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Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance

Results of the Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care in Stroke Study

Matthias Wendt, MD; Martin Ebinger, MD; Alexander Kunz, MD; Michal Rozanski, MD; Carolin Waldschmidt, MD; Joachim E. Weber, MD; Benjamin Winter, MD; Peter M. Koch, MD; Erik Freitag; Jenrik Reich; Daniel Schremmer; Heinrich J. Audebert, MD; for the STEMO Consortium*

Background and Purpose—Specialized management of patients with stroke is not available in all hospitals. We evaluated whether prehospital management in the Stroke Emergency Mobile (STEMO) improves the triage of patients with stroke. Methods—STEMO is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic scanner and point-of-care laboratory. We compared the prehospital triage of patients with suspected stroke at dispatcher level who either received STEMO care or conventional care. We assessed transport destination in patients with different diagnoses. Status at hospital discharge was used as short-term outcome. Results—From May 2011 to January 2013, 1804 of 6182 (29%) patients received STEMO care and 4378 of 6182 (71%) patients conventional care. Two hundred forty-five of 2110 (11.6%) patients with cerebrovascular events were sent to hospitals without Stroke Unit in conventional care when compared with 48 of 866 (5.5%; P<0.01%) patients in STEMO care. In patients with ischemic stroke, STEMO care reduced transport to hospitals without Stroke Unit from 10.1% (151 of 1497) to 3.9% (24 of 610; P<0.01). The delivery rate of patients with intracranial hemorrhage to hospitals without neurosurgery department was 43.0% (65 of 151) in conventional care and 11.3% (7 of 62) in STEMO care (P<0.01). There was a slight trend toward higher rates of patients discharged home in neurological patients when cared by STEMO (63.5% versus 60.8%; P=0.096). Conclusions—The triage of patients with cerebrovascular events to specialized hospitals can be improved by STEMO ambulances. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01382862. (Stroke. 2015;46:740-745. DOI: 10.1161/STROKEAHA.114.008159.)

Key Words: ambulances prehospital emergency care stroke triage

S pecific management in specialized hospital facilities has

been shown to improve process quality and outcomes in a

variety of diseases. 13 In the context of neurological disorders, this applies to the treatment of acute stroke in Stroke Units 4 or of intracranial hemorrhages in hospitals with organized stroke care or neurosurgery facilities. 4,5 Correct prehospital diagnosis is important because it avoids admissions to nonappropriate hospi- tals with suboptimal care or leading to time-consuming second- ary patient transfers. In addition, prehospital diagnostic work-up can accelerate emergency management by in-advance notifica- tion of hospital teams. 6,7 However, diagnosis of neurological dis- orders is often difficult for the variety of symptom presentations

and causes. For example, initial diagnosis of stroke in an emer- gency department yielded a stroke mimic rate of 19%, based on history and clinical examination only. 8 If additional laboratory findings and a computed tomographic (CT) scan were available, the stroke mimic rate was only 4%. 9 In the prehospital setting with usually limited diagnostic equipment and neurological expertise, correct diagnosis is even more difficult. Sensitivity of stroke diagnosis on the basis of validated prehospital stroke scores was reported between 74% and 95% with positive pre- dictive values (PPVs) between 13% and 99%. 10 The feasibility of advanced prehospital neurological work-up, including CT imaging of the brain and point-of-care laboratory, has recently been shown in 2 projects using specialized ambulances. 11,12 In

Received November 16, 2014; final revision received November 16, 2014; accepted December 10, 2014. From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E., M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.). *A list of all STEMO Consortium participants is given in the Appendix. Correspondence to Matthias Wendt, MD, Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany. E-mail matthias.wendt@charite.de © 2015 American Heart Association, Inc.

