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Frogs have a highly conserved body plan, yet they employ a diverse array of locomotor modes, making them ideal organisms for investigating the relationships between morphology and locomotor function, in particular whether anatomical complexity is a prerequisite for functional complexity. We use diffusible iodine contrast-enhanced microCT (diceCT) imaging to digitally dissect the gross muscle anatomy of the pelvis and hindlimbs for 30 species of frogs representing five primary locomotor modes, including the first known detailed dissection for some of the world's smallest frogs, forming the largest digital comparative analysis of musculoskeletal structure in any vertebrate clade to date. By linking musculoskeletal dissections and phylogenetic comparative methods, we then quantify and compare relationships between anatomy and function across over 160 million years of anuran evolution. In summary, we have found that bone lengths and pelvic crest sizes are generally not reliable predictors of muscle sizes, which highlights important implications for future palaeontological studies. Our investigation also presents previously unreported differences in muscle anatomy between frogs specialising in different locomotor modes, including several of the smallest frog hindlimb muscles, which are extremely difficult to extract and measure using traditional approaches. Furthermore, we find evidence of many-to-one and one-to-many mapping of form to function across the phylogeny. Additionally, we perform the first quantitative analysis of how the degree of muscle separation can differ between frogs. We find evidence that phylogenetic history is the key contributing factor to muscle separation in the pelvis and thigh, while the separation of shank muscles is influenced more strongly by locomotor mode. Finally, our anatomical 3D reconstructions are published alongside this manuscript to contribute towards future research and serve as educational materials.
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The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.
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American Heart Association , Hemorragia Cerebral , Humanos , Hemorragia Cerebral/terapia , Estados Unidos , Accidente Cerebrovascular/terapia , Guías de Práctica Clínica como Asunto/normasRESUMEN
INTRODUCTION: Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences. METHODS: This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences. RESULTS: A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents' preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2%-77.1%) preferred their survey DCE choice to their agency's current implementation practices. In the rank order preferences, most participants selected "knowledge of the underlying evidence behind the change" as the most important component of the process of implementation. CONCLUSIONS: In this study of EMS clinicians' implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.
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Servicios Médicos de Urgencia , Auxiliares de Urgencia , Humanos , Masculino , Adulto , Femenino , Servicios Médicos de Urgencia/métodos , Estudios Transversales , Encuestas y Cuestionarios , HospitalesRESUMEN
BACKGROUND: Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation. OBJECTIVE: The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments. METHODS: The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator. RESULTS: In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources. CONCLUSION: The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.
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Servicios Médicos de Urgencia , Auxiliares de Urgencia , Humanos , Consenso , Auxiliares de Urgencia/educación , Encuestas y CuestionariosRESUMEN
Frogs exhibit complex anatomical features of the pelvis, limbs and spine, long assumed to represent specialisations for jumping. Yet frogs employ a wide range of locomotor modes, with several taxa featuring primary locomotor modes other than jumping. Using a combination of techniques (CT imaging and 3D visualization, morphometrics, phylogenetic mapping), this study aims to determine the link between skeletal anatomy and locomotor style, habitat type and phylogenetic history, shedding new light on how functional demands impact morphology. Body and limb measurements for 164 taxa from all the recognised anuran families are extracted from digitally segmented CT scans of whole frog skeletons and analysed using various statistical techniques. We find that the expansion of the sacral diapophyses is the most important variable for predicting locomotor mode, which was more closely correlated with frog morphology than either habitat type or phylogenetic relationships. Predictive analyses suggest that skeletal morphology is a useful indicator of jumping but less so for other locomotor modes, suggesting that there is a wide range of anatomical solutions to performing locomotor styles such as swimming, burrowing or walking.
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Evolución Biológica , Locomoción , Humanos , Animales , Filogenia , Anuros/anatomía & histología , NataciónRESUMEN
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Servicios Médicos de Urgencia , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/terapia , Servicio de Urgencia en Hospital , Calidad de la Atención de SaludRESUMEN
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Servicios Médicos de Urgencia , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Cuidados Críticos , Hospitales , Tiempo de TratamientoRESUMEN
Introduction: Prehospital evidence-based guidelines (EBGs) are developed to optimize clinical outcomes for emergency medical services (EMS) patients. However, widespread implementation of EBGs is often inconsistent. Therefore, this study aimed to assess the baseline knowledge and practices of EMS leaders related to EBG implementation.Methods: This was a qualitative study using focus groups to assess prehospital implementation awareness and knowledge. Participants were EMS EBG authors, EMS medical directors, and EMS professional organization leaders. Focus groups were held via video conference, audio recorded, and transcribed. Thematic coding used domains and constructs of the Consolidated Framework for Implementation Research (CFIR).Results: Six focus groups were conducted with a total of 18 participants. A total of 1,044 codes were analyzed. "Process" was the CFIR domain with the most codes (n = 350, 33.5%), followed by the "inner setting" (the EMS agency; n = 250, 23.9%), "characteristics of the intervention" (n = 203, 19.4%), "outer setting" (the health care system and community the EMS agency serves, and the broader national EMS professional context; n = 141, 13.5%), and "characteristics of individuals" (n = 100, 9.6%). The ten most frequent constructs across all domains were: reflecting and evaluating, executing, cosmopolitanism, planning, external policy and incentives, design quality and packaging, learning climate, culture, complexity, and other personal attributes.Conclusion: EMS leadership and stakeholder views on EBG implementation identified dominant themes related to the process of implementation and the culture and learning/implementation climate of EMS agencies. Opinions were mixed on the utility of the CFIR as a potential guide for EMS implementation. Further work is required to gain the frontline EMS clinician perspective on implementation and tie key themes to quantitative prehospital implementation outcomes.
