title: A citywide prehospital protocol increases access to stroke thrombolysis in Toronto.
abstract: OBJECTIVE
  Intravenous tissue plasminogen activator for ischemic stroke is approved for eligible patients who can be treated within a 3-hour window, but treatment rates remain disappointingly low, often <5%. To improve rapid access to stroke thrombolysis in Toronto, Canada, a citywide prehospital acute stroke activation protocol was implemented by the provincial government to transport acute stroke patients directly to one of 3 regional stroke centers, bypassing local hospitals. This comprised a paramedic screening tool, ambulance destination decision rule, and formal memorandum of understanding of system stakeholders. This report describes the initial impact of the activation protocol at our regional stroke center.
  
  
  METHODS
  We compared consecutive patients with stroke arriving to our stroke center during the first 4 months of this new triage protocol (February 14 to June 14, 2005) versus the same 4-month period in 2004.
  
  
  RESULTS
  The protocol resulted in an immediate doubling in the number of patients with acute stroke arriving to our regional stroke center within 2.5 hours of symptom onset. We observed a 4-fold increase in patients who were eligible for and treated with tissue plasminogen activator. The tissue plasminogen activator treatment rate for ischemic stroke patients increased from 9.5% to 23.4% (P=0.01), and one in 2 patients with ischemic stroke arriving within 2.5 hours received thrombolysis during this period (one in 5 of patients with ischemic stroke overall). The median onset-to-needle time for tissue plasminogen activator-treated patients was significantly reduced. Many implementation challenges were identified and addressed.
  
  
  CONCLUSIONS
  This prehospital triage was immediately successful in improving tissue plasminogen activator access for patients with ischemic stroke, enabling our center to achieve one of the highest tissue plasminogen activator treatment rates in North America and underscoring the need for coordinated systems of acute stroke care. Sustainability of such an initiative will be dependent on interdisciplinary teamwork, ongoing paramedic training, adequate hospital staffing, bed availability, and repatriation agreements with community hospitals.
authors.affiliation: North and East GTA-Ontario Regional Stroke Centre and Division of Neurology, Department of Medicine, and Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. david.gladstone@sunnybrook.ca
authors.forename: David J
authors.initials: DJ
authors.lastname: Gladstone
authors.forename: Lance H
authors.initials: LH
authors.lastname: Rodan
authors.forename: Demetrios J
authors.initials: DJ
authors.lastname: Sahlas
authors.forename: Liesly
authors.initials: L
authors.lastname: Lee
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Murray
authors.forename: Jon E
authors.initials: JE
authors.lastname: Ween
authors.forename: James R
authors.initials: JR
authors.lastname: Perry
authors.forename: Jordan
authors.initials: J
authors.lastname: Chenkin
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
authors.forename: Shann
authors.initials: S
authors.lastname: Beck
authors.forename: Sandra E
authors.initials: SE
authors.lastname: Black
mesh_terms: D000552:Ambulances; D002985:Clinical Protocols; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians; D004636:Emergency Service, Hospital; D006297:Health Services Accessibility; D006761:Hospitals; D006764:Hospitals, Community; D015277:Hotlines; D006801:Humans; D007373:Interinstitutional Relations; D020767:Intracranial Thrombosis / Q000188:drug therapy*; D009864:Ontario; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D018579:Patient Selection; D010360:Patient Transfer; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D014187:Transportation of Patients; D016896:Treatment Outcome; D014218:Triage