DOI: 10.1161/STROKEAHA.114.008159

Stroke is available at http://stroke.ahajournals.org

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the Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care in Stroke (PHANTOM-S) study, patient care in the Stroke Emergency Mobile (STEMO) was safe, increased the rate of intravenous thrombolysis in patients with ischemic stroke and reduced time to treatment. 12,13 In the present evaluation, we investigated whether prehospital care in the STEMO concept leads to improved delivery of patients with cerebrovascular dis- eases (CVDs) to appropriate hospitals.

Materials and Methods

Details of PHANTOM-S and the pilot study were previously de- scribed. 1214 The proportion of patients referred to specialized cen- ters was a prespecified secondary outcome for several diagnostic categories.

Stroke Emergency Mobile

STEMO is a specialized ambulance equipped with a CT scanner (CereTom; NeuroLogica, Danvers, MA), point-of-care laboratory devices (ABX Micros 60; Horiba Medical, Irvine, CA; CoaguChek XS Plus, Roche Diagnostics, Mannheim, Germany; i-STAT Portable Clinical Analyzer; American Screening Corporation, Shreveport, LA) and teleradiology technology (VIMED-STEMO; MEYTEC GmbH, Werneuchen, Germany). Teleradiology technology was used for transmission of CT imaging to a hospital-based neuroradiologist on call and documentation of readings in the medical report on board.

STEMO is staffed with a neurologist, a paramedic, and a radiology technician. All participating neurologists have experience of 4-year clinical neurology and a special education in emergency medicine.

In addition to the clinical practice as a physician, this education in-

cludes 6-month practice on an intensive care unit, 6-month experi- ence in anesthesiology or in an emergency department. The radiology technician is also trained as a paramedic assistant (Rettungssanitäter). STEMO and the team were based at a fire station close to the city center of Berlin. The dispatch center communicated with STEMO via radio connection. The catchment area was defined by a calculated 75% probability of arriving at scene within 16 minutes. This area in- cluded 1 300 000 inhabitants.

Conventional Emergency Medical Services

In Germany, normal ambulances are staffed with 1 paramedic (Rettungsassistent) with a professional training of 2 years. The sec- ond patient on ambulances is either another paramedic or a paramedic assistant with an education of 3 months (520 hours). Emergency physicians (Notärzte) are simultaneously deployed in case of criti- cally ill patients. In Berlin, this applies to patients with stroke only in the case of decreased level of consciousness or unstable vital param- eters. The Emergency Medical Services (EMS) in Berlin is organized and operated by the Berlin Fire Brigade with STEMO as an integrated specialized ambulance. EMS personnel in Berlin are trained in acute stroke assessment during professional education and as part of non- systematic EMS stroke training conducted by various Stroke Units.

A directive of the Chief EMS officer to deliver all suspected patients

with stroke to hospitals with Stroke Units is in place since 2011. The city of Berlin has a well-established stroke care infrastructure with 14 Stroke Units serving as acute and monitoring stroke units. 4

Study Design

From May 2011 to January 2013 (21 months), we compared weeks with STEMO care (STEMO weeks) and weeks without STEMO care (control weeks). The acute stroke dispatch was activated in the dis- patch center in case of a suspected acute stroke with symptom onset either within 4 hours or unknown. For this purpose, the dispatch cen- ter used a previously validated algorithm to identify patients with a high probability for stroke. 15 STEMO operated in randomized weeks from 7:00 AM to 11:00 PM all days of the week. For randomization of study periods, we used 4-week blocks as described in detail before. 14

Prehospital Triage With a Stroke Ambulance

741

During STEMO weeks, STEMO (if available) and an additional regular ambulance were simultaneously deployed. The paramedics on the regular ambulance were able to cancel STEMO before its arrival based on their first assessment. During non-STEMO weeks and during STEMO weeks in case of STEMO unavailability, regular ambulances were deployed. Within this conventional care system, an emergency physician was coalarmed simultaneously only in case of reported unstable vital parameters or reduced consciousness.