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Servicios Médicos de Urgencia , Humanos , Liderazgo , Atención a la Salud , Investigación Cualitativa , Grupos FocalesRESUMEN
BACKGROUND AND PURPOSE: Patients with acute ischemic stroke (AIS) eligible for thrombolysis benefit when thrombolysis is administered quickly, and mobile stroke units (MSU) can facilitate timely thrombolysis. We sought to compare time metrics and clinical outcomes of AIS patients receiving thrombolysis in an MSU compared with patients arriving via local emergency medical services (EMS). METHODS: We performed a retrospective, non-randomized, cohort study comparing MSU-arriving to EMS-arriving AIS patients from January 20, 2017 through November 30, 2020. The primary outcome was rate of return to baseline functional status as measured by the modified Rankin Score (mRS) 90 days after thrombolysis. Secondary outcomes included evaluation and treatment intervals from last known well, treatment rate in the first hour of symptoms, hospital length of stay, and mortality. Chi square and Student's t-test were used to compare groups. RESULTS: Of 1752 total patients with prehospital suspected stroke, 975 (55.7%) were transported via MSU, of whom 431 (44.2%) were diagnosed with stroke, including 368 (85.4%) with AIS, and 69 AIS patients (18.8%) received thrombolysis. Of 777 (44.3%) EMS-arriving patients, 373 (48%) were diagnosed with stroke, including 305 (81.8%) with AIS, and 74 (24.3%) received thrombolysis. Though not statistically significant, point estimates of the proportion of AIS patients treated with thrombolysis returning to baseline functional status were more commonly observed for MSU than for EMS transports when the baseline mRS was 0-2 (45.8% vs 33.3%), 0-3 (41.9% vs 33.3%), and 4-5 (71.4% vs 20.0%). MSU patients were more likely to receive thrombolysis in the first 60 minutes of symptom onset (31.9% vs 12.2%, p = 0.006). Overall mortality rates regardless of baseline mRS were similar between groups. CONCLUSIONS: AIS patients received thrombolysis faster in the MSU compared with EMS and more frequently within 60 minutes of stroke onset. Point estimates for 90-day clinical outcomes of AIS patients treated with thrombolysis favored MSU without a statistically significant difference.
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Servicios Médicos de Urgencia , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Estudios Retrospectivos , Estudios de Cohortes , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Terapia Trombolítica , Resultado del Tratamiento , Accidente Cerebrovascular/diagnósticoRESUMEN
INTRODUCTION: Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES: We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS: We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS: This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.
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Servicios Médicos de Urgencia , Humanos , Medicina Basada en la Evidencia , Recursos HumanosRESUMEN
Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.
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Servicios Médicos de Urgencia , Humanos , Servicios Médicos de Urgencia/métodos , Medicina Basada en la Evidencia/métodos , EscolaridadRESUMEN
Joint range of motion (RoM) analyses are fundamental to our understanding of how an animal moves throughout its ecosystem. Recent technological advances allow for more detailed quantification of this RoM (e.g. including interaction of degrees of freedom) both in ex vivo joints and in vivo experiments. Both types of data have been used to draw comparisons with fossils to reconstruct locomotion. Salamanders are often used as analogues for early tetrapod locomotion; testing such hypotheses requires an in-depth analysis of salamander joint RoM. Here, we provide a detailed dataset of the ex vivo ligamentous rotational joint RoM in the hindlimb of the fire salamander Salamandra salamandra, using a new method for collecting and visualising joint RoM. We also characterise in vivo joint RoM used during walking, via scientific rotoscoping and compare the in vivo and ex vivo data. In summary, we provide (1) a new method for joint RoM data experiments and (2) a detailed analysis of both in vivo and ex vivo data of salamander hindlimbs, which can be used for comparative studies.
