Original Contribution

Stroke: prospective evaluation of a prehospital management process based onrescuers under medical direction☆,☆☆

Laure Alhanati, MD, Stéphane Dubourdieu, MD, Clément Hoffmann, MD, Francis Béguec, MD,Stéphane Travers, MD, Hugues Lefort, MD, Olga Maurin, MD, Daniel Jost, MD, Laurent Domanski, MD,Jean-Pierre Tourtier, MD⁎

Fire Brigade of Paris, Emergency Medical Service, 1 Place Jules Renard, 75017 Paris, France

a b s t r a c ta r t i c l e i n f o

Article history:

Received 9 October 2013

Received in revised form 2 January 2014

Accepted 22 January 2014

Available online xxxx

Background: Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We

assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating

thrombolysis of eligible patients.

Methods: This was a prospective observational study conducted over 4 months in Paris, France. Prehospital

patients with suspected stroke were included after telephone consultation with a physician. If the time since

the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit

(NVU); if symptom onset was more than 6 hours ago, they were transported to an emergency department

(ED). Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and

hospital arrival and imaging were assessed. Comparison used Fisher exact test.

Results: Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic

stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150minutes. Of 64

patients admitted to the ED, 36 patients had a stroke (ischemic, 24). None were thrombolysed. Globally, 36%

of ischemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65

minutes (ED vs NVU, P = .61). The interval call-imaging was 202 minutes (interquartile range, 105.5-254.5)

for ED and 92 minutes (interquartile range, 77-116) for NVU (P b .001).

Conclusions: The prehospital management of stroke by rescuers, under strict medical direction, seemed to be

feasible and effective for selection of patients with stroke in an urban environment and may improve the

access to thrombolysis.

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

Cerebrovascular accident (stroke) is a main cause of death

worldwide and is one of the most common causes of disability in

developed countries [1]. Strokes affect 130000 people each year in

France, making stroke the leading cause of acquired disability in

adults and the third leading cause of mortality [2]. Approximately 90%

of all strokes are due to cerebral ischemia [3]. The specific treatment

for ischemic stroke is recanalization of occluded arteries within the

very first hours of symptom onset [4-6]. Less than one-third of

patients with acute stroke arrive at the hospital early enough to

receive thrombolytic treatment, and less than 5% actually receive it [7-

11]. Of those patients, outcomes are closely related to the time to

treatment [12–14].

There is rare published trial of prehospital stroke diagnosis and

treatment; there are several reports of prehospital delay in acute

stroke care. The reportedmedian times from symptom onset to arrival

at hospital vary strongly, ranging from 3 to 6 hours, and median times

from arrival at hospital to thrombolysis were assessed to bemore than

1 hour [15-19].

The timely and accurate diagnosis of acute ischemic stroke by

prehospital providers is critical in the chain of survival in stroke, and

chances of successful treatment are time dependent.

Accurate diagnosis in the field may lead to improved treatment

intervals such as door-to-imaging and door-to-treatment times,

which could improve chances of success.

In accordance with international guidelines, the fire brigade of

Paris (Brigade des Sapeurs-Pompiers de Paris [BSPP]) has developed a

specific prehospital management procedure for stroke. It is based on

American Journal of Emergency Medicine xxx (2014) xxx–xxx

☆ Contribution of authors: Alhanati L: Design of the study, acquisition of data,

analysis and interpretation of data, drafting the article. Dubourdieu S: Conception and

design of the study, analysis and interpretation of data. Hoffmann C: Acquisition of data.

Béguec F: Acquisition of data. Travers S, Lefort H, Maurin O, Jost D, Domanski L:

Acquisition of data, analysis and interpretation of data. Domanski L: Interpretation of

data, design of the study. Tourtier JP: Design of the study, drafting the article intellectual

content, final approval of the version to be submitted.☆☆ Disclosures: No funding of any kind, no conflict of interest of any kind for all

authors.

⁎ Corresponding author. Fire Brigade of Paris, Emergency Medical Service, 1 Place

Jules Renard, 75017 Paris. Tel.: +33 670208162; fax: +33 156796754.

E-mail address: medecinchef.bmu@pompiersparis.fr (J.-P. Tourtier).

0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ajem.2014.01.034

Contents lists available at ScienceDirect

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Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers undermedical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

management by firemen rescuers (under strict medical direction) and

immediate transport. The aim of this procedure is to facilitate rapid

admission to a neurovascular unit (NVU) after medical control of the

patient's assessment and after contacting a neurologist [20].