Patients

All patients with acute stroke dispatch were included, except for pa- tients aged <18 years. Patients who received regular care were trans- ported after prehospital assessment to the nearest hospital that seemed to be appropriate to the EMS staff—except of patients who refused hospital admission or requested admission to a specific hospital. Patients who received STEMO care were physically examined by the STEMO neurologist after arrival. If necessary, point-of-care laborato- ry including blood count, glucose, electrolytes, international normal- ized ratio, and creatinine was performed. A CT scan was performed if indicated for immediate therapeutic decisions or for patient’s triage. An additional CT angiography was performed whenever additional information about specific arterial occlusion was requested. Imaging data were sent via teleradiology to the neuroradiologist on call, who interpreted these immediately and gave feedback to the STEMO phy- sician. In difficult cases including decisions about thrombolysis, a senior neurologist was involved via telephone or videoconferencing. Thereafter, patients were transported to the nearest appropriate hos- pital according to the judgment of the emergency physician (again respecting the patient’s preferences). If STEMO was not available (in case of a simultaneous alarm or maintenance), patients received regular care as described for control weeks. In the present analysis, we compared patients with STEMO deployment (STEMO deployed regardless of actual STEMO care) and without STEMO deployment (all patients during control weeks and patients during STEMO weeks without STEMO deployment). In addition, we determined short-term outcome as provided by the acute hospital discharge status.

Diagnostic Accuracy of Prehospital Diagnosis

Hospital discharge diagnoses were categorized according to the docu- mented International Classification of Diseases-Tenth Revision dis- charge codes into CVDs (G45.x [except G45.4], I60.x, I61.x, I63.x, and I64.x), other neurological diagnoses (A8.x, A35.x, C70.x, C71.x, C72.x, F0.x, F1.x, G0.x–G99.x, H46.x–H48.x, H51.x, H53.1–H53.4, H54.x, H81.x, R25.x–R29.x, R55.x, S00.x–S09.x, and T39.x–T65.x) and non-neurological diagnoses (all others). Intracranial hemor- rhage comprises spontaneous intracerebral hemorrhages, traumatic intracerebral hemorrhages, subdural hematoma, epidural hematoma, and subarachnoid hemorrhages. Prehospital diagnoses established in STEMO were compared with final discharge diagnoses. Diagnostic accuracy was calculated with sensitivity, specificity, PPV, and nega- tive predictive value.

Data Collection

All patients with stroke dispatch received a deidentified alphanumeric code by the Dispatch Center. Clinical data were documented by par- ticipating hospitals in case report forms. The case report forms were sent to the Center for Stroke Research Berlin. Data were merged us- ing the alphanumeric code with deidentified databanks provided by the fire brigade and the Berlin Stroke Registry. 16 Information about demographics, comorbidities (atrial fibrillation and diabetes melli- tus), discharge diagnosis, and discharge status (in-hospital death, re- ferral to another hospital and discharge home) were taken from case report forms. Secondary emergency referral was defined as referral to another hospital within 2 days from admission. Additional informa- tion about prehospital diagnosis was retrieved for patients cared on STEMO from the STEMO documentation system. An independent Center for Stroke Research Berlin team conducted audits and data monitoring.

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Ethics

The study was approved by the Charité Ethics Committee, the Data Protection Commissioner of the state of Berlin, and data protection representatives of participating hospitals. Three-month functional follow-up is not reported in this study because it could only be col- lected in patients who had given signed informed consent. This was eventually restricted to patients cared in STEMO making a compari- son with conventional care impossible. 13

Statistical Analysis

Pearson χ 2 test or Fisher exact test were used to compare categori- cal variables. The Mann–Whitney U test was used for comparisons of continuous variables. A 2-sided significance level of α =0.05 was used. Standardized plausibility checks were performed under statisti- cal supervision. All analyses were conducted with IBM-SPSS version 19 statistics software.