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Salamandra , Animales , Ecosistema , Rango del Movimiento Articular , Urodelos , CaminataRESUMEN
Quantifying joint range of motion (RoM), the reachable poses at a joint, has many applications in research and clinical care. Joint RoM measurements can be used to investigate the link between form and function in extant and extinct animals, to diagnose musculoskeletal disorders and injuries or monitor rehabilitation progress. However, it is difficult to visually demonstrate how the rotations of the joint axes interact to produce joint positions. Here, we introduce the spherical frame projection (SFP), which is a novel 3D visualisation technique, paired with a complementary data collection approach. SFP visualisations are intuitive to interpret in relation to the joint anatomy because they 'trace' the motion of the coordinate system of the distal bone at a joint relative to the proximal bone. Furthermore, SFP visualisations incorporate the interactions of degrees of freedom, which is imperative to capture the full joint RoM. For the collection of such joint RoM data, we designed a rig using conventional motion capture systems, including live audio-visual feedback on torques and sampled poses. Thus, we propose that our visualisation and data collection approach can be adapted for wide use in the study of joint function.
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Movimiento , Animales , Fenómenos Biomecánicos , Rango del Movimiento ArticularRESUMEN
OBJECTIVE: Recognition of out-of-hospital cardiac arrest (OHCA) during 9-1-1 calls is critically important, but little is known about how laypersons and emergency medical dispatchers (EMDs) communicate. We sought to describe 9-1-1 calls for OHCA. METHODS: We performed a mixed-methods, retrospective analysis of 9-1-1 calls for OHCA victims in a large urban emergency medical services (EMS) system using a random sampling of cases containing the term "cardiopulmonary resuscitation" (CPR) in the EMS electronic report. A constant comparison qualitative approach with four independent reviewers continued until thematic saturation was achieved. Quantitative analysis employed computational linguistics. Callers' emotional states were rated using the emotional content and cooperation score (ECCS). RESULTS: Thematic saturation was achieved after 46 calls. Three "OHCA recognition" themes emerged [ 1) disparate OHCA terms used, 2) OHCA mimics create challenges, 3) EMD questions influence recognition]. Three "CPR facilitation" themes emerged [ 1) directive language may facilitate CPR, 2) specific instructions assist CPR, 3) caller's emotions affect CPR initiation]. Callers were generally "anxious but cooperative." Callers saying "pulse" was associated with OHCA recognition. CONCLUSION: Communication characteristics appear to influence OHCA recognition and CPR facilitation. PRACTICE IMPLICATIONS: Dispatch protocols that acknowledge characteristics of callers' communication may improve OHCA recognition and CPR facilitation.
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Reanimación Cardiopulmonar , Operador de Emergencias Médicas , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Reanimación Cardiopulmonar/métodos , Comunicación , Sistemas de Comunicación entre Servicios de Urgencia , Humanos , Paro Cardíaco Extrahospitalario/terapia , Estudios RetrospectivosRESUMEN
BACKGROUND: Optimal care for patients with stroke relies on timely recognition and rapid transport to appropriate treatment, often by emergency medical services (EMS). Our primary objective was to describe EMS time intervals for patients with suspected stroke in the United States. We also sought to quantify the variation in EMS time intervals by geographic location and urbanicity. METHODS: We conducted a cross-sectional evaluation of EMS 9-1-1 activations (ie, calls for service) included in the 2018 and 2019 National EMS Information System datasets. We included ground or air EMS activations for a 9-1-1 scene response where a patient aged ≥18 years with suspected stroke was treated and transported by EMS. Time intervals for dispatch, response, scene, transport, and total prehospital time (ie, from dispatch to hospital arrival) were calculated, stratified by ground and air transport type. RESULTS: A total of 410 187 activations for suspected stroke were included, of which 98% were a ground transport. The median total prehospital time for ground transports was 35 minutes (interquartile range, 27-45, 90th percentile 58). Median total prehospital time for air transports was substantially longer at 56 minutes (interquartile range, 43-70, 90th percentile 86). Times varied by Census division and urbanicity with the shortest ground total prehospital times in the East North Central division and urban areas and longest times in the East South Central and rural and frontier areas. CONCLUSIONS: Timely EMS response and transport is critical for optimizing care of patients with suspected stroke. Using a large, national dataset of EMS activations, we found variations by geographic location and urbanicity in total prehospital time for ground and air EMS activations for patients with stroke.
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Servicios Médicos de Urgencia , Accidente Cerebrovascular/terapia , Tiempo de Tratamiento , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnóstico , Factores de Tiempo , Estados Unidos , Adulto JovenRESUMEN
Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.
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Servicios Médicos de Urgencia , Niño , Consenso , Técnica Delphi , Servicios Médicos de Urgencia/métodos , Humanos , Encuestas y CuestionariosRESUMEN
STUDY OBJECTIVE: Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers. METHODS: We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models. RESULTS: Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]). CONCLUSION: Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.