Barriers and facilitators to more timely treatment of aneurysmal subarachnoid haemorrhage across two tertiary referral centres in Australia: A thematic analysis.

BACKGROUND: Delays in treatment of aSAH appear to be common but the causes are not well understood. We explored facilitators and barriers to timely treatment of aSAH. METHODS: We used a multiple case study with cases of aSAH surviving> 1 day identified prospectively. We conducted semi-structured interviews with the patient, their next-of-kin and health professionals involved in the case. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital) followed by thematic analysis across cases using a case-study matrix. RESULTS: Twenty-seven cases with 90 interviewees yielded five themes related to facilitators or barriers of timely treatment. "Early recognition" led to urgent response. "Accessibility to health care" depended on patient's location, transport, and environmental conditions. Good "Coordination" between and within health services was a key facilitator. "Complexity" of patient's condition affected time to treatment in multiple time periods. "Availability of resources" was identified most frequently during the diagnostic and treatment phases as both barrier and facilitator. CONCLUSIONS: The identified themes may be modifiable at the patient/health professional level and health system level and may improve timely treatment of aSAH through targeted interventions, subsequently contributing to improve morbidity and mortality of patients with aSAH.

Current trauma care system in Saudi Arabia: A scoping literature review.

BACKGROUND: Trauma is one of the leading causes of death worldwide with millions of people dying each year, particularly in low or middle-income countries. This paper describes and evaluates the current trauma system (TS) in Saudi Arabia (SA). METHODS: A scoping literature review was performed, incorporating an extensive search of Medline and Embase databases for refereed literature, as well as a search of grey literature to locate unpublished articles or reports in English or Arabic. All publications were assessed against the World Health Organization (WHO) Trauma System Maturity Index (TSMI) and American College of Surgeon's (ACS) criteria. RESULTS: Despite local injury prevention efforts, Motor Vehicle Crashes (MVC) remain the primary cause of injuries in SA. Prehospital trauma care in SA aligns with level III care as described in the WHO TSMI classification system, based on the presence of formal emergency medical services and universal access to care. With respect to the ACS classification, no clear written guidelines, either for field triage or trauma destination protocols such as trauma bypass, were identified in prehospital trauma care. The role of secondary and tertiary facilities in treating trauma patients is unclear, with no clear referral linkages, suggesting a level I to III grading of SA's trauma care facilities. Currently, there is no national or regional electronic trauma registry, no quality assurance program, and active involvement in research projects related to injuries is limited. CONCLUSION: The current SA TS has strengths but there are key features missing in comparison to other systems globally. As MVCs remain a leading cause of death/ disability, efforts to reduce the prevalence and impact of MVC burden in SA through development of a stronger national TS are warranted.

Mapping the continuum of care to surgery following traumatic spinal cord injury.

BACKGROUND: Traumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times. METHODS: A retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines. RESULTS: Of the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit. CONCLUSION: Notwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.

A Retrospective Study Investigating: Factors associated with mode of arrival and emergency department management for patients with acute stroke.

BACKGROUND: Presentation by ambulance to the emergency department is critical for stroke patients to receive time dependent treatments. However, little is known of the factors that influence presentation by ambulance. METHODS: Retrospective analysis of all patients with an emergency department medical diagnosis of stroke who presented to one of three Victorian emergency departments over a three-year period (2011-2013). A multivariable model was used to investigate demographic characteristics (including triage assessment category, triage identified as stroke, time to CT, and time to diagnosis within the emergency department) as predictors of arrival by ambulance. RESULTS: 3548 stroke patients were identified; mean age was 70 years, 53% were males, and 92% had an ischemic stroke. Arrival by ambulance occurred in 71% (n=2509) with arrival by private transport accounting for 29% (n=1039) of patients. Factors significantly associated with arrival by ambulance were older age (p=<0.001), being born in Australia (p=<0.001), and speaking English in the home (p=0.003). Arrival by ambulance was independently associated with rapid stroke care in the emergency department, arrival within 2h from symptom onset, attending an advanced stroke service (access to thrombolysis), triaged for stroke, medical assessment within 25min and referral for CT within 45min. CONCLUSION: In this Australian multicenter study, it was identified that patients who arrived by ambulance received faster acute stroke care within the emergency department. Public health education which targets patients who are younger and from a non-English speaking background is needed as these demographics were not associated with timely arrival by ambulance to the emergency department.

