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Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.

Background: The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results: We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population-wide stroke-related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real-world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population-wide gain of 8 to 18 disability-adjusted life years in the 3 real-world geographies and in most simulated abstract geographies (net gain -4 to 66 disability-adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability-adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability-adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions: Variable stroke severity cutoff scores were associated with the highest reduction in stroke-related disability. The mothership strategy yielded better clinical outcome than the drip-'n'-ship strategy in most geographies.

IMPORTANCE: The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. OBJECTIVE: To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. EXPOSURES: Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. MAIN OUTCOMES AND MEASURES: Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. RESULTS: Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. CONCLUSIONS AND RELEVANCE: This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.

Aim To establish prehospital triage in accordance with the new guidelines for endovascular therapy, we retrospectively analyzed the monitoring data of the city-wide transportation system using the Maria Prehospital Stroke Scale (MPSS), a novel prehospital stroke scale for emergency medical technicians (EMTs) to predict the likelihood of thrombolytic therapy after transportation. Methods Kawasaki City, Japan, has six comprehensive stroke centers (CSCs) and six primary stroke centers (PSCs). In CSCs, endovascular therapy can be carried out 24 h a day, 7 days a week, but not in PSCs. There is no “drip and ship” protocol for further endovascular therapy from PSCs to CSCs. We determined the predictive value of MPSS scoring by the EMTs for the performance of endovascular therapy after transportation. Results There were 2031 patients (mean age, 71.1 ± 13.3 years) registered from April 2012 to March 2015. Multivariate logistic regression analysis indicated that the MPSS score and type of stroke center were independent predictors for performance of endovascular therapy. In particular, the odds ratio (OR) for endovascular therapy was significant for MPSS score 3 (OR, 2.914; 95% confidence interval (CI), 1.152–7.372; P = 0.024), MPSS score 4 (OR, 5.474; 95%CI, 2.300–13.029; P = 0.000), and MPSS score 5 (OR, 11.459; 95%CI, 4.334–30.296; P = 0.000) when MPSS score 1 was set as a reference. The diagnostic accuracy of the MPSS score evaluated by EMTs was 0.689 (95%CI, 0.627–0.751). Conclusions Prehospital triage using MPSS scores evaluated by EMTs can predict the likelihood of performance of endovascular therapy after transportation, and may become a tool offering a flexible solution for designing a new transportation protocol.

Stroke is the leading cause of disability in the United States with most of these patients being transported by emergency medical services. These providers are the first medical point of contact and must be able to rapidly and accurately identify stroke and transport these patients to the appropriate facilities for treatment. There are many conditions that have similar presentations to stroke and can be mistakenly identified as potential strokes, thereby affecting the initial prehospital triage.A retrospective observational study examined patients with suspected strokes transported to a single comprehensive stroke center (CSC) by a helicopter emergency medical service (HEMS) agency from 2007 through 2013. Final diagnosis was extracted from the Get with the Guidelines (GWTG) database and hospital discharge diagnosis for those not included in the database. Frequencies of discharge diagnosis were calculated and then stratified into interfacility vs. scene transfers.In this study 6,243 patients were transported: 3,376 patients were screened as potential strokes, of which 2,527 had a final diagnosis of stroke (2,242 ischemic stroke and 285 transient ischemic attack), 166 had intracranial hemorrhage, and 655 were stroke mimics. Stroke mimics were more common among scene transfers (223, 32%) than among interfacility transfers (432, 16%).In our study approximately 20% of potential stroke patients transported via HEMS were mimics. Identifying the need for CSC resources can be an important factor in creating a prehospital triage tool to facilitate patient transport to an appropriate health care facility.

Background and Purpose— Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics. Methods— The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases. Results— Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%. Conclusions— The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.

