Early stroke care in Italy--a steep way ahead: an observational study

Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2)

OBJECTIVES

Ambulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus on timings and logistics of trial delivery.

DESIGN

Multicentre prospective, single-blind, parallel group randomised controlled trial.

SETTING

Eight National Health Service ambulance services in England and Wales; 54 acute stroke centres.

PARTICIPANTS

Paramedics enrolled 1149 patients assessed as likely to have a stroke, with Face, Arm, Speech and Time score (2 or 3), within 4 hours of symptom onset and systolic blood pressure >120 mm Hg.

INTERVENTIONS

Paramedics administered randomly assigned active transdermal glyceryl trinitrate or sham.

PRIMARY AND SECONDARY OUTCOMES

Modified Rankin scale at day 90. This paper focuses on response time intervals, distances travelled and baseline characteristics of patients, compared between ambulance services.

RESULTS

Paramedics enrolled 1149 patients between September 2015 and May 2018.

FINAL DIAGNOSIS

intracerebral haemorrhage 13%, ischaemic stroke 52%, transient ischaemic attack 9% and mimic 26%. Timings (min) were (median (25-75 centile)): onset to emergency call 19 (5-64); onset to randomisation 71 (45-116); total time at scene 33 (26-46); depart scene to hospital 15 (10-23); randomisation to hospital 24 (16-34) and onset to hospital 97 (71-141). Ambulances travelled (km) 10 (4-19) from scene to hospital. Timings and distances differed between ambulance service, for example, onset to randomisation (fastest 53 min, slowest 77 min; p<0.001), distance from scene to hospital (least 4 km, most 20 km; p<0.001).

CONCLUSION

We completed a large prehospital stroke trial involving a simple-to-administer intervention across multiple ambulance services. The time from onset to randomisation and modest distances travelled support the applicability of future large-scale paramedic-delivered ambulance-based stroke trials in urban and rural locations.

TRIAL REGISTRATION NUMBER

ISRCTN26986053.

Factors affecting emergency medical dispatchers' decision-making: a qualitative study

Introduction

Prehospital emergency medical service dispatchers should make prompt and appropriate decisions to save the life of victims. The complexity of timely and reasonable decision-making in life-threatening conditions has driven researchers to investigate varying aspects of the emergency medical dispatch (EMD) process. The purpose of this study was to explore the contributors to appropriate and prompt decision-making among dispatchers.

Methods

A qualitative study through thematic analysis was designed. Data were collected using observation and semistructured interviews with 16 authorities and dispatchers in seven EMDs across Iran.

Results

The study found “responsiveness” as the main category contributing to improved decision-making in EMD. The components introduced in this study for dispatchers’ responsiveness consisted of two categories. The first was “personal values” including faith and belief, eagerness to help, service excellence, altruism, respect, and impartiality in clinical judgment. The second was “professional attitudes” resulting from education and experience, including the recognition of emergency as a threat to health, sensitivity in triage, response to all requests for help, care for early warnings, commitment to organizational goals and standards, attention to the emergency medical service social support responsibility, and professional temperance.

Conclusion

In this study, responsiveness was identified as a main category in improving the decision-making process among dispatchers. To attain responsiveness, institutionalization of its values and establishment of EMD-specific professional attitudes in dispatchers should be taken into consideration.

The Impact of Ambulance Practice on Acute Stroke Care

Background and Purpose— Few patients with acute stroke are treated with alteplase, often due to significant prehospital delays after symptom onset. The aims of this study were to: (1) identify factors associated with rapid first medical assessment in the emergency department after a call for ambulance assistance, and (2) determine the impact of ambulance practice on times from the ambulance call to first medical assessment in the emergency department.

Methods— During a 6-month period in 2004, all ambulance-transported patients with stroke or transient ischemic attack arriving from a geographically defined region in Melbourne, Australia (population 383 000) to one of 3 hospital emergency departments were assessed prospectively. Ambulance records including the tape recording of the call for ambulance assistance and hospital medical records, were analyzed.

Results— One hundred ninety-eight patients were included in the study. One hundred eighty-seven ambulance patient care records were complete and available for analysis. Factors associated with first medical assessment in the emergency department <60 minutes from the ambulance call and <10 minutes from hospital arrival were: Glasgow Coma Scale <13 ( P <0.001 and P =0.021) and hospital prenotification ( P =0.04 and P <0.001). Paramedic stroke recognition and hospital prenotification were associated with shorter times from the ambulance call to first medical assessment ( P =0.001 and P <0.001).

Conclusions— Paramedic stroke recognition and hospital prenotification are associated with shorter prehospital times from the ambulance call to hospital arrival and in-hospital times from hospital arrival to first medical assessment. This highlights the importance of including ambulance practice in comprehensive care pathways that span the whole process of stroke care.