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Original Investigation |

Prehospital Triage to Primary Stroke Centers and Rate of Stroke Thrombolysis

Shyam Prabhakaran, MD, MS1; Kathleen O’Neill, MHA2; Leslie Stein-Spencer, RN3; James Walter, MD4; Mark J. Alberts, MD1
[+] Author Affiliations
1Department of Neurology, Northwestern University, Chicago, Illinois
2American Heart Association, Midwest Affiliate, Chicago, Illinois
3Chicago Fire Department, Chicago, Illinois
4Department of Emergency Medicine, University of Chicago, Chicago, Illinois
JAMA Neurol. 2013;70(9):1126-1132. doi:10.1001/jamaneurol.2013.293.
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Published online

Importance  Implementation of prehospital stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region.

Objective  To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois.

Design  Retrospective multicenter cohort study from September 1, 2010, to August 31, 2011 (6 months before and after intervention that began March 1, 2011).

Setting  Ten primary stroke center hospitals in Chicago.

Patients  All admitted patients with stroke and transient ischemic attack.

Intervention  Prehospital triage policy of patients with stroke to primary stroke centers.

Main Outcomes and Measures  Intravenous tPA use (measured as a fraction of patients with ischemic strokes arriving through the emergency department).

Results  There were 1075 stroke and transient ischemic attack admissions in the pretriage period and 1172 in the posttriage period. Patient demographic characteristics including age, sex, and risk factors were similar between the 2 periods (mean age, 65 years; 53% female). Compared with the pretriage period, use of emergency medical services increased from 30.2% to 38.1% (P < .001) and emergency medical services prenotification increased from 65.5% to 76.5% (P = .001) after implementation. Rates of intravenous tPA use were 3.8% and 10.1% (P < .001) and onset-to-treatment times decreased from 171.7 to 145.7 minutes (P = .03) in the pretriage and posttriage periods, respectively. Stroke unit admission, symptomatic intracranial hemorrhage rates, and in-hospital mortality were not significantly different between periods. Adjusting for mode of arrival, prehospital notification, and onset-to-arrival time, the posttriage period was independently associated with increased tPA use for patients with ischemic stroke presenting through the emergency department (adjusted odds ratio = 2.21; 95% CI, 1.34-3.64).

Conclusions and Relevance  Implementation of a prehospital stroke triage policy in Chicago resulted in significant improvements in emergency medical services use and prenotification and more than doubled intravenous tPA use at primary stroke centers.

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Figure 1.
Regional Primary Stroke Centers

Regional primary stroke centers grouped by the following: outside Chicago city limits (red); Get With the Guidelines–Stroke (GWTG-S)–participating primary stroke centers certified before March 2011 and within Chicago city limits (black); non–GWTG-S–participating primary stroke center (green); and primary stroke centers within city limits certified after March 2011 (blue). The map shows the geographic distribution of the centers against a background of annual number of strokes coded by color and zip code (source: Illinois Hospital Association COMPdata database).

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Figure 2.
Patients With Stroke Arriving Through Emergency Department and Treated With Tissue Plasminogen Activator

Proportions of patients with stroke arriving through the emergency department treated with tissue plasminogen activator during 3 periods of measurement: 1 year prior to stroke triage policy implementation (March 2010 to February 2011; n = 1181), the first year after implementation (March 2011 to February 2012; n = 1330), and the second year after implementation (March 2012 to December 2012; n = 1147). The second year is incomplete, containing only 10 months of data. Error bars indicate 95% CIs around point estimates.

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