Results

A total of 7098 stroke dispatches were activated by the Dispatch Center of the Berlin Fire Brigade. 13 Patient inclusion is summarized as a flow chart in the Figure. Hospital docu- mentation was available for 6182 (94%) of 6573 patients with hospital admission. During STEMO weeks, STEMO could not be deployed in a high proportion of patients (n=1409; 44%) either because STEMO was already in operation (n=1288; 91%) or because of maintenance (n=121; 9%). Of 1804 STEMO deployments, 349 (19%) were cancelled before STEMO arrival. In-hospital data were collected from 28 hos- pitals. Patient characteristics were well balanced between the 2 groups except for slightly higher rates of atrial fibrillation and diabetes mellitus in the STEMO group (Table 1). We found an almost equal proportion of patients with CVD, neurological but non-CVD patients, and non-neurological patients in both groups. Table 2 shows transport destinations and short-term outcomes. With regard to admissions of patients to hospitals

without a Stroke Unit, there were no significant differences in hospital deliveries for patients with non-neurological or neu- rological but non-CVD diagnoses. For the group of patients with CVD and the subgroup of patients with ischemic stroke, we found a significantly lower proportion of patients deliv- ered to hospitals without Stroke Unit in the STEMO group (patients with CVD, 5.5% versus 11.6%; P<0.01 and patients with ischemic stroke, 3.9% versus 10.1%; P<0.01). In the STEMO group, patients with intracranial hemorrhages were significantly less frequently delivered to hospitals without neurosurgery (11.3% versus 43.0%; P<0.01). Secondary emergency referrals to another hospital were more frequent in patients with cerebrovascular events and in particular in patients with intracranial hemorrhages when cared in conven- tional care. However, these differences did not reach statisti- cal significance. No differences in outcomes were found in the group of non-neurological patients. In the groups of all neurological patients (and those without CVD), there was a trend toward higher rates of patients discharged home (all neu- rological patients, 63.5% versus 60.8%; P=0.096 and neuro- logical patients without CVD, 83.5% versus 79.5%; P=0.08) in patients with STEMO deployment. Except for patients with non-CVD neurological diseases, in-hospital mortality was consistently lower for patients in the STEMO group (not reaching statistical significance). Prehospital diagnostic accu- racy on cerebrovascular events revealed a sensitivity of 89%, specificity 77%, PPV 79%, and negative predictive value 87% (Tables 3 and 4).

Discussion

Patient care within the STEMO-concept was associated with more frequent delivery of patients with cerebrovascu- lar events to appropriate hospitals in particular for patients

Total deployments n=7098 STEMO weeks Control weeks n=3668 n=3430 324 days 322 days 455 patients
Total
deployments
n=7098
STEMO weeks
Control weeks
n=3668
n=3430
324 days
322 days
455 patients excluded
461 patients excluded
240
No transport to hospital
273
No transport to hospital
166
No match with hospital
database
154
No match with hospital
database
37
Delivery to a hospital with
< 10 admissions
27
Delivery to a hospital with
< 10 admissions
9
Prehospital death
3
Prehospital death
3
Available hospital
No information on
hospital destination
4
No information on
hospital destination
Available hospital
documentation
documentation
n=3213
n=2969
Conventional care
during STEMO
weeks n=1409
STEMO
Conventional care
deployments
n=4378
n=1804
STEMO
STEMO care
cancellation
n=1455
n=349

Figure. Study flow chart. STEMO indicates Stroke Emergency Mobile.

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Table 1.

Patient Characteristics

Wendt et al

 

Conventional

STEMO

Care Group

Group

n=4378

n=1804

P Value

Demographics

Age, years, mean (SD)

74.2 (14.9)

73.9 (15.0)

0.51

Sex, men, n (%)

1970 (45.0)

646 (44.1)

0.50

Risk factors, n (%)

Atrial fibrillation

962 (22.0)

440 (24.4)

0.04

Diabetes mellitus

983 (22.5)

451 (25.0)

0.03

Discharge diagnoses, n (%)

Cerebrovascular

2110 (48.2)

866 (48.0)

0.89

TIA

461 (10.5)

185 (10.3)