Prehospital Emergency Care in Childhood Arterial Ischemic Stroke.

BACKGROUND AND PURPOSE: Immediately calling an ambulance is the key factor in reducing time to hospital presentation for adult stroke. Little is known about prehospital care in childhood arterial ischemic stroke (AIS). We aimed to determine emergency medical services call-taker and paramedic diagnostic sensitivity and to describe timelines of care in childhood AIS. METHODS: This is a retrospective study of ambulance-transported children aged <18 years with first radiologically confirmed AIS, from 2008 to 2015. Interhospital transfers of children with preexisting AIS diagnosis were excluded. RESULTS: Twenty-three children were identified; 4 with unavailable ambulance records were excluded. Nineteen children were included in the study. Median age was 8 years (interquartile range, 3-14); median Pediatric National Institutes of Stroke Severity Scale score was 8 (interquartile range, 3-16). Emergency medical services call-taker diagnosis was stroke in 4 children (21%). Priority code 1 (lights and sirens) ambulances were dispatched for 13 children (68%). Paramedic diagnosis was stroke in 5 children (26%), hospital prenotification occurred in 8 children (42%), and 13 children (68%) were transported to primary stroke centers. Median prehospital timelines were onset to emergency medical services contact 13 minutes, call to scene 12 minutes, time at scene 14 minutes, transport time 43 minutes, and total prehospital time 71 minutes (interquartile range, 60-85). CONCLUSIONS: Emergency medical services call-taker and paramedic diagnostic sensitivity and prenotification rates are low in childhood AIS.

Parental Care-Seeking Behavior and Prehospital Timelines of Care in Childhood Arterial Ischemic Stroke.

BACKGROUND AND PURPOSE: Taking appropriate action in the prehospital setting is important for rapid stroke diagnosis in adults. Data are lacking for children. We aimed to describe parental care-seeking behavior and prehospital timelines of care in childhood arterial ischemic stroke. METHODS: A structured questionnaire was developed, using value-focused event-driven conceptual modeling techniques, to interview parents of children presenting to the emergency department with arterial ischemic stroke from 2008 to 2014. RESULTS: Twenty-five parents (median age 41 years, interquartile range 36-45) were interviewed. Twenty-four children were awake, and 1 child was asleep at stroke onset; 23 had sudden onset symptoms. Location at stroke onset included home (72%), school (8%), or other setting (20%). Carergivers present included parent (76%), another child (8%), teacher (4%), or alone (8%). Eighty-four percent of parents thought symptoms were serious, and 83% thought immediate action was required, but only 48% considered the possibility of stroke. Initial actions included calling an ambulance (36%), wait and see (24%), calling a general practitioner (16%) or family member (8%), and driving to the emergency department or family physician (both 8%). Median time from onset to emergency department arrival was 76 minutes (interquartile range 53-187), being shorter for ambulance-transported patients. CONCLUSIONS: Stroke recognition and care-seeking behavior are suboptimal, with less than half the parents considering stroke or calling an ambulance. Initiatives are required to educate parents about appropriate actions to facilitate time-critical interventions.

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery.

Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.

Acute coronary syndrome diagnosis at hospital discharge: how often do we get it right in the emergency department?