The objective of this study was to prospectively evaluate this

prehospital process of stroke management for improvement in

diagnosis, treatment, and time intervals.

2. Methods

2.1. Geographical situation

The BSPP employs 8500 firemen, and its mission is to provide

assistance and first-aid care to residents of Paris and the 3 adjacent

districts, which represents a population of 10 million people. There

are 40 hospital emergency departments (ED) and 14 NVUs in this

area. The fire brigade of Paris performs 500000 prehospital

emergency interventions per year and is equipped with ambulances

(Véhicules de Secours et d’Assistance aux Victimes) with a team of

3 fireman rescuers as well as medical transportation means:

intensive care ambulances with a physician and a nurse. Telephone

calls (emergency numbers in Europe: 112, emergencies; 18, fire

brigade) from the population requesting an intervention (2.1

million calls per year) are analyzed by specialized operators and

by physicians in the coordination center, and a rescue team can be

dispatched immediately.

2.2. The prehospital stroke management process

Before 2007, following the field rescuers evaluation, a medical

teamwas called to confirm the diagnosis and practice the transport to

NVU or emergency medical services, depending mainly on physician

assessment and disponibility of hospital. In February 2007, an

innovative specific process for stroke management by rescuers team

aimed at facilitating rapid admission to an NVUwas set up by the Paris

Fire Brigade (at that time, prehospital management of stroke was

generally ensured by a medical team). As a result, following a call to

the emergency number by the victim or the victim's family and in the

absence of any immediate life-threatening situation detected at the

time of the call, an ambulance (Véhicules de Secours et d’Assistance

aux Victimes) teamed by 3 firemen rescuers was dispatched.

The work has been approved by the appropriate ethical commit-

tees related to the institution.

An on-the-spot assessment consisted of collecting the basic

elements: age, sex, medical history and treatments, functional

complaints, Glasgow score and signs of stroke on the Face Arm

Speech Test diagnosis scale, heart rate, blood pressure, respiratory

rate, oxygen saturation (SpO2), temperature, and capillary blood

glucose when a blood glucose apparatus was available at the patient's

home [21]. The firemen then transmitted assessment by telephone to

a physician in the medical coordination center.

In all cases of suspected stroke, this assessment was systemat-

ically reviewed by the physician who either confirmed or excluded

the suspicion of stroke. A specific standard form was then used

(Appendix 1) to record all the essential information items for the

neurologist, including the time since the onset of symptoms

(corresponding to the time when the patient's neurologic state

was last considered to be normal by the witness or by the patient in

the absence of a witness), a list of the patient's symptoms, and a

decision-making algorithm.

If the victim did not show any criteria for medical management

(severe consciousness disorder, life-threatening respiratory or circu-

latory distress, associated seizures, suspected meningeal hemor-

rhage), the coordinating physician took into account the time since

the onset of symptoms. In agreement with local neurologists, a

maximum estimated interval of 6 hours since the onset of the first

symptoms was considered to be potentially compatible with

thrombolytic therapy in the case of an ischemic stroke (4.5 hours

according to ischemic stroke recommendations and up to 6 hours for

certain types of stroke such as those involving the basilar trunk) [14].

If the time since the onset of symptoms was less than 6 hours, the

physician of the coordination center would contact the closest NVU

with an available place for the patient. A contraindication to

thrombolysis did not exclude the transfer to an NVU [22].

When direct transport to an NVU was decided, the patient was

transported urgently.When the time since the onset of symptomswas

longer than 6 hours, but less than 24 hours, the triage physician would

seek the opinion of the closest NVU's neurologist to determine

whether the patient should be transferred directly to the NVU,

depending on his/her clinical status and available place, or to a nearby

ED (ED management process).

The paramedics would systematically collect the patient's pre-

scriptions and also request a member of the patient's family to

accompany them or, failing this, would record a telephone number

where the relative could be reached. During transport, the patient was

placed in a supine position in the absence of contraindication. The

patient was placed under close neurologic and hemodynamic

monitoring and given oxygen inhalation. In the event of any

neurologic deterioration during transport, the coordinating physician

was urgently recontacted to decide the intervention of an intensive

care ambulance (sent on the spot with a physician).

