The rural Prehospital Acute Stroke Triage (PAST) trial protocol: a controlled trial for rapid facilitated transport of rural acute stroke patients to a regional stroke centre.
BACKGROUND
Access to intravenous thrombolysis for acute ischaemic stroke is limited worldwide, particularly in regional and rural areas including in Australia. We are testing the effectiveness of a new rural Prehospital Acute Stroke Triage protocol that includes prehospital assessment and rapid transport of patients from a rural catchment to the major stroke centre in Newcastle, NSW, Australia. The local district hospitals within the rural catchment do not have the capability or infrastructure to deliver acute stroke thrombolysis. The trial has relevance to stroke clinicians, health service managers and planners responsible for rural populations.


OBJECTIVE
To implement a system of rapid prehospital assessment and facilitated transport that will significantly increase stroke thrombolysis rates to 10% of ischaemic stroke cases in the rural catchment. Validate an eight-point modified National Institutes of Health Stroke Scale for use by paramedics in the prehospital setting to assess patients' potential eligibility for stroke thrombolysis.


METHODS
The joint project between the John Hunter Hospital Acute Stroke Team and the Ambulance Service of NSW will use a prospective cohort with an historical control group. Tools and protocols have been developed and education undertaken for ambulance field and operations centre personnel. These include a cut-down eight-item National Institutes of Health Stroke Scale (Hunter NIHSS-8) score to be used in the field by paramedics and a transport decision matrix to expedite transport for a suspected stroke patient (road or road plus air transport).


RESULTS
The primary outcome measure will be the rate of intravenous tissue plasminogen activator delivery for those who suffer an ischaemic stroke following protocol implementation, in comparison with historical rates over a corresponding period prior to implementation, for residents within the catchment. Sixty cases are required in the postimplementation time epoch to demonstrate a statistically significant absolute increase in thrombolysis rates for ischaemic strokes from <1% to 10%, (power of 80%, α error of 0.05). The major secondary outcome will be inter-rater reliability of the Hunter NIHSS-8.
Stroke Program, Centre for Brain & Mental Health Research, John Hunter Hospital, University of Newcastle and Hunter Medical Research Institute, Lookout Road, New Lambton Heights 2305, NSW, Australia.
Ashley R
AR
Garnett
Dianne L
DL
Marsden
Mark W
MW
Parsons
Debbie A
DA
Quain
Neil J
NJ
Spratt
Allan R
AR
Loudfoot
Paul M
PM
Middleton
Christopher R
CR
Levi
D000208:Acute Disease; D044362:Australasia; D018849:Controlled Clinical Trials as Topic / Q000379:methods*; D004632:Emergency Medical Services / Q000592:standards*; D006780:Hospitals, Rural / Q000592:standards*; D006801:Humans; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000592:standards*; D014187:Transportation of Patients / Q000592:standards*; D014218:Triage / Q000592:standards