title: Impact of Expanding the Prehospital Stroke Bypass Time Window in a Large Geographic Region.
abstract: The Ontario Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) was revised to allow paramedics to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact and safety of implementing the Revised ASMRPP.
  
  
  
  We conducted a 12-month implementation study involving prehospital patients presenting with possible stroke symptoms. A total of 1317 basic and advanced life support paramedics, of 9 land services in 10 rural counties and 5 cities, used the Revised ASMRPP to take appropriate patients directly to 6 designated stroke centers.
  
  
  
  We enrolled 1277 patients with 98.8% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.1 (range 16-101), male 51.1%, mean time scene to hospital 16.7 minutes (range 0-92). Paramedics demonstrated excellent interobserver agreement (κ, 0.94; 95% confidence interval, 0.91-0.96) and 97.9% accuracy in interpretation of the Revised ASMRPP. Prehospital adverse events occurred in 14.7% of patients, but few were life-threatening. Overall, 71.4% of 755 cases had a stroke code activated at the hospital and 23.2% received thrombolysis. For the 189 potential stroke patients picked up in 1 city, the ASMRPP classified thrombolysis administration with sensitivity 100% and specificity 37.3% and a final diagnosis of stroke, with sensitivity 86.1% and specificity 41.9%.
  
  
  
  In a large urban-rural area with 9 paramedic services, we demonstrated accurate, safe, and effective implementation of the Revised ASMRPP. These revisions will allow more patients with stroke to benefit from early treatment.
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.). istiell@ohri.ca.
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Clement
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Kristy
authors.initials: K
authors.lastname: Campbell
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Mukul
authors.initials: M
authors.lastname: Sharma
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Doug
authors.initials: D
authors.lastname: Socha
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Marco L A
authors.initials: ML
authors.lastname: Sivilotti
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Albert
authors.initials: A
authors.lastname: Jin
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Perry
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Jim
authors.initials: J
authors.lastname: Lumsden
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Cally
authors.initials: C
authors.lastname: Martin
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Mark
authors.initials: M
authors.lastname: Froats
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: Richard
authors.initials: R
authors.lastname: Dionne
authors.affiliation: From the Department of Emergency Medicine (I.G.S., J.J.P., R.D.) and Clinical Epidemiology Program, Ottawa Hospital Research Institute (I.G.S., C.M.C., J.J.P., J.T.), University of Ottawa, The Ottawa Hospital, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada (M.S.); Hastings-Quinte Paramedic Services, Belleville, Ontario, Canada (D.S.); Department of Emergency Medicine (M.L.A.S., M.F.) and Department of Medicine (A.J.), Queen's University, Kingston, Ontario, Canada; Regional Paramedic Program for Eastern Ontario, Ottawa, Canada (K.C., R.D.); Champlain Regional Stroke Network, Ottawa, Ontario, Canada (J.L.); and Stroke Network of Southeastern Ontario, Kingston General Hospital, Canada (C.M.).
authors.forename: John
authors.initials: J
authors.lastname: Trickett
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence / Q000592:standards*; D004634:Emergency Medical Technicians / Q000592:standards*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D020521:Stroke / Q000175:diagnosis* / Q000628:therapy*; D013997:Time Factors; D014187:Transportation of Patients / Q000592:standards*; D055815:Young Adult
keywords: cities; glucose; paramedic; prehospital; stroke; thrombolysis