Aims/Objectives/BackgroundThis is the first external validation of a European empirically derived prediction model for identifying major trauma in an unselected group of injured patients transported by ambulance in the United Kingdom.Methods/DesignThis study was an external validation of a Dutch prediction model for identifying major trauma using a retrospective cohort of injured patients who ambulance crews transported to hospitals in the South West region of England. Major trauma was defined as Injury Severity Score (ISS)>15.Participants were patients ≥16 years with a suspected injury and transported by ambulance from February 1, 2017 to February 1, 2018. This study had a census sample of cases available to us over a one year period.We tested the accuracy of the prediction model in terms of discrimination, calibration, clinical usefulness, sensitivity and specificity and under- and over triage rates compared to existing trauma triage practices in the South West region.Results/ConclusionsA total of 68 698 adult patients were included in the final external validation cohort. The median age of patients was 72 (i.q.r. 46–84); 55.5% were female; and 524 (0.8%) had an ISS>15. In comparison the Dutch cohort was younger (45 years), more were male (58.3%) and more patients had an ISS>15. (8.8%) The model achieved good discrimination with a C-Statistic 0.75 (95% CI, 0.73 – 0.78). At a maximal specificity of 50% the model resulted in a sensitivity of 86%. The model improved undertriage rates at the expense of increased overtriage rates compared with routine trauma triage methods in the South West of England.The Dutch prediction model for identifying major trauma can lower the undertriage rate to 17%, however it would increase the overtriage rate to 50% in this UK cohort. Further research is needed to determine whether the model can be practically implemented by paramedics and is cost-effective.

Prehospital triage of the seriously injured patient is fraught with challenges, and trauma scoring systems in current triage guidelines warrant further investigation. The primary objective of this study was to assess the correlation of the physiologically based Revised Trauma Score (RTS) and MGAP score (mechanism of injury, Glasgow Coma Scale, age, blood pressure) with the anatomically based Injury Severity Score (ISS). The secondary objectives for this study were to compare the accuracy of the MGAP score and the RTS for the prediction of in-hospital mortality for trauma patients.This study was a retrospective cohort including 10 years of patient data in a large single-center trauma registry at a primary adult resource center (Level I) for trauma patients. Participants included adults (age ≥18 years). The primary outcome measure was injury severity (measured by ISS) and a secondary analysis compared the RTS and MGAP for the prediction of patient mortality. Descriptive statistics were used to describe the cohort and correlation methods were employed. Each score's accuracy for the prediction of mortality was calculated using the area under receiver operating characteristic (AUROC) curves.In total, 43,082 trauma patient records were reviewed; 32,798 patients had complete RTS data available and 32,371 patients had complete data available for MGAP analyses. The correlation between scene RTS and ISS was poor (-.29), as was the correlation between MGAP and ISS (-.28). For the prediction of mortality, admission MGAP demonstrated the highest sensitivity and specificity for mortality (AUROC 0.96; 95% CI, 0.95-0.96).While elements of the RTS remain the first criterion recommended to quantify the totality of physiological injury severity, the composite RTS score derived from this system correlates poorly with actual anatomical injury severity. The MGAP scoring system demonstrated higher sensitivity and specificity for mortality but was not superior to the RTS for predicting anatomical injury severity. In the future development of national and international field triage guidelines for trauma patients, the findings from this study may be considered in order to improve the accuracy of prehospital triage. The findings in this analysis complement a growing body of evidence that suggests that MGAP may be a superior and more easily calculable prehospital scoring system for the prediction of mortality in trauma patients.

Proper identification of patients with acute ischemic stroke in the prehospital setting can be challenging. This chapter reviews the most commonly employed prehospital stroke screening tools. Such tools were initially designed to optimize the timely detection of strokes in the field by the emergency medical personnel. However, in conjunction with the recent advances in endovascular stroke therapy, new field screens have been developed with the goal of identifying patients with higher likelihood of emergent large vessel occlusion strokes. These new screens can assist the emergency medical personnel with patient triage to the most appropriate facility within a regional stroke system of care.