Ischemic stroke

1497 (34.2)

610 (33.8)

Intracerebral hemorrhage

100 (2.3)

45 (2.5)

Subarachnoid hemorrhage

8 (0.2)

3 (0.2)

Other cerebrovascular events

44 (1.0)

23 (1.3)

Neurological noncerebrovascular

1058 (24.2)

418 (23.2)

0.40

Subdural hematoma

16 (0.4)

5 (0.3)

Traumatic brain injury

27 (0.6)

9 (0.5)

Epilepsy

331 (7.6)

129 (7.2)

Syncope

85 (1.9)

37 (2.1)

Headache

81 (1.9)

45 (2.5)

Vertigo

52 (1.2)

17 (0.9)

Decreased awareness and neuropsychological disorders

93 (2.1)

41 (2.3)

Movement disorder

24 (0.5)

14 (0.8)

Transient global amnesia

33 (0.8)

8 (0.4)

Delirium/intoxication (acute confusional state)

128 (2.9)

46 (2.5)

Mononeuropathy

55 (1.3)

9 (0.5)

Others

133 (3.0)

58 (3.2)

Non-neurological

1210 (27.6)

520 (28.8)

0.55

Ischemic heart disease

34 (0.8)

17 (0.9)

Nonischemic heart disease

50 (1.1)

33 (1.8)

Dehydration

88 (2.0)

41 (2.3)

Infection

225 (5.1)

104 (5.8)

Metabolic disorders

155 (3.5)

56 (3.1)

Hypertension/hypotension

81 (1.9)

37 (2.1)

Dyspnoea/COPD

16 (0.4)

3 (0.2)

Frailty

23 (0.5)

8 (0.4)

Noncentral nervous malignoma

33 (0.8)

17 (0.9)

Nonorganic psychiatric disorders

64 (1.5)

26 (1.4)

Others

441 (10.1)

178 (9.9)

COPD indicates chronic obstructive pulmonary disease; STEMO, Stroke Emergency Mobile; and TIA, transient ischemic attack.

with ischemic strokes or intracranial hemorrhages. There was no statistically significant difference in short-term out- comes, but the observed trends toward better outcome in the STEMO group are in line with previously established evidence. 4 STEMO care reduced the inadequate delivery of patients with ischemic stroke to a hospital without Stroke

Prehospital Triage With a Stroke Ambulance

Table 2.

Transport Destinations and Short-Term Outcome

743

Conventional Care

 

Group

STEMO Group

P Value

All patients

n=4378

n=1804

Delivered to hospitals without neurological department, n (%)

416

(9.5)

158 (8.8)

0.36

Secondary emergency

185

(4.2)

72 (4.0)

0.64

referral

In-hospital mortality, n (%)

173 (4.0)

62 (3.4)

0.34

Discharged home, n (%)

2839 (64.8)

1196 (66.3)

0.28

Non-neurological patients

n=1210

n=520

Delivered to hospitals without neurological department, n (%)

226

(18.7)

99 (19.0)

0.86

Secondary emergency

72

(6.0)

38 (7.3)

0.29

referrals

In-hospital mortality, n (%)

63 (5.2)

23 (4.4)

0.49

Discharged home, n (%)

913 (75.5)

381 (73.3)

0.34

All neurological patients

n=3168

n=1284

Delivered to hospitals without neurological department, n (%)

190

(6.0)

59 (4.6)

0.07

Secondary emergency

113

(3.6)

34 (2.6)

0.12

referrals

In-hospital mortality, n (%)

110 (3.5)

39 (3.0)

0.47

Discharged home, n (%)

1926 (60.8)

815 (63.5)

0.10

Noncerebrovascular but

n=1058

n=418

neurological patients

Delivered to hospitals without neurological department, n (%)

63

(6.0)

30 (7.2)

0.38

Secondary emergency

54

(5.1)

178 (4.3)

0.52

referrals

In-hospital mortality, n (%)

10 (0.9)

