J Clin Neurol.  2010 Sep;6(3):138-142. 10.3988/jcn.2010.6.3.138.

Prehospital Notification from the Emergency Medical Service Reduces the Transfer and Intra-Hospital Processing Times for Acute Stroke Patients

• Bae HJ
• Kim DH
• Yoo NT
• Choi JH
• Huh JT
• Cha JK
• Kim SK
• Choi JS
• Kim JW

• KMID: 1462849
• DOI: http://doi.org/10.3988/jcn.2010.6.3.138

Abstract

BACKGROUND AND PURPOSE
There is little information available about the effects of Emergency Medical Service (EMS) hospital notification on transfer and intrahospital processing times in cases of acute ischemic stroke.
METHODS
This study retrospectively investigated the real transfer and imaging processing times for cases of suspected acute stroke (AS) with EMS notification of a requirement for intravenous (IV) tissue-type plasminogen activator (t-PA) and for cases without notification. Also we compared the intra-hospital processing times for receiving t-PA between patients with and without EMS prehospital notification.
RESULTS
Between December 2008 and August 2009, the EMS transported 102 patients with suspected AS to our stroke center. During the same period, 33 patients received IV t-PA without prehospital notification from the EMS. The mean real transfer time after the EMS call was 56.0+/-32.0 min. Patients with a transfer distance of more than 40 km could not be transported to our center within 60 min. Among the 102 patients, 55 were transferred via the EMS to our emergency room for IV t-PA. The positive predictive value for stroke (90.9% vs. 68.1%, p=0.005) was much higher and the real transfer time was much faster in patients with an EMS t-PA call (47.7+/-23.1 min, p=0.004) than in those without one (56.3+/-32.4 min). The door-to-imaging time (17.8+/-11.0 min vs. 26.9+/-11.5 min, p=0.01) and door-to-needle time (29.7+/-9.6 min vs. 42.1+/-18.1 min, p=0.01) were significantly shorter in the 18 patients for whom there was prehospital notification and who ultimately received t-PA than in those for whom there was no prehospital notification.
CONCLUSIONS
Our results indicate that prehospital notification could enable the rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.

Keyword

stroke; thrombolysis; prehospital notification; stroke care system

MeSH Terms

Emergencies
Emergency Medical Services
Humans
Retrospective Studies
Stroke
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

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  Fig. 1 Location of our stroke centre and distribution of transfer hospitals.

Reference

1. The National Institute of Neurologic Disorder and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995. 333:1581–1587.

2. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995. 274:1017–1025.

3. Chiu D, Krieger D, Villar-Cordova C, Kasner SE, Morgenstern LB, Bratina PL, et al. Intravenous tissue plasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice. Stroke. 1998. 29:18–22.

4. Smith MA, Doliszny KM, Shahar E, McGovern PG, Arnett DK, Luepker RV. Delayed hospital arrival for acute stroke: the Minnesota Stroke Survey. Arch Intern Med. 1998. 129:190–196.

5. Katzan IL, Furlan AJ, Lloyd LE, Frank JI, Harper DL, Hinchey JA, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA. 2000. 283:1151–1158.

6. Yu KH, Bae HJ, Kwon SU, Kang DW, Hong KS, Lee YS, et al. Analysis of 10,811 cases with acute ischemic stroke from the Korean Stroke Registry: hospital-based multicenter prospective registration study. J Korean Neurol Assoc. 2006. 24:535–543.

7. Lacy CR, Suh DC, Bueno M, Kostis JB. Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke. 2001. 32:63–69.

8. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007. 38:1655–1711.

9. Rajajee V, Saver J. Prehospital care of the acute stroke patient. Tech Vasc Interv Radiol. 2005. 8:74–80.

10. Kim SK, Lee SY, Bae HJ, Lee YS, Kim SY, Kang MJ, et al. Pre-hospital notification reduced the door-to-needle time for iv t-PA in acute ischemic stroke. Eur J Neurol. 2009. 16:1331–1335.

11. Yun YH, Chung JY, Kang MJ, Huh JT, Park KW, Cha JK, et al. A retrospective study on intracerebral haemorrhage reduction by MRI versus CT in intravenous thrombolysis for acute ischaemic stroke. Hong Kong J Emer Med. 2009. (in press).

12. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR. Time of hospital presentation in patients with acute stroke. Arch Intern Med. 1993. 153:2558–2561.

13. Belvís R, Cocho D, Martí-Fàbreagas J, Pagonabarraga J, Aleu A, García-Bargo MD, et al. Benefits of a prehospital stroke code system. Feasibility and efficacy in the first year of clinical practice in Barcelona, Spain. Cerebrovasc Dis. 2005. 19:96–101.

14. Schroeder EB, Rosamond WD, Morris DL, Evenson KR, Hinn AR. Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study. Stroke. 2000. 31:2591–2596.

15. Kereiakes DJ, Gibler WB, Martin LH, Pieper KS, Anderson LC. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati Heart Project. Am Heart J. 1992. 123:835–840.

16. Wester P, Rådberg J, Lundgren B, Peltonen M. Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Seek-Medical-Attention-in-Time Study Group. Stroke. 1999. 30:40–48.

17. Nam HS, Han SW, Ahn SH, Lee JY, Choi HY, Park IC, et al. Improved time intervals by implementation of computerized physician order entry-based stroke team approach. Cerebrovasc Dis. 2007. 23:289–293.

18. Turin TC, Kita Y, Rumana N, Ichikawa M, Sugihara H, Morita Y, et al. Case fatality of stroke and day of the week: is the weekend effect an artifact? Takashima stroke registry, Japan (1988-2003). Cerebrovascular Dis. 2008. 26:606–611.

19. Albright KC, Raman R, Ernstrom K, Hallevi H, Martin-Schild S, Meyer BC, et al. Can comprehensive stroke centers erase the 'weekend effect'? Cerebrovascular Dis. 2009. 27:107–113.

20. Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification of stroke and transient ischemic attack in the field. Prehosp Emerg Care. 1998. 2:170–175.

21. Zweifler RM, York D, U TT, Mendizabal JE, Rothrock JF. Accuracy of paramedic diagnosis of stroke. J Stroke Cerebrovasc Dis. 1998. 7:446–448.