Efficient patient transportation by ground emergency medical services (GEMS) or helicopter emergency medical services (HEMS) to a trauma center is vital for optimal care. We investigated differences between the modes of transport in terms of demographics, injury, scene location, and outcome.Morristown Medical Center (MMC), Morristown, NJ METHODS: All 903 trauma admissions in 2016 by advanced life support (ALS) to MMC, a Level I Trauma Center, were retrospectively analyzed.22% of admissions were HEMS and 78% were GEMS. HEMS patients had higher Injury Severity Scores (ISS) (p0.001); however, mortality and length of stay were not statistically different. The percentage of pediatric patients transported by HEMS that were discharged home after emergency department evaluation was greater than the older populations (p0.001). Older age and higher ISS had the largest impact on mortality (p0.001).We believe our current use of HEMS is adequate since patient outcomes between HEMS and GEMS was similar, even though HEMS patients have higher ISS. However, helicopter use in the pediatric population was over-utilized, possibly due to the scarcity of hospitals capable of managing pediatric traumas. Implementation of the Air Medical Prehospital Triage scoring system may also help correct for these unnecessary HEMS transports.

ObjectivesThis study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption.MethodsThis was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale.ResultsAfter EMT’s underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike’s Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption.ConclusionsA five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

Introduction: Thrombectomy may be beneficial up to 24 hours since last normal. We previously reported the feasibility of the Cincinnati Stroke Triage Assessment Tool (C-STAT) for prehospital triage. We estimated the potential impact of the expanded thrombectomy time window on overtriage to our comprehensive stroke center (CSC). Methods: From June-November, 2015, Cincinnati Fire Department (CFD) providers performed C-STAT after a positive prehospital “FAST: face, arm, speech, time” stroke screen in suspected stroke/TIA patients. Preferential triage was not employed at that time. Final diagnoses and presence/absence of large vessel occlusion (LVO) was ascertained via chart review. Impact on triage volumes by positive C-STAT up to 24 hours from last seen normal was estimated. Results: Of 158 patients with prehospital suspicion for stroke/TIA, 105 were FAST positive, within 24 hours of onset, and had complete C-STAT and clinical data available. The Table shows the characteristics of enrolled subjects. Forty six percent (17/37) of C-STAT+ patients were non-strokes. C-STAT sensitivity and specificity for LVO were: 71% (36, 92) and 69% (55, 80). Within six hours of symptom onset, 57% (12/21) of C-STAT+ prehospital suspected stroke patients were not triaged to the CSC. From 6-24 hours, 62% (10/16) C-STAT+ patients were not triaged to the CSC. Overall, preferential triage using C-STAT would increase transport of prehospital suspected stroke cases to the CSC by 11% (12/105) within six hours and 21% (22/105) within 24 hours. Conclusions: Within CFD, preferential triage using C-STAT would increase transport of prehospital suspected stroke cases to the CSC by 11% within six hours and an additional 10% within 24 hours. Almost half of prehospital C-STAT+ cases were non-strokes. More stringent criteria for CSC triage (e.g., exclusion of seizure/hypoglycemia) may improve performance. Acceptable overtriage rates for prehospital suspected stroke should be established.

Stroke is a life threatening medical condition that is caused either by a blood clot or a bleeding inside the brain. It is generally agreed that immediate treatment of stroke patients is crucial for their ability to recover; however, before treatment can be initiated, the stroke patient has to be diagnosed using, for example, a computed tomography scan of the brain. This, in turn, requires that the patient is transported to a hospital for diagnosis, which is a procedure that consumes valuable time and resources. In the current paper, we present an agent-based simulation model for assessment of logistical stroke patient triage policies. Using a population of stroke patients as input, the model enables to simulate the activities and the main decisions involved in the logistical operations of stroke patients. In an experimental study covering the southernmost part of Sweden, we used the simulation model in order to assess two different policies regarding where to send patients for diagnosis; the nearest hospital policy and the nearest hospital towards the stroke center policy. Our simulation results show that the patients in need of special treatment favor from being transported in direction towards the stroke center, whereas the patients who are not in need of specialist treatment favor from being sent to the closest hospital. (Less)

