, 2.44; 95% CI [1.57, 3.82]). Living alone reduced the likelihood of early arrival (adjusted OR, 0.53; 95% CI [0.33, 0.86]).

CONCLUSIONS

Only when patients perceived symptoms as severe or when EMS was selected as the first contact, early arrival for stroke treatment was ensured.

Emergency medical dispatchers' ability to identify large vessel occlusion stroke during emergency calls

Background

In acute ischemic stroke, conjugated eye deviation (CED) is an evident sign of cortical ischemia and large vessel occlusion (LVO). We aimed to determine if an emergency dispatcher can recognise LVO stroke during an emergency call by asking the caller a binary question regarding whether the patient’s head or gaze is away from the side of the hemiparesis or not. Further, we investigated if the paramedics can confirm this sign at the scene. In the group of positive CED answers to the emergency dispatcher, we investigated what diagnoses these patients received at the emergency department (ED). Among all patients brought to ED and subsequently treated with mechanical thrombectomy (MT) we tracked the proportion of patients with a positive CED answer during the emergency call.

Methods

We collected data on all stroke dispatches in the city of Tampere, Finland, from 13 February 2019 to 31 October 2020. We then reviewed all patient records from cases where the dispatcher had marked ‘yes’ to the question regarding patient CED in the computer-aided emergency response system. We also viewed all emergency department admissions to see how many patients in total were treated with MT during the period studied.

Results

Out of 1913 dispatches, we found 81 cases (4%) in which the caller had verified CED during the emergency call. Twenty-four of these patients were diagnosed with acute ischemic stroke. Paramedics confirmed CED in only 9 (11%) of these 81 patients. Two patients with positive CED answers during the emergency call and 19 other patients brought to the emergency department were treated with MT.

Conclusion

A small minority of stroke dispatches include a positive answer to the CED question but paramedics rarely confirm the emergency medical dispatcher’s suspicion of CED as a sign of LVO. Few patients in need of MT can be found this way. Stroke dispatch protocol with a CED question needs intensive implementation.

Prehospital time of suspected stroke patients treated by emergency medical service: a nationwide study in Thailand

Background

This work was to study the prehospital time among suspected stroke patients who were transported by an emergency medical service (EMS) system using a national database.

Methods

National EMS database of suspected stroke patients who were treated by EMS system across 77 provinces of Thailand between January 1, 2015, and December 31, 2018, was retrospectively analyzed. Demographic data (i.e., regions, shifts, levels of ambulance, and distance to the scene) and prehospital time (i.e., dispatch, activation, response, scene, and transportation time) were extracted. Time parameters were also categorized according to the guidelines.

Results

Total 53,536 subjects were included in the analysis. Most of the subjects were transported during 06.00-18.00 (77.5%) and were 10 km from the ambulance parking (80.2%). Half of the subjects (50.1%) were served by advanced life support (ALS) ambulance. Median total time was 29 min (IQR 21, 39). There was a significant difference of median total time among ALS (30 min), basic (27 min), and first responder (28 min) ambulances, Holm P = 0.009. Although 91.7% and 88.3% of the subjects had dispatch time ≤ 1 min and activation time ≤ 2 min, only 48.3% had RT ≤ 8 min. However, 95% of the services were at the scene ≤ 15 min.

Conclusion

Prehospital time from EMS call to hospital was approximately 30 min which was mainly utilized for traveling from the ambulance parking to the scene and transporting patients from the scene to hospitals. Even though only 48% of the services had RT ≤ 8 min, 95% of them had the scene time ≤ 15 min.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00361-w.

Medical dispatchers' perception of the interaction with the caller during emergency calls - a qualitative study

BACKGROUND

Medical dispatching is a highly complex procedure and has an impact upon patient outcome. It includes call-taking and triage, prioritization of resources and the provision of guidance and instructions to callers. Whilst emergency medical dispatchers play a key role in the process, their perception of the process is rarely reported. We explored medical dispatchers' perception of the interaction with the caller during emergency calls. Secondly, we aimed to develop a model for emergency call handling based on these findings.