OBJECTIVE: Acute coronary syndrome (ACS) encompasses unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI) and ST segment myocardial infarction (STEMI). In 2007-2008 in Australia, there were 95 000 hospitalisations for ACS. There is limited data about the level of agreement between the ED and hospital discharge diagnosis. The objective of the present study is to describe the proportion of ED patients with a concordant ACS hospital discharge diagnosis and determine factors associated with this. METHODS: The present study was a retrospective case series of consecutive presentations of patients with ACS to the EDs of Southern Health, Victoria, Australia, during a 6 month period between August 2011 and January 2012. RESULTS: One thousand and twenty-eight patients diagnosed with ACS in the ED were identified. Hospital discharge diagnosis was recorded for 704 cases. The mean age was 63 years (SD 14.5) and 69% were male. One hundred and nineteen patients (16.9%) were diagnosed with a STEMI, 322 (45.7%) with a NSTEMI and 263 (37.4%) with UA. There were 68.3% who had a concordant discharge diagnosis of ACS. An ED diagnosis of STEMI (87.4), English as the primary language (OR 1.81 [1.13-2.89]) and chest pain as the presenting complaint (OR 2.70 [1.72-4.23]) were associated with a concordant diagnosis of ACS. CONCLUSION: Almost one-third of patients who are admitted to the hospital with ACS have a different hospital discharge diagnosis. English as a primary language and presenting with chest pain are associated with a more concordant diagnosis. More research needs to be performed to better understand these findings.

What is stroke symptom knowledge?

BACKGROUND: No commonly agreed definition exists for 'stroke symptom knowledge' among members of the general public. Recalling at least one correct stroke symptom has been used in the past. However, this criterion was not associated with rapid presentation to hospital. Rapid presentation is vital in order to provide effective acute stroke treatment. AIMS AND/OR HYPOTHESIS: We sought to identify a base level of community stroke symptom knowledge associated with stroke recognition when symptoms occur, an immediate ambulance call, and 'stroke recognition and immediately calling an ambulance' as a single sequence of events. METHODS: For six-months in 2004-2005, we identified all patients with stroke living in a defined region of Melbourne and who were transported by ambulance to one of the three hospitals. The person who called the ambulance (caller) was interviewed. RESULTS: One hundred ninety-eight patients were identified and 150 callers interviewed. Symptoms reported most frequently were limb weakness (67%), speech problems (57%), and facial weakness (24%). Reporting at least two of the symptoms - facial weakness, limb weakness, or speech problems (62% of callers) - was associated with stroke recognition (P = 0·004), immediately calling an ambulance (P = 0·065), and both 'stroke recognition and immediately calling an ambulance' (P = 0·053). CONCLUSIONS: Knowing at least two of the symptoms - facial weakness, limb weakness, and speech problems - appears to be an appropriate indicator of stroke symptom knowledge as it is associated with stroke recognition and appropriate action. Recognizing stroke symptoms and immediately calling an ambulance increase the potential to reduce prehospital time delays and improve eligibility of acute stroke patients for rapid treatment.

Establishment of an effective acute stroke telemedicine program for Australia: protocol for the Victorian Stroke Telemedicine project.

RATIONALE: Urgent treatment of acute stroke in rural Australia is problematic partly because of limited access to medical specialists. Utilization of telemedicine could improve delivery of acute stroke treatments in rural communities. AIM: The study aims to demonstrate enhanced clinical decision making for use of thrombolysis within 4·5 h of ischemic stroke symptom onset in a rural setting using a telemedicine specialist support model. DESIGN: A formative program evaluation research design was used. The Victorian Stroke Telemedicine program was developed and will be evaluated over five stages to ensure successful implementation. The phases include: (a) preimplementation phase to establish the Victorian Stroke Telemedicine program including the clinical pathway, data collection tools, and technology processes; (b) pilot clinical application phase to test the pathway in up to 10 patients; (c) modification phase to refine the program; (d) full clinical implementation phase where the program is maintained for one-year; and (e) a sustainability phase to assess project outcomes over five-years. Qualitative (clinician interviews) and quantitative data (patient, clinician, costs, and technology processes) are collected in each phase. STUDY OUTCOMES: The primary outcome is to achieve a minimum 10% absolute increase in eligible patients treated with thrombolysis. Secondary outcomes are utilization of the telestroke pathway and improvements in processes of stroke care (e.g., time to brain scan). We will report door to telemedicine consultation time, length of telemedicine consultation, clinical utility and acceptability from the perspective of clinicians, and 90-day patient outcomes. SUMMARY: This research will provide evidence for an effective telestroke program for use in regional Australian hospitals.