Background and Purpose— Prehospital stroke severity scales may help to triage acute ischemic stroke patients with large vessel occlusion (LVO) for direct transportation to a comprehensive stroke center. The impact on resource use and time to reperfusion treatment for patients with and without LVO is unknown. Methods— Based on empirical distributions of stroke symptom severity, prehospital delay times, and stroke symptom severity-dependent likelihood of LVO, we simulate prehospital incidents of stroke-like symptoms in abstract geographical environments to estimate the impact of prehospital triage strategies based on different cutoffs of the rapid arterial occlusion evaluation scale. Results— Compared with transporting each patient to the nearest stroke center, implementation of a prehospital triage strategy based on a rapid arterial occlusion evaluation scale cutoff score ≥5 is associated with more patients with suspected acute stroke at comprehensive stroke centers and less patients at primary stroke centers (+11.7% [95% confidence interval: +8.1% to +15.3%] and −18.4% [−19.1% to −17.7%], respectively). Mean time to groin puncture is reduced by 29.6 minutes (−35.2 to −24.7 minutes) while mean time to thrombolysis does not change significantly (±0.0 minutes [−0.3 to +0.3 minutes]). The total number of secondary transfers is reduced by 60.9% (−62.8% to −59.0%); mean time of ambulance use per patient is unchanged. Results are robust with regards to variation in model parameters. Conclusions— Implementation of prehospital triage based on stroke severity scales would have strong impact on patient flow and distribution. The benefit of earlier thrombectomy for patients with LVO may outweigh the harm associated with delayed access to thrombolysis for some patients without LVO. Randomized trials using clinical stroke severity scales as a triage tool are needed to confirm our findings.

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 P P 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.

RationalePrehospital stroke care in specialized ambulances increases thrombolysis rates, reduces alarm-to-treatment times, and improves the prehospital triage. Preliminary analyses suggest cost-effectiveness. However, scientific proof of better functional outcome compared to usual care is still lacking.AimTo prove better functional outcomes after deployment of the Stroke Emergency Mobile compared to regular ambulances.Sample size estimatesA sample size of 686 patients will be required in each arm (Stroke Emergency Mobile group vs. regular care) to detect a difference regarding the primary outcome with 80% power at a two-sided significance level of 0.05.Methods and designThis is a pragmatic, prospective study with blinded outcome assessment. Primary outcome will be functional status as defined by modified Rankin Scale score three months after the incident event. We will include cerebral ischemia patients within a predefined catchment area in Berlin, Germany. The study population consists of patients who might be candidates for acute recanalizing treatments, with onset-to-alarm time ≤4 h, symptoms not resolved at time of ambulance arrival, and able to walk without assistance prior to the qualifying incident. About 45% of Stroke Emergency Mobile dispatches are expected to be handled by regular ambulances, since Stroke Emergency Mobile will be already in operation creating the control group.Primary outcomeFunctional outcome after three months measured by the modified Rankin Scale over the entire range.DiscussionThe results will inform decision makers on the effectiveness of Stroke Emergency Mobile.

