Call to hospital times for suspected stroke patients in the North East of England: a service evaluation

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Abstract

Introduction:

Stroke is a leading cause of mortality and morbidity. The role of the ambulance service in acute stroke care focuses on recognition followed by rapid transport to specialist care. The treatment options for acute ischaemic strokes are time dependent, so minimising the pre-hospital phase of care is important. The aim of this service evaluation was to report historical pre-hospital times for suspected stroke patients transported by the North East Ambulance Service NHS Foundation Trust (NEAS) and identify areas for improvement.

Methods:

This was a retrospective service evaluation using routinely collected data. Data on overall call to hospital times, call to arrival times, on scene times and leave scene to hospital are reported.

Results:

Data on 24,070 patients with an impression of stroke transported by NEAS between 1 April 2011 and 31 May 2018 are reported. The median call to hospital time increased from 41 to 68 minutes, call to arrival from 7 to 17 minutes, on scene from 20 to 30 minutes and leave to hospital from 12 to 15 minutes.

Conclusion:

The pre-hospital call to hospital time for stroke patients increased between 2011 and 2018. The call to arrival phase saw a sharp increase between 2015 and 2017, whereas on scene and leave scene to hospital saw steadier increases. Increasing demand on the ambulance service, reorganisation of regional stroke services and other factors may have contributed to the increase in times. Reducing the on scene phase of pre-hospital stroke care would lead to patient benefits and is the area where ambulance clinicians have the most influence.

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Most cited references 18

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Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials

Jonathan Emberson, Kennedy R Lees, Patrick D Lyden … (2014)

Summary Background Alteplase is effective for treatment of acute ischaemic stroke but debate continues about its use after longer times since stroke onset, in older patients, and among patients who have had the least or most severe strokes. We assessed the role of these factors in affecting good stroke outcome in patients given alteplase. Methods We did a pre-specified meta-analysis of individual patient data from 6756 patients in nine randomised trials comparing alteplase with placebo or open control. We included all completed randomised phase 3 trials of intravenous alteplase for treatment of acute ischaemic stroke for which data were available. Retrospective checks confirmed that no eligible trials had been omitted. We defined a good stroke outcome as no significant disability at 3–6 months, defined by a modified Rankin Score of 0 or 1. Additional outcomes included symptomatic intracranial haemorrhage (defined by type 2 parenchymal haemorrhage within 7 days and, separately, by the SITS-MOST definition of parenchymal type 2 haemorrhage within 36 h), fatal intracranial haemorrhage within 7 days, and 90-day mortality. Findings Alteplase increased the odds of a good stroke outcome, with earlier treatment associated with bigger proportional benefit. Treatment within 3·0 h resulted in a good outcome for 259 (32·9%) of 787 patients who received alteplase versus 176 (23·1%) of 762 who received control (OR 1·75, 95% CI 1·35–2·27); delay of greater than 3·0 h, up to 4·5 h, resulted in good outcome for 485 (35·3%) of 1375 versus 432 (30·1%) of 1437 (OR 1·26, 95% CI 1·05–1·51); and delay of more than 4·5 h resulted in good outcome for 401 (32·6%) of 1229 versus 357 (30·6%) of 1166 (OR 1·15, 95% CI 0·95–1·40). Proportional treatment benefits were similar irrespective of age or stroke severity. Alteplase significantly increased the odds of symptomatic intracranial haemorrhage (type 2 parenchymal haemorrhage definition 231 [6·8%] of 3391 vs 44 [1·3%] of 3365, OR 5·55, 95% CI 4·01–7·70, p<0·0001; SITS-MOST definition 124 [3·7%] vs 19 [0·6%], OR 6·67, 95% CI 4·11–10·84, p<0·0001) and of fatal intracranial haemorrhage within 7 days (91 [2·7%] vs 13 [0·4%]; OR 7·14, 95% CI 3·98–12·79, p<0·0001). The relative increase in fatal intracranial haemorrhage from alteplase was similar irrespective of treatment delay, age, or stroke severity, but the absolute excess risk attributable to alteplase was bigger among patients who had more severe strokes. There was no excess in other early causes of death and no significant effect on later causes of death. Consequently, mortality at 90 days was 608 (17·9%) in the alteplase group versus 556 (16·5%) in the control group (hazard ratio 1·11, 95% CI 0·99–1·25, p=0·07). Taken together, therefore, despite an average absolute increased risk of early death from intracranial haemorrhage of about 2%, by 3–6 months this risk was offset by an average absolute increase in disability-free survival of about 10% for patients treated within 3·0 h and about 5% for patients treated after 3·0 h, up to 4·5 h. Interpretation Irrespective of age or stroke severity, and despite an increased risk of fatal intracranial haemorrhage during the first few days after treatment, alteplase significantly improves the overall odds of a good stroke outcome when delivered within 4·5 h of stroke onset, with earlier treatment associated with bigger proportional benefits. Funding UK Medical Research Council, British Heart Foundation, University of Glasgow, University of Edinburgh.

