Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance

Specific management in specialized hospital facilities has been shown to improve process quality and outcomes in a variety of diseases. In the context of neurological disorders, this applies to the treatment of acute stroke in Stroke Units or of intracranial hemorrhages in hospitals with organized stroke care or neurosurgery facilities. Correct prehospital diagnosis is important because it avoids admissions to nonappropriate hospitals with suboptimal care or leading to time-consuming secondary patient transfers. In addition, prehospital diagnostic work-up can accelerate emergency management by in-advance notification of hospital teams. However, diagnosis of neurological disorders is often difficult for the variety of symptom presentations and causes. For example, initial diagnosis of stroke in an emergency department yielded a stroke mimic rate of 19%, based on history and clinical examination only. If additional laboratory findings and a computed tomographic (CT) scan were available, the stroke mimic rate was only 4%. In the prehospital setting with usually limited diagnostic equipment and neurological expertise, correct diagnosis is even more difficult. Sensitivity of stroke diagnosis on the basis of validated prehospital stroke scores was reported between 74% and 95% with positive predictive values (PPVs) between 13% and 99%. The feasibility of advanced prehospital neurological work-up, including CT imaging of the brain and point-of-care laboratory, has recently been shown in 2 projects using specialized ambulances. In the Pre-Hospital Acute Background and Purpose—Specialized management of patients with stroke is not available in all hospitals. We evaluated whether prehospital management in the Stroke Emergency Mobile (STEMO) improves the triage of patients with stroke. Methods—STEMO is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic scanner and point-of-care laboratory. We compared the prehospital triage of patients with suspected stroke at dispatcher level who either received STEMO care or conventional care. We assessed transport destination in patients with different diagnoses. Status at hospital discharge was used as short-term outcome. Results—From May 2011 to January 2013, 1804 of 6182 (29%) patients received STEMO care and 4378 of 6182 (71%) patients conventional care. Two hundred forty-five of 2110 (11.6%) patients with cerebrovascular events were sent to hospitals without Stroke Unit in conventional care when compared with 48 of 866 (5.5%; P<0.01%) patients in STEMO care. In patients with ischemic stroke, STEMO care reduced transport to hospitals without Stroke Unit from 10.1% (151 of 1497) to 3.9% (24 of 610; P<0.01). The delivery rate of patients with intracranial hemorrhage to hospitals without neurosurgery department was 43.0% (65 of 151) in conventional care and 11.3% (7 of 62) in STEMO care (P<0.01). There was a slight trend toward higher rates of patients discharged home in neurological patients when cared by STEMO (63.5% versus 60.8%; P=0.096). Conclusions—The triage of patients with cerebrovascular events to specialized hospitals can be improved by STEMO ambulances. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01382862. (Stroke. 2015;46:00-00. DOI: 10.1161/STROKEAHA.114.008159.)