Background Dispatch centres (DCs) are considered an essential but expensive component of many highly developed healthcare systems. The number of DCs in a country, region, or state is usually based on local history and often related to highly decentralised healthcare systems. Today, current technology (Global Positioning System or Internet access) abolishes the need for closeness between DCs and the population. Switzerland went from 22 DCs in 2006 to 17 today. This study describes from a quality and patient safety point of view the merger of two DCs. Methods The study analysed the performance (over and under-triage) of two medical DCs for 12 months prior to merging and for 12 months again after the merger in 2015. Performance was measured comparing the priority level chosen by dispatcher and the severity of cases assessed by paramedics on site using the National Advisory Committee for Aeronautics (NACA) score. We ruled that NACA score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/diseases) should require a priority dispatch with lights and siren (L&S). While NACA score 3. Results Prior to merging, Dispatch A had a sensitivity/specificity regarding the use of lights and sirens and severity of cases of 86%/48% with over- and under-triage rates of 78% and 5%, respectively. Dispatch B had sensitivity and specificity of 92%/20% and over- and under-triage rates of 84% and 7%, respectively. After they merged, global sensitivity/specificity reached 87%/67%, and over- and under-triage rates were 71% and 3%, respectively Conclusions A part the potential cost advantage achieved by the merger of two DCs, it can improve the quality of services to the population, reducing over- and under-triage and the use of lights and sirens and therefore, the risk of accidents. This is especially the case when a DC with poor triage performance merges with a high-performing DC.

BACKGROUND The American College of Surgeons developed the National Field Triage Decision Scheme (NFTDS) that has been adapted by many trauma centers in the nation, but quantitative evidence of its efficacy is unclear. We compare the NFTDS and state of Ohio guidelines to the "observed" rates and with rates derived using a statistical model. METHODS We used 4757 trauma records from 2008-2012 available from the state and calculated undertriage (UT) and overtriage (OT) rates. We then simulated the NFTDS and the state guidelines for those years and estimated the corresponding UT and OT rates. We finally compared these rates with those derived from a multivariate logistic regression model. RESULTS For the state data, both NFTDS and state guidelines produced lower UT rate (∼9%) compared with the observed rate (∼17%), whereas the OT rates were higher (>85%) than the observed rates (∼54%). The statistical model identified novel factors that were not directly available in the NFTDS; change in responsiveness (odds ratio [OR] = 1.924) and complaint in body (OR = 3.140), back (OR = 1.890), chest (OR = 3.191), head (OR = 3.878), and abdomen (OR = 2.966). Although the statistical model performed similar to observed rates, it performed considerably better than NFTDS (UT = 1.93% versus 9.03%; OT = 66.42% versus 87.52%) and state guidelines (UT = 2.18% versus 8.72%; OT = 64.09% versus 86.52%). CONCLUSIONS The current NFTDS and state's triage guidelines do not appear to achieve the ACS recommendation of

Background: Faster treatment with tPA may be achieved by optimizing prehospital triage with mobile stroke units (MSUs). The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study is a prospective comparative effectiveness trial of outcomes in patients randomized to MSU or standard management (SM). Purpose: To evaluate the inter-rater agreement for tPA eligibility between a telemedicine vascular neurologist (TM-VN) and the onboard vascular neurologist (OB-VN) in acute stroke patients seen on the MSU. Methods: Cluster randomization of MSU and SM weeks started on August 18, 2014. On scene, both the TM-VN and OB-VN evaluated the patient and independently documented their tPA treatment decision, NIHSS and CT interpretation. Agreement was determined using Cohen’s kappa (K) statistic. TM related technical failures that impeded remote assessment were recorded. Results: The remote TM-VN evaluated 173 patients. In 4 (2%) cases the TM-VN was not able to make a decision about tPA because of technical difficulties ( 1 case due to TM camera failure and 3 cases due to poor connectivity). The TM-VN agreed with the OB-VN on 88% of evaluations, with a K of 0.73 representing substantial agreement. Baseline NIHSS correlation between the TM-VN and OB-VN was 0.88. Agreement about ICH on CTH was a near-perfect K of 0.97. Conclusions: We conclude from these results that remote VN assessment of stroke patients in the MSU via TM is clinically and technologically feasible, reliable and accurate. TM assessment of CTH and NIHSS was also comparable to the OB evaluation. These findings will allow either OB-VN or TM-VN assessment for the remainder of the study.

Introduction: The impact of prehospital triage of stroke mimics to designated stroke centers may be considerable, yet little information exists regarding stroke mimics in the prehospital setting. We aimed to describe the rate and clinical characteristics of neurological and non-neurological stroke mimics transported by Emergency Medical Services (EMS) to the Emergency Department (ED) for acute stroke evaluation. Methods: A retrospective, cross-sectional, observational analysis of a centralized EMS database of patients transported by EMS to the ED for suspected stroke during an 18-month period. Hospital charts and neuroimaging were utilized to determine the final diagnosis (acute stroke, stroke mimic, as well as specific underlying diagnoses). Results: A total of 960 patients were transported by EMS to the ED with suspected stroke, among whom 405 (42.2%) were stroke mimics (mean age ± SD: 66.9 ± 17.1 years; 54% male). Stroke mimics were neurological in origin in 223 (55.1%) patients and non-neurological in 182 (44.9%). Most common neurological diagnoses were seizures (n=44,19.7%), migraines (n=42,18.8%) and peripheral neuropathies (n=25, 11.2%). Most common non-neurological mimics included cardiovascular (15.9%), psychiatric (11.9%), and infectious (8.9%) diagnoses. Neurological mimics were younger (64.1 ± 17.3 years) than non-neurological mimics (70.5 ± 16.1 years, p Conclusions: Stroke mimics represent a substantial number of patients transported by EMS for suspected stroke, with a considerable amount being non-neurological in origin. Prospective prehospital studies are warranted to help refine prehospital identification of acute stroke and thus minimize the number of stroke mimics transported by EMS for acute stroke evaluation.

Background Overtriage not only wastes resources but also displaces the patient from their community and causes delay of treatment for the more seriously injured. This study aimed to validate the Random Forest computer model (RFM) as means of better triaging trauma patients to level 1 trauma centers. Methods Adult trauma patients with “medium activation” presenting via helicopter to a level 1 trauma center from May 2007 to May 2009 were included. The “medium activation” trauma patient is alert and hemodynamically stable on scene but has either subnormal vital signs or accumulation of risk factors that may indicate a potentially serious injury. Variables included in the RFM analysis were demographics, mechanism of injury, prehospital fluid, medications, vitals, and disposition. Statistical analysis was performed via the Random Forest algorithm to compare our institutional triage rate to rates determined by the RFM. Results A total of 1653 patients were included in this study, of which 496 were used in the testing set of the RFM. In our testing set, 33.8% of patients brought to our level 1 trauma center could have been managed at a level 3 trauma center, and 88% of patients who required a level 1 trauma center were identified correctly. In the testing set, there was an overtriage rate of 66%, whereas using the RFM, we decreased the overtriage rate to 42% (P The RFM predicted patient disposition with a sensitivity of 89%, specificity of 42%, negative predictive value of 92%, and positive predictive value of 34%. Conclusions Although prospective validation is required, it appears that computer modeling potentially could be used to guide triage decisions, allowing both more accurate triage and more efficient use of the trauma system.

INTRODUCTION: Prehospital time is crucial for treating acute disease; therefore, it is important to activate helicopter emergency medical services (HEMS) promptly. We investigated the differences in the activation intervals (the time elapsed from receiving the emergency call to the time of HEMS request) under various conditions to evaluate the current status of HEMS-related prehospital triage in Japan. METHODS: We retrospectively investigated activation intervals under exogenous (trauma, n = 553; intoxication, n = 56; and burns, n = 32) and endogenous conditions (acute coronary syndrome [ACS], n = 47; and stroke, n = 173) between January 31, 2008, and January 31, 2012, by reviewing flight records. RESULTS: Activation intervals were trauma (14.3 ± 11.5 min), intoxication (10.3 ± 8.6 min), burns (15.0 ± 13.1 min), ACS (17.9 ± 14.6 min), and stroke (19.1 ± 13.1 min). One-way analysis of variance showed a significant difference between exogenous and endogenous groups (P < .001). Post-hoc analysis using Tukey's honestly significant difference test showed significant differences between ACS and intoxication (P < .05), stroke and intoxication (P < .001), and stroke and trauma (P < .001). CONCLUSIONS: Endogenous conditions had longer activation intervals, which may reflect a lack of mechanisms assessing their severity. We are considering developing new triage criteria for dispatchers.