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Time Is Brain—Quantified

Jeffrey L Saver (2006)

The phrase "time is brain" emphasizes that human nervous tissue is rapidly lost as stroke progresses and emergent evaluation and therapy are required. Recent advances in quantitative neurostereology and stroke neuroimaging permit calculation of just how much brain is lost per unit time in acute ischemic stroke. Systematic literature-review identified consensus estimates of number of neurons, synapses, and myelinated fibers in the human forebrain; volume of large vessel, supratentorial ischemic stroke; and interval from onset to completion of large vessel, supratentorial ischemic stroke. The typical final volume of large vessel, supratentorial ischemic stroke is 54 mL (varied in sensitivity analysis from 19 to 100 mL). The average duration of nonlacunar stroke evolution is 10 hours (range 6 to 18 hours), and the average number of neurons in the human forebrain is 22 billion. In patients experiencing a typical large vessel acute ischemic stroke, 120 million neurons, 830 billion synapses, and 714 km (447 miles) of myelinated fibers are lost each hour. In each minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. Compared with the normal rate of neuron loss in brain aging, the ischemic brain ages 3.6 years each hour without treatment. Altering single input variables in sensitivity analyses modestly affected the estimated point values but not order of magnitude. Quantitative estimates of the pace of neural circuitry loss in human ischemic stroke emphasize the time urgency of stroke care. The typical patient loses 1.9 million neurons each minute in which stroke is untreated.

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Streamlining of prehospital stroke management: the golden hour.

Matthew R. Levine, Klaus Fassbender, Clotilde Balucani … (2013)

Thrombolysis with alteplase administered within a narrow therapeutic window provides an effective therapy for acute ischaemic stroke. However, mainly because of prehospital delay, patients often arrive too late for treatment, and no more than 1-8% of patients with stroke obtain this treatment. We recommend that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy. Measures for improvement include continuous public awareness campaigns, education of emergency medical service personnel, the use of standardised, validated scales for recognition of stroke symptoms and for triaging to the appropriate institution, and advance notification to the receiving hospital. In the future, use of telemedicine technologies for interaction between the emergency site and hospital, and the strategy of treatment directly at the emergency site (mobile stroke unit concept), could contribute to more efficient use of resources and reduce the time taken to instigate treatment to within 60 min--the golden hour--of the onset of the symptoms of stroke. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Daniel Haworth

Graham McClelland

Journal

Journal ID (nlm-ta): Br Paramed J

Journal ID (publisher-id): BPJ

Title: British Paramedic Journal

Publisher: The College of Paramedics

ISSN (Electronic): 1478-4726

Publication date (Print and electronic): 01 September 2019

Publication date (Electronic): 01 September 2019

Publication date (Print): 01 September 2019

Volume: 4

Issue: 2

Pages: 31-36

Affiliations

[1]North East Ambulance Service NHS Foundation Trust: ORCID iD: https://orcid.org/0000-0003-0334-3300

[2]North East Ambulance Service NHS Foundation Trust: ORCID iD: https://orcid.org/0000-0002-4502-5821

Author notes

[*]Corresponding author: Graham McClelland, North East Ambulance Service NHS Foundation Trust, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne NE15 8NY, UK. Email: graham.mcclelland@ 123456neas.nhs.uk

Article

Other ID: BPJ-4-2-31

DOI: 10.29045/14784726.2019.09.4.2.31

PMC ID: 7706759

PubMed ID: 33328834

SO-VID: f36b91ab-446a-47ce-af19-c1a515ed965f

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Call to hospital times for suspected stroke patients in the North East of England: a service evaluation

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Stroke MRI

Most cited references 18

Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials

Time Is Brain—Quantified

Streamlining of prehospital stroke management: the golden hour.

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