Clinical Study
FASTER (Face, Arm, Speech, Time, Emergency Response): Experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke

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Abstract

Despite benefit in acute ischaemic stroke, less than 3% of patients receive tissue plasminogen activator (tPA) in Australia. The FASTER (Face, Arm, Speech, Time, Emergency Response) protocol was constructed to reduce pre-hospital and Emergency Department (ED) delays and improve access to thrombolysis. This study aimed to determine if introduction of the FASTER protocol increases use of tPA using a prospective pre- and post-intervention cohort design in a metropolitan hospital. A pre-hospital assessment tool was used by ambulance services to screen potential tPA candidates. The acute stroke team was contacted, hospital bypass allowed, triage and CT radiology alerted, and the patient rapidly assessed on arrival to ED. Data were collected prospectively during the first 6 months of the new pathway and compared to a 6-month period 12 months prior to protocol initiation. In the 6 months following protocol introduction, 115 patients presented within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, significantly greater than five (7%) of 67 patients over the control period, p = 0.03. Overall, 42 patients were referred via the FASTER pathway, with 21 of these receiving tPA (50%). One inpatient stroke was also treated. Only two referrals (<5%) were stroke mimics. Introduction of the FASTER pathway also significantly reduced time to thrombolysis and time to admission to the stroke unit. Therefore, fast-track referral of potential tPA patients involving the ambulance services and streamlined hospital assessment is effective and efficient in improving patient access to thrombolysis.

Introduction

The use of tissue plasminogen activator (tPA) in acute ischaemic stroke has become a cornerstone of acute stroke therapy, reducing disability while also having a positive impact on in-hospital costs both in the short and medium term.[1], [2], [3] The 3-hour therapeutic window makes streamlining the chain of referral critical to delivery of treatment. Up to 30% of all patients with ischaemic strokes may present to medical attention within the thrombolytic treatment window, yet current figures for Australia suggest only about 3% of patients receive this treatment.4 Overseas studies have demonstrated that use of extended organised stroke care involving Emergency Department (ED) and pre-hospital paramedic retrieval teams can achieve thrombolysis rates of up to 20%.[5], [6]

Several key factors have been identified in the process. Community-based components include increased public awareness of stroke symptoms and appropriate emergency services alert via telephone (000 in Australia), urgent emergency medical services (EMS) dispatch to the scene, recognition of the signs and symptoms of stroke by paramedics, and rapid transfer of patients to a facility equipped to deliver tPA therapy and provide the appropriate level of acute stroke care. On arrival in the ED, protocols allowing immediate focused clinical assessment, appropriate imaging (particularly in those where intervention is a possibility) and appropriate access to tPA, need to be in place. In an important recent Australian study, Quain et al. described the introduction of a Pre-hospital Acute Stroke Triage (PAST) protocol, where this facilitated chain of referral resulted in 21.4% of eligible patients receiving thrombolytic treatment, improving lysis rates by a factor of over four.7 However whether this success can be replicated in other Australian populations and health services is unknown.

Twelve months after the initiation of the PAST protocol in the John Hunter Hospital in Newcastle, NSW, the same process of referral was adopted by the Central Coast Area Health Service. Gosford and Wyong Hospitals are the two acute centres servicing a population of 400,000 on the Central Coast. There is an eight-bed stroke unit in Gosford Hospital and four-bed unit in Wyong. The Central Coast is serviced by five consultant neurologists equally involved in an on-call general neurology and stroke roster. Thrombolysis is carried out by the acute stroke team in Gosford. This team comprises an on-call neurologist, an acute stroke nurse, a stroke fellow, routine ED medical and nursing staff, and a 24-hour CT service. The first point of contact for acute stroke patients potentially eligible for intervention is the stroke fellow, both in- and out-of-hours including weekends. If the Fellow is unavailable, then the on-call neurologist takes the referral. This is supported whenever possible by the acute stroke nurse.

Continuing education with nursing staff in ED has led to expertise in the management of patients receiving tPA while the patient is in the ED. Gosford hospital had on-site radiographers for CT, both in- and out-of-hours, prior to implementation of the pathway and all scans are read acutely by the treating neurology team. We carried out the current study to determine if the introduction of an ambulance service-based hospital pre-notification scheme for acute stroke could result in reduced time to assessment for thrombolysis and increased use of tPA in the Central Coast Area Health Service.

Section snippets

Methods

A comparative study with historical controls was used, with data after the introduction of the FASTER (Face, Arm, Speech, Time, Emergency Response) protocol compared to data from historical controls from the same hospital in the corresponding period 1 year earlier. All information was prospectively obtained as part of a departmental database which has been previously described.8 The study population comprised all patients with an initial diagnosis of acute stroke presenting to Gosford Hospital.

Results

In the first 6 months following the introduction of the protocol, 115 patients presented to Gosford Hospital within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, 21 via the FASTER pathway and one was an inpatient at the time of stroke. This proportion was significantly greater compared to five (7%) of 67 patients over the control period, p = 0.03.

There were 42 referrals via the FASTER protocol of which 21 received thrombolysis (50%). Four were found not to meet the

Discussion

Our results show a similar impact of the FASTER protocol on the delivery of acute stroke treatment as was described by the John Hunter Hospital experience.7 Replicating the results in a different Health Area Service with different demographic, geographic and healthcare resources provides support for the effectiveness of this form of health system intervention.

We demonstrated a substantial and statistically significant increase in the proportion of patients receiving tPA, along with a

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