6 (1.4)

0.41

Discharged home, n (%)

841 (79.5)

349 (83.5)

0.08

All cerebrovascular patients

n=2110

n=866

Delivered to hospitals without Stroke Unit, n (%)

245

(11.6)

48 (5.5)

<0.01

Secondary emergency

59

(2.8)

16 (1.8)

0.13

referrals

In-hospital mortality, n (%)

100 (4.7)

33 (3.8)

0.27

Discharged home, n (%)

1085 (51.4)

466 (53.8)

0.24

Patients with ischemic stroke

n=1497

n=610

Delivered to hospitals without Stroke Unit, n (%)

151

(10.1)

24 (3.9)

<0.01

Secondary emergency

33

(2.2)

11 (1.8)

0.56

referrals

In-hospital mortality, n (%)

81 (5.4)

28 (4.6)

0.44

Discharged home, n (%)

642 (42.9)

279 (45,7)

0.23

Patients with intracranial hemorrhages*

n=151

n=62

Delivered to hospitals without neurosurgery department, n (%)

65

(43.0)

7 (11.3)

<0.01

 

(

Continued )

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744

Table 2.

Stroke

Continued

March 2015

Conventional Care

Group

STEMO Group

P Value

Secondary emergency

19 (12.6)

3 (4.8)

0.09

referrals

In-hospital mortality, n (%)

20 (13.2)

6 (9.7)

0.47

Discharged home, n (%)

50 (33.1)

18 (29.0)

0.56

STEMO indicates Stroke Emergency Mobile. *Consisting of spontaneous intracerebral hemorrhages, traumatic intracerebral hemorrhages, subdural and epidural hematoma, and subarachnoid hemorrhages.

Unit by >50% and of patients with intracranial hemorrhage to

a hospital without neurosurgery by >60% (relative risk reduc-

tion). This may be the consequence of improved prehospital diagnosis or of better persuasion of patients by emergency physicians. Secondary referrals of patients with cerebrovas- cular events were higher in conventional care. However, the

majority of patients with cerebrovascular events delivered to

a hospital without Stroke Unit remained in the hospital of

primary delivery, despite recommendations that all patients with acute stroke should be treated on a Stroke Unit. 17 This indicates that primary delivery is crucial for the place of acute care. The results of the STEMO prehospital diagnostic accuracy on cerebrovascular events (sensitivity, 89%; speci- ficity, 77%; PPV, 79%; and negative predictive value, 87%) compare well with the validation results of the Recognition of Stroke in the Emergency Room (ROSIER) scale (sensitiv- ity, 93%; specificity, 83%; PPV, 90%; and negative predic- tive value, 88%). 18 With shorter observation time, affirmation of a stroke diagnosis is often more difficult, particularly in

most frequent stroke mimics of Todd paresis or migrainous aura. Rather than a single factor, the combination of prese- lection via the dispatch center, specialist neurological assess- ment, diagnostic support with CT, as well as point-of-care laboratory, and telemedicine all add to diagnostic accuracy. Of note, the specialization of the emergency team on board the STEMO did not result in poorer outcomes in patients with non-neurological diseases. Admission rates of patients with ischemic stroke to a primary stroke center vary between regions. Data from the United States show that only 55% of patients have access to a primary stroke center within 60 min- utes, and only 28% of patients with stroke in New Zealand were managed on a Stroke Unit. 19,20 These low rates may be

a consequence of the shortage of hospitals with specialized

departments. However, even after implementation of a pre- hospital stroke triage policy in the Chicago metropolitan area

Table 3.

Diagnosis Validated Against Final Discharge Diagnosis of Cerebrovascular Events*

Test Parameters for Prehospital Stroke

True-positives

611

False-positives

162

True-negatives

529

False-negatives

76

*Cerebrovascular

events

include

ischemic

or

hemorrhagic

stroke

and

transient ischemic attacks.

Table 4.