Australian public's awareness of stroke warning signs improves after national multimedia campaigns.

BACKGROUND AND PURPOSE: The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia. METHODS: A total of 12 439 surveys were performed across 6 states during 6 years on random state-weighted samples of Australians≥40 years old. RESULTS: Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 (P<0.001), as did the unprompted recall of ≥2 most common stroke warning signs 20% to 53% (P<0.001). Awareness of stroke advertising was independently associated with recalling ≥2 common signs (adjusted odds ratio=1.88, 95% confidence interval [1.74-2.04]; P<0.001). Awareness was not greater in respondents with previous stroke or risk factors, except atrial fibrillation. CONCLUSIONS: The Australian public's awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.

Triage assessments and the activation of rapid care protocols for acute stroke patients.

BACKGROUND: Rapid care protocols developed to reduce in-hospital delay times in the assessment of acute stroke patients are now common in Emergency Departments. Correct triage identification and prioritisation is vital to instigate this process and increase the eligibility of patients for acute stroke treatments. OBJECTIVE: We set out to examine triage assessments of acute stroke patients and investigate factors associated with the instigation of rapid care protocols (allocation of triage category 1 or 2) for acute stroke patients presenting within 2 h of symptom onset. METHODS: A retrospective assessment of emergency department records was undertaken for stroke patients presenting to three hospitals in Melbourne over six months in 2010. RESULTS: 798 patients were included in the study. Among acute stroke patients who presented within 2 h (n=185), 173 (94%) were identified as stroke at triage with 10 cases identified as "altered conscious state". In all cases not identified as stroke the patient was diagnosed with intracerebral haemorrhage. 132 cases (71%) were allocated a triage category 1 or 2. Facial weakness (p=0.002) and presentation to Monash Medical Centre (p=<0.001), were significantly associated with triage category 1 or 2. CONCLUSION: Virtually all acute stroke patients were identified at triage, however 30% were not allocated an urgent triage category (1 or 2). Further education strategies may be required to develop awareness of rapid care protocols for acute stroke patients among triage nurses and ensure the uniform application of Acute Stroke Guidelines and local rapid care pathways.

Can the FAST and ROSIER adult stroke recognition tools be applied to confirmed childhood arterial ischemic stroke?

BACKGROUND: Stroke recognition tools have been shown to improve diagnostic accuracy in adults. Development of a similar tool in children is needed to reduce lag time to diagnosis. A critical first step is to determine whether adult stoke scales can be applied in childhood stroke.Our objective was to assess the applicability of adult stroke scales in childhood arterial ischemic stroke (AIS) METHODS: Children aged 1 month to < 18 years with radiologically confirmed acute AIS who presented to a tertiary emergency department (ED) (2003 to 2008) were identified retrospectively. Signs, symptoms, risk factors and initial management were extracted. Two adult stroke recognition tools; ROSIER (Recognition of Stroke in the Emergency Room) and FAST (Face Arm Speech Test) scales were applied retrospectively to all patients to determine test sensitivity. RESULTS: 47 children with AIS were identified. 34 had anterior, 12 had posterior and 1 child had anterior and posterior circulation infarcts. Median age was 9 years and 51% were male. Median time from symptom onset to ED presentation was 21 hours but one third of children presented within 6 hours. The most common presenting stroke symptoms were arm (63%), face (62%), leg weakness (57%), speech disturbance (46%) and headache (46%). The most common signs were arm (61%), face (70%) or leg weakness (57%) and dysarthria (34%). 36 (78%) of children had at least one positive variable on FAST and 38 (81%) had a positive score of ≥1 on the ROSIER scale. Positive scores were less likely in children with posterior circulation stroke. CONCLUSION: The presenting features of pediatric stroke appear similar to adult strokes. Two adult stroke recognition tools have fair to good sensitivity in radiologically confirmed childhood AIS but require further development and modification. Specificity of the tools also needs to be determined in a prospective cohort of children with stroke and non-stroke brain attacks.