METHODS

To provide an in-depth understanding of the dispatching process, an explorative qualitative interview study was designed. A grounded theory design and thematic analysis were applied.

RESULTS

A total of 5 paramedics and 6 registered nurses were interviewed. The emerging themes derived from dispatchers' perception of the emergency call process were related to both the callers and the medical dispatchers themselves, from which four and three themes were identified, respectively. Dispatchers reported that for callers, the motive for calling, the situation, the perception and presentation of the problem was influencing factors. For the dispatchers the expertise, teamwork and organization influenced the process. Based on the medical dispatchers´ perception, a model of the workflow and interaction between the caller and the dispatcher was developed based on themes related to the caller and the dispatcher.

CONCLUSIONS

According to medical dispatchers, the callers seem to lack knowledge about best utilization of the emergency number and the medical dispatching process, which can be improved by public awareness campaigns and incorporating information into first aid courses. For medical dispatchers the most potent modifiable factors were based upon the continuous professional development of the medical dispatchers and the system that supports them. The model of call handling underlines the complexity of medical dispatching that embraces the context of the call beyond clinical presentation of the problem.

Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke

Background and Purpose:

Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort.

Methods:

This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression.

Results:

A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74–0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93–1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy.

Conclusions:

Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.

Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

Background: Despite recent advances in acute stroke care, only 1–8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD). Objective: This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital. Methods: A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses. Results: The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47–23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09–19.34) and the weekend (OR 2.64; 95% CI 1.19–5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97–25.55), using a prenotification system (OR 6.46; 95% CI 1.71–8.39), patient’s perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60–10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38–7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32–5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16–4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03–3.82). Conclusions: The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience

Background

The use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay.

Objectives

The objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals.

Methods

The study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles.

Results

The main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively).

Conclusion

Increasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.

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Stroke management faces a lot of difficulties in developing countries.

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Only 5.8% of those were eligible for received IV thrombolysis.

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Studied patients relatives were not aware about the therapeutic window despite their recognition of stroke symptoms.

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Minor and non-motor strokes defects may mislead the on-duty doctor to withhold IV r-tPA in indicated cases.

A Retrospective Study Investigating: Factors associated with mode of arrival and emergency department management for patients with acute stroke

BACKGROUND

Presentation by ambulance to the emergency department is critical for stroke patients to receive time dependent treatments. However, little is known of the factors that influence presentation by ambulance.

METHODS

Retrospective analysis of all patients with an emergency department medical diagnosis of stroke who presented to one of three Victorian emergency departments over a three-year period (2011-2013). A multivariable model was used to investigate demographic characteristics (including triage assessment category, triage identified as stroke, time to CT, and time to diagnosis within the emergency department) as predictors of arrival by ambulance.

RESULTS

3548 stroke patients were identified; mean age was 70 years, 53% were males, and 92% had an ischemic stroke. Arrival by ambulance occurred in 71% (n=2509) with arrival by private transport accounting for 29% (n=1039) of patients. Factors significantly associated with arrival by ambulance were older age (p=<0.001), being born in Australia (p=<0.001), and speaking English in the home (p=0.003). Arrival by ambulance was independently associated with rapid stroke care in the emergency department, arrival within 2h from symptom onset, attending an advanced stroke service (access to thrombolysis), triaged for stroke, medical assessment within 25min and referral for CT within 45min.

CONCLUSION

In this Australian multicenter study, it was identified that patients who arrived by ambulance received faster acute stroke care within the emergency department. Public health education which targets patients who are younger and from a non-English speaking background is needed as these demographics were not associated with timely arrival by ambulance to the emergency department.

Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

A Reduction in Time with Electronic Monitoring In Stroke (ARTEMIS): study protocol for a randomised multicentre trial

INTRODUCTION

Time is the most crucial factor limiting efficacy of intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT). The delay between alarming the Emergency Medical Services (EMS) dispatch office and IVT/IAT initiation, that is, the 'total system delay' (TSD), depends on logistics and team effort. A promising method to reduce TSD is real-time audio-visual feedback to caregivers involved. With 'A Reduction in Time with Electronic Monitoring in Stroke' (ARTEMIS), we aim to investigate the effect of real-time audio-visual feedback on actual TSD to IVT/IAT to caregivers.

METHODS AND ANALYSIS

ARTEMIS is a multiregional, multicentre, randomised open end-point trial including patients ≥18 years considered IVT/IAT-eligible by the EMS dispatch office or on-site EMS personnel. Patients are electronically tracked and randomised for real-time audio-visual feedback on TSD to caregivers via premounted handhelds and tablets throughout the TSD trajectory. Primary outcome is TSD to IVT/IAT. Secondary outcomes comprise proportion of IVT/IAT-treated patients, symptomatic intracerebral haemorrhage, IVT/IAT-treated stroke mimics, clinical outcome after three months and cost-effectiveness. Separate analyses for IAT-patients with or without prior IVT, within or out of office hours and EMS region will be performed. With 75 IAT-patients and 225 IVT-patients in each arm, we will be able to demonstrate a 20 min difference in TSD to IAT and a 10 min difference in TSD to IVT (p=0.05 and power=0.8).

ETHICS AND DISSEMINATION

Study findings will be disseminated through peer-reviewed journals and (inter)national conference presentations.

TRIAL REGISTRATION NUMBER

NCT02808806; Pre-results.

Improving Call-to-Door Time Using School-Based Intervention by Emergency Medical Technicians: The Akashi Project

BACKGROUND

Identification of stroke signs by emergency medical technicians (EMTs) is important for initiating the "stroke chain of survival." The aim of the present study was to clarify the effect of EMT-led lessons on stroke awareness for schoolchildren in the Akashi project on the transportation time to arrive at the hospital.

METHODS

Stroke lessons were given by EMTs to 887 elementary school children in elementary schools between September 2014 and October 2015. Data on transportation times from prehospital records and final diagnoses at discharge were collected from both pre- (period 1; January-June 2014) and posteducation (period 2; January-June 2016) periods. Transportation time or onset-to-door time was divided into two parts: the onset-to-call time and the call-to-door time.

RESULTS

One hundred forty-four patients in period 1 and 143 in period 2 were transported with potential strokes identified by EMTs. Among these, 119 (83%) in period 1 and 114 (80%) in period 2 had final diagnosis of stroke or transient ischemic attack. The mean age in period 2 was older than that in period 1 (75 years old versus 72 years old); however, there were no significant differences in gender and consciousness level between the 2 periods. The median call-to-door time of 28 minutes for period-2 patients was significantly shorter than that for period-1 patients (32 minutes, P = .0057). There were no differences in median onset-to-door times and onset-to-call times between the 2 periods.

CONCLUSIONS

School-based education about stroke conducted by EMTs may be a promising strategy to cut the prehospital delay and to widely spread stroke awareness via school children and EMTs.

Stroke identification by criteria based dispatch - a register based study

BACKGROUND

Rapid and precise dispatch of resources is a key element in pre-hospital emergency medicine. Emergency medical communication centres (EMCCs) dispatch resources based on protocols and guidelines, balancing the acute need of the individual and the resource allocation of the pre-hospital emergency medical system. The aim of this study was to determine the validity of stroke identification by the Norwegian dispatch guidelines.

METHOD AND MATERIAL

This was a register-based study where patients suspected for stroke were compared to those with the final diagnosis of stroke as an indicator group for the guideline validation. One EMCC and its three associated hospitals participated with 13 months of data. Four subcodes of the stroke dispatch code were defined as suspicious of stroke and further analysed. Factors associated with stroke identification were explored.