Against Final Discharge Diagnosis of Cerebrovascular Events*

95% CI for Prehospital Stroke Diagnosis Validated

95% CI

Estimated Value

Lower Limit

Upper Limit

Sensitivity

0.89

0.86

0.91

Specificity

0.77

0.73

0.80

Positive predictive value

0.79

0.76

0.82

Negative predictive value

0.87

0.85

0.90

CI indicates confidence interval. *Cerebrovascular events include ischemic or hemorrhagic stroke and transient ischemic attacks.

with 17 primary stroke centers, the admission rate of patients

with ischemic stroke to these stroke centers was only 81.1%. 21 Although it is difficult to compare these data with ours, the 96% correct admission rate for this group of patients reflects

a clear improvement when compared with conventional care.

Hence, the STEMO concept offers additional potentials on top of increased thrombolysis rate and reduction of onset-to-

treatment time. 1113,22 Although improved outcomes could not

be

proved on the basis of hospital discharge data alone, there

is

established evidence that patients with stroke benefit from

treatment in organized stroke care. 23 The advantages of this

specialized ambulance have to be weighed against the costs

of the project, including expenses for investments, staff, and

consumables. This is currently under investigation in another

analysis of the PHANTOM-S trial. Strengths of the study are

the high number of patients with participation of 28 hospitals.

A limitation of the study is that we could only compare the

concept of specialized prehospital care in 1 ambulance with conventional care in multiple regular ambulances. To avoid

a selection bias, we did include all patients with STEMO

deployment in the STEMO group although the STEMO oper- ation was cancelled in a substantial number of patients in this group (19%). Misallocation rates were even lower in patients who were eventually cared by STEMO (3.2% in patients with ischemic stroke and 8.9% in patients with intracranial hemor- rhage). Another limitation of the study is the unavailability of diagnostic accuracy in conventional care because prehospital paramedic assessment is not regularly documented as diagno- sis in the Berlin EMS system. In addition, generalizability of the STEMO system to other healthcare systems has not been shown yet. For example, it may be difficult to train vascu- lar neurologists in emergency medicine in countries without emergency physicians working in EMS. Finally, we are not able to provide functional outcome results as the study meth- odology did not allow the collection of long-term outcome.

Conclusions

The STEMO concept improves the triage of patients with cerebrovascular events in the prehospital setting. Additional studies are needed to show that this observation holds true in other areas and translates into improved patients outcomes.

Appendix

STEMO Consortium: Berliner Feuerwehr, Berlin, Germany; BRAHMS GmbH, Hennigsdorf, Germany;

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Wendt et al

Charité-Universitätsmedizin Berlin, Berlin, Germany; MEYTEC GmbH, Werneuchen, Germany.

Acknowledgments

We thank all participating paramedics and radiographers for out- standing team work. We are grateful to Kerstin Bollweg for data col- lection and management in cooperating hospitals.

Sources of Funding

The research leading to these results has received funding from the Zukunftsfonds Berlin with cofunding by the European Union (within the European regional development funds), the Federal Ministry of Education and Research via the grant Center for Stroke Research Berlin (01 EO 0801).

Disclosures

Dr Audebert reports receiving speaker honoraria from BMS, Lundbeck Pharma, Pfizer, Sanofi, EVER Neuropharma, and Boehringer Ingelheim. He has a consultant or advisory relationship to Roche Diagnostics, Lundbeck Pharma, and Bayer Vital. The other authors report no conflicts.

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Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance: Results of the
Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance: Results of the

Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance:

Results of the Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care in Stroke Study Matthias Wendt, Martin Ebinger, Alexander Kunz, Michal Rozanski, Carolin Waldschmidt, Joachim E. Weber, Benjamin Winter, Peter M. Koch, Erik Freitag, Jenrik Reich, Daniel Schremmer and Heinrich J. Audebert for the STEMO Consortium

Stroke. 2015;46:740-745; originally published online January 29, 2015; doi: 10.1161/STROKEAHA.114.008159

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