Family physician decisions following stroke symptom onset and delay times to ambulance call.

BACKGROUND: For stroke patients, calling an ambulance has been shown to be associated with faster times to hospital than contacting a family physician. However little is known about the impact of decisions made by family physicians on delay times for stroke patients once they have been called.We aimed to test the hypotheses that among ambulance transported stroke patients:• Factors associated with first calling a family physician, could be identified.• Time to ambulance call will be longer when a family physician is first contacted.• Medical examination prior to the ambulance call will be associated with longer delay times. METHODS: For 6 months in 2004, all ambulance-transported stroke patients who presented from a defined region in Melbourne, Australia to one of three hospitals were assessed. Ambulance and hospital records were analysed. The patient and the person who called the ambulance were interviewed to obtain their description of the stroke event. RESULTS: 198 patients were included in the study. In 32% of cases an ambulance was first called. No demographic or situational factors were associated with first calling a doctor. Patients with a history of stroke or TIA were less likely to call a doctor following symptom onset (p = 0.01). Patients with a severe stroke (Glasgow Coma Scale < 9) never called a doctor first.When a family physician was contacted (22% of cases), the time to ambulance call was significantly longer than when an ambulance was first called (p = 0.0018) (median 143 and 44 minutes, respectively). In 36% of calls to a family physician, the doctor elected to first examine the patient. Time to ambulance call was shorter when the doctor vetted the call and advised the caller to immediately call an ambulance (45%) (median 412 and 92 minutes respectively: p = 0.06). CONCLUSION: Time delays to ambulance call were significantly longer for stroke patients when a family physician was first contacted. Further extensive delays were experienced by patients when the family physician elected to examine the patient.Family physicians and their staff have an important role to play in averting potential delays for stroke patients by screening calls and providing immediate advice to "call an ambulance".

Stroke public awareness campaigns have increased ambulance dispatches for stroke in Melbourne, Australia.

BACKGROUND AND PURPOSE: Launch of the National Stroke Foundation stroke awareness campaigns has occurred annually during Stroke Week (September) since 2004. From 2006, the campaign used FAST (Face, Arm, Speech, Time) with calling an ambulance added in 2007. The aim of this study was to explore the impact of these campaigns on ambulance dispatches for stroke (Medical Priority Dispatch Card 28) in Melbourne, Australia. METHODS: A cross-sectional study examining the monthly proportions of ambulance dispatches for stroke between August 1999 and 2010 was conducted. The proportions of dispatches for stroke were used due to increases in the population and in ambulance dispatches over the study period. These proportions were statistically compared for the month before Stroke Week (August) and the month after Stroke Week (October) for each year and seasonal variation was examined. RESULTS: Between 1999 and 2009, the annual proportion of dispatches for stroke increased from 2.1% (n=4327) to 2.95% (n=9918). When stroke dispatches in August were compared with those in October, a significant increase in October was only detected since the call an ambulance message was added to FAST: 2007 (2.62% to 3.00%, P=0.006), 2008 (2.62% to 3.05%, P=0.003), and 2009 (2.70% to 3.09%, P=0.007). From 2005, the peak season for stroke dispatches shifted from winter to spring. CONCLUSIONS: Ambulance dispatches for stroke significantly increased after the National Stroke Foundation campaigns began, particularly in years receiving greater funding and featuring the FAST symptoms and the message to call an ambulance. Monitoring ambulance use appears to be an effective measure of campaign penetration.

Acute childhood arterial ischemic and hemorrhagic stroke in the emergency department.