RESULTS

The sensitivity for identifying a stroke patient at initial EMCC contact was 57.9% (51.5, 64.1), specificity was 99.1% (98.9, 99.2), positive predictive value was 45.7% (40.1, 51.4) and negative predictive value was 99.4% (99.3, 99.5). The emergency medical access telephone (113) was initial EMCC contact line in only 48% of the cases. Paralyses and admittance to a smaller hospital were associated with increased probability for stroke (OR 2.6, P = 0.001 and OR 2.7, P = 0.01), respectively.

CONCLUSION

The sensitivity for identification of stroke patients by the dispatch guidelines is modest, while the specificity is high. The 113 telephone line was initial EMCC access point for less than half of the stroke patients.

Dispatch and prehospital transport for acute septic patients: an observational study

Background

In order to dispatch ambulances with the correct level of urgency, the dispatch center has to balance the perceived urgency and traffic safety considerations with the available resources. As urgency is not clear in all clinical situations, some high urgency patients may end up with a suboptimal mode of transport.

Patients with severe sepsis or septic shock suffer from highly time dependent conditions but they present with a wide range of symptoms, which might be difficult to identify in the dispatch system.

The aim of the study is to investigate the modes of prehospital transport among acute admitted patients with sepsis, severe sepsis and septic shock.

Methods

We included all adult patients (≥15 years) presenting to an acute medical unit at Odense University Hospital with a first-time admission of community-acquired sepsis between September 2010-August 2011. Cases and prehospital ambulance transport were identified by structured manual chart review. In all cases it was registered, whether the ordinary ambulance was assisted by the mobile emergency care unit (MECU), manned by anesthesiologists.

Results

We included 1,713 patients median age 72 years (IQR 57–81), 793 (46.3%) male, 621 (36.3%) had sepsis, 1,071 (62.5%) severe sepsis, and 21 (1.2%) septic shock.

In the group of sepsis patients, 390 (62.8%) arrived without public prehospital transport, 197 (31.7%) were transported by ambulance, and 34 (5.5%) were assisted by MECU. In the group of severe sepsis patients, the same percentage 62.8% arrived without public pre-hospital transport, a lower percentage 28.2% were transported by ambulance, and a larger percentage 9.0% were transported by MECU. Among 21 patients with septic shock, 10 arrived without public pre-hospital transport (47.7%), 7 (33.3%) were transported by ambulance, and 4 (19.0%) by MECU.

The 30-day mortality hazard ratio was associated with mode of transport, with the adjusted highest hazard ratio found in the group of MECU transported patients 1.76 (95%Cl 1.16–2.66).

Conclusions

A substantial proportion of patients with severe sepsis and septic shock arrive to hospital without public prehospital transport or by unspecialized ambulances.

Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges

In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.

Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki

Background and Purpose—

Significant portion of the prehospital delay consists of minutes spent on the scene with the patient. We implemented a training program for the emergency medical services personnel with the aim to optimize the on-scene time (OST) and to study the impact of different elements of prehospital practice to the OST duration.

Methods—

In this prospective interventional study, key operational emergency medical service performance variables were analyzed from all thrombolysis candidates transported to the Helsinki University Hospital emergency department. The catchment period was 4 months before and 4 months after the implementation.

Results—

One hundred and forty-one patients were managed as thrombolysis candidates before and 148 patients after the training program implementation. The OST duration for the groups was 25 (20.5–31) and 22.5 (18–28.5) minutes, respectively ( P <0.001). Physician consultations via telephone were associated with a longer (odds ratio 0.546 [0.333–0.893]) and advanced life support training with a shorter OST (odds ration 1.760 [1.070–2.895]).

Conclusions—

Implementation of the emergency medical services training program successfully decreased the OST of thrombolysis candidates by 10%. Higher expertise level of the ambulance crew was associated with shorter OST, and decisions to consult a physician via telephone were reflected by longer OST.