2.3. Data collection

This prospective cohort study was conducted from September 1 to

December 31, 2011. All patients for whom the BSPP “Stroke” process

was applied were included in the study, except for patients

immediately presenting medical management criteria, for whom an

intensive care ambulance was directly dispatched. The data were

collected from various documents: specific Paris fire brigade coordi-

nating physician forms (Appendix 1) recording age, sex, time of the

emergency call, clinical symptoms, and transfer decision (to NVU or a

hospital ED). Hospital discharge summaries were also obtained. Close

contact was established with a corresponding physician in each

department (NVU and EDs) to define the method for recovering

hospital discharge summaries: theywere either collecteddirectly from

the department, sent by letter, e-mailed, or faxed. For each case, the

time since the onset of symptoms, the time of admission to the ward,

the initial National Institute of Health Stroke Score (NIHSS), the time of

medical imaging, whether thrombolysis was performed (including

start and end times), any reasons why thrombolysis was not

performed, and the final diagnosis were collected.

For calculating time intervals, some definitions were used. The

call-hospital interval matched with the interval between the time

when the call was received by the triage center and the time of the

patient's admission to hospital. The call-imaging interval was the

interval between the call and the time at which neurologic imaging

(computed tomography or magnetic resonance imaging) was per-

formed. At last, the stroke-thrombolysis interval was the time interval

between the time when the patient was last asymptomatic and the

time at which thrombolysis was performed.

The primary end points were the rate of stroke diagnosis

confirmations among patients transported by firemen rescuers

teams and the rate of patients who were thrombolysed in the NVU

management process and in the ED management process.

The secondary end points were the various prehospital manage-

ment time intervals: call-hospital, call-imaging, and stroke onset-

thrombolysis intervals.

The data were anonymized and entered into an Excel spreadsheet.

Statistical calculations were performed using Excel and Stata

software. The quantitative data were compared by Fisher exact test.

2 L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers undermedical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

3. Results

From September 1 to December 31, 2011, 462 patients were

included in the study: 225 women (48.7%) and 237 men (51.3%) with

a median age of 72 years (interquartile range [IQR]25-75, 58-81).

Of this total, 454 patients (98.3%) were transported by rescuers

teams: 357 patients (77.3%) were transferred to an NVU and 97 were

transferred to nearby EDs (21%). One patient (0.2%) received care by

an additional medical team. Data concerning the initial triage were

missing for 7 patients (1.5%) (Fig.).

3.1. Patients transferred to an NVU

The median age of patients transferred to an NVU was 72 years

(IQR, 58-82), and the median NIHSS score was 8 (IQR, 3-15.25).

Hospital discharge summaries were obtained for 271 (76%) of

these 357 patients and showed that 218 patients had a stroke, that is,

80.4% of the patients admitted to an NVU. The stroke was ischemic in

more than three-fourths of cases (n= 166). The other diagnoses (n=

53) consisted of seizures with no abnormality on imaging in slightly

more than 40% of cases (n= 23), psychiatric disorders (n= 6; 11.3%),

and migraines with aura (n = 4; 7.6%). Two cases of hypoglycemia

were also observed.

Regarding thrombolysed patients, the mean stroke-thrombolysis

interval was 150 minutes (IQR, 115-180). A total of 69 patients

received thrombolytic therapy: 25.5% of the patients admitted to an

NVU (69/271 discharge summaries available) and 42% of the patients

transferred to an NVU with an ischemic stroke (69/166 confirmed

ischemic strokes).

3.2. Patients transferred to a nearby ED

Themedian age of patients transferred to a nearby EDwas 77 years

(IQR, 63-85), and the median NIHSS score was 7 (IQR, 4-15.5).

Of the 97 patients admitted to a nearby ED, hospital discharge

summaries were obtained for 64 (66%) and showed that 36 patients

(56%) had a stroke, which was ischemic in three-fourths of cases.

None of these patients were thrombolysed. Twenty-eight patients

(44%) had not suffered a stroke. The final diagnoses were simple

epileptic seizure in 9 cases, a psychiatric etiology in 4 cases,

hypoglycemia in 2 cases, migraine in 2 patients, and a different

etiology was identified in 11 patients (acute alcohol intoxication,

brain metastasis, subdural hematoma, malaise/fainting, etc).

3.3. Intervals

The median intervals were as follows: call-hospital, 64 minutes (IQR,

53-79) for admission to anEDvs 65minutes (IQR, 52-75) for admission to

anNVU(P=.61); call-imaging, 202minutes (IQR, 105.5-254.5) for theED

and 92 minutes (IQR, 77-116) for the NVU (P b .001).

4. Discussion

Globally, 36% of all ischemic strokes (with discharge summaries)

were thrombolysed (27% of all strokes diagnosed). The thrombolysis

rate was 42% for patients with a constituted cerebral infarction who

were initially transferred to an NVU. This rate was much higher than

the national and Parisian average rates. In France, in 2005, only 1% of

patients received thrombolytic therapy, contrasting with European

studies in which the percentage of patients potentially eligible for

thrombolysis was estimated between 6% and 22% [23,24].

One of the possible explanations for this difference is that patients

probably called emergency services when their symptoms were more

straightforward and more severe, such as a motor deficit or a

consciousness disorder. Indeed, most patients in this study had

motor deficits (80% of patients transferred to an NVU).

Of the 254 patients with confirmed stroke in this study (patients

transferred to an NVU and patients transferred to an ED), 218 (85.8%)

were directly transferred to an NVU. This rate was much higher than

the national or even Paris region data, which estimated in 2009 that

around 27% of stroke victims were directly transferred to an NVU [25].

Fig. Flow of patients.

3L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers undermedical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

This high rate, therefore, suggested the interest of the management

process, under strict medical regulation.

Relatively short management times were observed for patients

transferred directly to an NVU: imaging was performed with an

average of 92 minutes after the call vs 202 minutes for patients

transferred to EDs (P b .05), suggesting the value of hospital process

that is ready to admit patients and to prioritize their access to brain

imaging 24 hours a day. As emergency centers are more ubiquitous

than NVUs, it could also be argue that resources would likely be better

spent on ED-based systems to improve efficiency in diagnosing and

treating patients with acute ischemic stroke.

The interval call-hospital time would seem difficult to reduce, given

the number of basic steps, which includes management time for the

initial call, intervention arrival time, time required to perform the

firemen rescuers assessment, search for an available place, and transfer

time. This time interval was identical whether patients were

transferred to an ED or an NVU. A recent British study showed that

only 39.5% of patients reach hospital before the third hour of symptoms

and 41.2% reach hospital within 4.5 hours [26]. The Centers for Disease

Control and Prevention study, published in 2007, also showed that

patients transferred by ambulance reached hospital in an average of 94

minutes after the onset of the symptoms vs 172 minutes for patients

who arrived at the hospital by their own means [27].

To our knowledge, few studies invested prospectively the same

topic. In Finland, after an intensive prehospital and hospital

restructuring program, the median total time delay from symptom

onset to thrombolytic intervention decreased from 149 to 112

minutes [28]. If in-hospital delays decreased significantly from 67 to

34 minutes, the median prehospital delay stayed unchanged.

Recently, in Germany, innovative and costly prehospital strategy

based on specialized ambulance (equipped with a computed

tomographic scanner, point-of-care laboratory, and telemedicine

connection; approximately €300000) has permitted to obtain an

enthusiastic median time from symptom onset to therapy decision of

only 56minutes, with a high level of evidence (randomized controlled

trial) [29]. Moreover, transcranial ultrasound for stroke diagnosis has

been described, and first clinical trials as well as numerous preclinical

work suggest that ultrasound can be used to accelerate clot lysis

(sonothrombolysis) in the presence as well as in the absence of tissue

plasminogen activator [30].

Our study presents a number of limitations, in particular, a

selection bias: the fire brigade of Paris manages an essentially urban

population with a dense hospital network. The Parisian region has

considerable medical resources, including 14 NVUs. It would,

therefore, seem difficult to fully transpose the results observed in

the Paris region to other districts, where emergency services are not

organized in the same way and where NVUs may be located at much

greater distances. In addition, the delivery model for prehospital care

is very different across the world, which makes comparisons difficult.

Another limitation of this study was the number of missing discharge

summaries, resulting in missing data.

5. Conclusions

It appeared feasible for rescuers, under strict medical control, to

diagnose stroke and rapidly transport these patients to an appropriate

destination in an urban environment, which may improve the access

to thrombolysis. However, there are still possibilities for improvement

on the efficiency of this procedure: continued training of firemen

rescuers and medical guidance as well as an increased number of

available beds in NVUs are needed to facilitate access to care for the

greatest number of stroke patients.

Further studies will, therefore, be needed to regularly reassess this

management process and further improve the time intervals involved

and, hopefully, improve the functional prognosis for the patients

concerned. More broadly, audit of prehospital process of care for

stroke must be encouraged.

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4 L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers undermedical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034

Appendix 1. BSPP Medical Regulation Chart for a Suspected Stroke Patient

5L. Alhanati et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx

Please cite this article as: Alhanati L, et al, Stroke: prospective evaluation of a prehospital management process based on rescuers undermedical direction, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.034