STUDY OBJECTIVE: Little is known about the presenting features of acute ischemic and hemorrhagic stroke in children presenting to the emergency department (ED). Yet, initial clinical assessment is a key step in the management pathway of stroke. We describe the presentation in the ED of children with confirmed acute ischemic and hemorrhagic stroke subtypes. METHODS: We conducted a retrospective descriptive case series of consecutive patients aged 1 month to younger than 18 years and presenting to a single-center tertiary ED with radiologically confirmed acute ischemic stroke or hemorrhagic stroke during a 5-year period. Patients were identified by medical record search with International Classification of Diseases, 10th Revision codes for hemorrhagic stroke and through the hospital stroke registry for acute ischemic stroke. Signs, symptoms, and initial management were described. RESULTS: Fifty patients with acute ischemic stroke and 31 with hemorrhagic stroke were identified. Mean age was 8.7 years (SD 5.2), and 51% were male. Fifty-six percent were previously healthy. Median time from onset of symptoms to ED presentation was 21 hours (interquartile range 6 to 48 hours) for acute ischemic stroke and 12 hours (interquartile range 4 to 72 hours) for hemorrhagic stroke. Acute ischemic stroke presented with symptoms of focal limb weakness (64%; 95% confidence interval [CI] 49% to 77%), facial weakness (60%; 95% CI 45% to 73%), and speech disturbance (46%; 95% CI 31% to 60%). Few patients with acute ischemic stroke presented with vomiting and altered mental status. Most patients with acute ischemic stroke had a Glasgow Coma Scale (GCS) score of 14 or greater (86%; 95% CI 73% to 94%) and presented with at least 1 focal neurologic sign (88%; 95% CI 73% to 98%). Hemorrhagic stroke presented with headache (73%; 95% CI 54% to 87%), vomiting (58%; 95% CI 40% to 75%), and altered mental status (48%; 95% CI 30% to 67%). GCS score in hemorrhagic stroke was less than 14 in 38% and less than 8 in 19% (95% CI 7% to 37%). Less than one third of patients had focal limb weakness, facial weakness, or slurred speech. Nineteen percent of patients with hemorrhagic stroke were intubated in the ED and admitted to the ICU. None of the acute ischemic stroke patients were intubated in the ED, and 4% were admitted to the ICU. CONCLUSION: Diagnosis of stroke in children with acute ischemic stroke and hemorrhagic stroke was delayed. Acute ischemic stroke presented mainly with focal findings; hemorrhagic stroke, with headache, vomiting, and mental status change.

The impact of ambulance practice on acute stroke care.

BACKGROUND AND PURPOSE: Few patients with acute stroke are treated with alteplase, often due to significant prehospital delays after symptom onset. The aims of this study were to: (1) identify factors associated with rapid first medical assessment in the emergency department after a call for ambulance assistance, and (2) determine the impact of ambulance practice on times from the ambulance call to first medical assessment in the emergency department. METHODS: During a 6-month period in 2004, all ambulance-transported patients with stroke or transient ischemic attack arriving from a geographically defined region in Melbourne, Australia (population 383,000) to one of 3 hospital emergency departments were assessed prospectively. Ambulance records including the tape recording of the call for ambulance assistance and hospital medical records, were analyzed. RESULTS: One hundred ninety-eight patients were included in the study. One hundred eighty-seven ambulance patient care records were complete and available for analysis. Factors associated with first medical assessment in the emergency department <60 minutes from the ambulance call and <10 minutes from hospital arrival were: Glasgow Coma Scale <13 (P<0.001 and P=0.021) and hospital prenotification (P=0.04 and P<0.001). Paramedic stroke recognition and hospital prenotification were associated with shorter times from the ambulance call to first medical assessment (P=0.001 and P<0.001). CONCLUSIONS: Paramedic stroke recognition and hospital prenotification are associated with shorter prehospital times from the ambulance call to hospital arrival and in-hospital times from hospital arrival to first medical assessment. This highlights the importance of including ambulance practice in comprehensive care pathways that span the whole process of stroke care.

Stroke symptoms and the decision to call for an ambulance.

BACKGROUND AND PURPOSE: Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. METHODS: For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. RESULTS: One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as "stroke." Factors independently associated with a call within 1 hour were: speech problems (P=0.009), caller family history of stroke (P=0.017), and the patient was not alone at symptom onset (P=0.018). CONCLUSIONS: Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment.