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01-11-2009 | Stroke | Article

Canadian prehospital triage protocol boosts access to thrombolysis


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MedWire News: The introduction of a prehospital triage protocol in Toronto, Canada, in 2005 led to a marked increase in the use of thrombolysis for ischemic stroke, research demonstrates.

The success of the citywide pilot scheme underscores the need for coordinated systems for organized stroke care, say the researchers, although they admit that sustaining the initiative will present further challenges.

The protocol was introduced as part of a regional governmental drive to improve stroke care. It featured a citywide prehospital activation protocol in which acute stroke patients were rapidly transported to one of three regional stroke centers, bypassing local hospitals.

Key elements of the triage protocol were a paramedic screening tool, ambulance destination decision rule, and formal memorandum of understanding among system stakeholders.

To assess the impact of the protocol, David Gladstone (Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada) and colleagues compared consecutive patients arriving in their stroke center during the first 4 months of the new protocol (mid-February to mid-June, 2005) versus the same period in 2004.

The total number of patients arriving in the stroke center rose from 217 in 2004 to 290 in 2005, Gladstone et al report in the journal Stroke. Of these, the number with a final diagnosis of ischemic stroke was 74 in 2004 and 128 in 2005.

More importantly, the proportion of patients with acute ischemic stroke arriving within 2.5 hours of symptom onset increased from 35.1% to 49.2%, while the proportion of patients who received treatment with tissue plasminogen activator (tPA) increased from 9.5% to 23.5%.

“One in two patients with ischemic stroke arriving within 2.5 hours received thrombolysis during this period (one in five of patients with ischemic stroke overall),” write Gladstone et al. Furthermore, one in five tPA-treated patients made a full neurological recovery at 24 hours.

The increased use of thrombolysis reflected a marked reduction in transport times, say the researchers, such that the median symptom onset-to-needle time fell from 195 to 141 minutes. By contrast, onset-to-arrival and arrival-to-needle times rose, from 7 to 30 minutes in both instances.

The researchers say their analysis confirms other reports demonstrating the benefits of prehospital and hospital protocols for acute stroke. They add that sustaining the initiative will be dependent on interdisciplinary teamwork, ongoing paramedic training, adequate hospital staffing, bed availability, and repatriation agreements with community hospitals.

“This report highlights the initial success of a prehospital stroke protocol and the strategies underway to overcome several implementation challenges,” they conclude.

“Hopefully, our experience will assist other regions in developing similar protocols to optimize the emergency management of patients with acute stroke.”

MedWire ( is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2009

By Joanna Lyford