title: Pre-hospital notification is associated with improved stroke thrombolysis timing.
abstract: Intravenous thrombolysis increases disability-free survival after acute ischaemic stroke in a time-dependent fashion. We aimed to determine whether pre-hospital notification, introduction of a CT scanner near to assessment site and introduction of out-of-hours thrombolysis services affect thrombolysis timing. Methods Timings related to thrombolysis were collected between May 2012 and June 2014 at a single hospital site; these included time to stroke physician assessment, time to cranial CT imaging and door to needle time. All thrombolysed ischaemic stroke patients admitted via the emergency department were included. Ambulance services were asked to pre-notify the emergency department of any suspected stroke patient during this period. Results We studied 182 patients (48% female; mean age 74 years; 59% pre-notified). Pre-hospital notification was associated with a significantly higher rate of CT scanning within 25 minutes (60% vs 24%, odds ratio [OR] 4.7, 95% confidence interval [CI] 2.4-9.0; p<0.001), earlier stroke physician assessment (median 6 vs 32 minutes; p<0.001) and receiving thrombolysis within 60 minutes (89% vs 49%, OR 8.0, 95% CI 3.8-16.9; p<0.001). Being treated outside normal working hours did not alter thrombolysis timing. Logistic regression identified the introduction of a near-site CT scanner (OR 4.6 [95% CI 1.7-12.5]) and pre-hospital notification (OR 4.7, [95% CI 2.3-9.6]) as independent predictors of door to CT time less than or equal to 25 minutes, and pre-hospital notification (OR 11.6, [95% CI 4.9-30.3]) and stroke severity (OR 1.15 per point of NIHSS scale, [95% CI 1.08-1.23]) as predictors of door to thrombolysis time less than or equal to 60 minutes. The most common perceived timing delays were radiology-related (33%), the need to acutely lower blood pressure (15%) and obtaining consent (12%). Conclusion Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis. Referral to an out of hours thrombolysis service was not associated with additional delay.
authors.affiliation: MX Khor, Acute Stroke Unit, Ward 204, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK. Email mingxiang.khor@nhs.net.
authors.forename: M X
authors.initials: MX
authors.lastname: Khor
authors.forename: A
authors.initials: A
authors.lastname: Bown
authors.forename: A
authors.initials: A
authors.lastname: Barrett
authors.forename: C E
authors.initials: CE
authors.lastname: Counsell
authors.forename: M J
authors.initials: MJ
authors.lastname: MacLeod
authors.forename: J M
authors.initials: JM
authors.lastname: Reid
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances; D003142:Communication; D004636:Emergency Service, Hospital; D005260:Female; D006760:Hospitalization; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010820:Physicians; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging / Q000628:therapy*; D015912:Thrombolytic Therapy; D061665:Time-to-Treatment; D014057:Tomography, X-Ray Computed
keywords: acute stroke; ambulance services; computed tomography; pre-hospital notification; thrombolysis