We appreciate the interest of Hastrup et al1 in our article in which we examined the accuracy of clinical scales to identify large-artery occlusion (LAO) in patients with acute ischemic stroke.2 Our results are consistent with those of other publications on this topic, including a recent study by Hastrup et al themselves.3,4 However, their interpretation differs from ours. Hastrup et al underline that several clinical scales have a good accuracy (70%–79%) to predict LAO and argue that such scales could improve prehospital triage. We agree that patients with LAO should be sent to a comprehensive stroke center rather than to a primary stroke center lacking neurointerventional facilities. However, we, like others,4 remain skeptical about …

Hastrup et al1 designed and validated an interesting and simple prehospital triage stroke scale named Prehospital Acute Stroke Severity (PASS) scale to identify large vessel occlusion (LVO) in patients with acute ischemic stroke. They compared PASS scale with other published prehospital scales for prediction of LVO and concluded that the PASS scale is simple and promising to predict LVO accurately before admission.1 According to our recent analysis, there is a significant correlation between various clinical scores based on the National Institutes of Health Stroke Scale score and LVO on arteriography. However, when the thresholds are set to aim for high sensitivity, specificity is low and vice versa. If …

The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines.This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed.A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8).Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.

Accurate identification of major trauma patients in the prehospital setting positively affects survival and resource utilization. Triage algorithms using predictive criteria of injury severity have been identified in paramedic-based prehospital systems. Our rescue system is based on prehospital paramedics and emergency physicians. The aim of this study was to evaluate the accuracy of the prehospital triage performed by physicians and to identify the predictive factors leading to errors of triage.Retrospective study of trauma patients triaged by physicians. Prehospital triage was analyzed using criteria defining major trauma victims (MTVs, Injury Severity Score15, admission to ICU, need for immediate surgery and death within 48 h). Adequate triage was defined as MTVs oriented to the trauma centre or non-MTV (NMTV) oriented to regional hospitals.One thousand six hundred and eighty-five patients (blunt trauma 96%) were included (558 MTV and 1127 NMTV). Triage was adequate in 1455 patients (86.4%). Overtriage occurred in 171 cases (10.1%) and undertriage in 59 cases (3.5%). Sensitivity and specificity was 90 and 85%, respectively, whereas positive predictive value and negative predictive value were 75 and 94%, respectively. Using logistic regression analysis, significant (P0.05) predictors of undertriage were head or thorax injuries (odds ratio2.5). Predictors of overtriage were paediatric age group, pedestrian or 2 wheel-vehicle road traffic accidents (odds ratio2.0).Physicians using clinical judgement provide effective prehospital triage of trauma patients. Only a few factors predicting errors in triage process were identified in this study.

Background The timely provision of emergency medical services might be influenced by discrepancies in triagesetting between emergency medical dispatch centre and ambulance crews (ACR) on the scene resulting in overloaded emergency departments (ED) and ambulance activities. The aim of this study was to identify such discrepancies by reviewing ambulance transports within a metropolitan city in the western region of Sweden. Methods All data regarding ambulance transports in Gothenburg, Sweden, during a 6-month period were obtained and analyzed by reviewing the available registry. Results There was a discrepancy between emergency medical dispatch centre and ACR in priority setting, which may result in a number of unnecessary transports to the hospital with consequent overloading of ED and a negative impact on ambulance availability. Conclusion Appropriate ambulance use is one important part of emergency preparedness. Overuse results in decreased emergency medical services (EMS) availability and ED-overcrowding. Several factors, such as an imprecise triage system and increased public demands, may influence such overutilization. Improving the triage system and comprehensive public education on appropriate use of ambulances are two important steps toward a better use of national EMS resources.

Stroke is the third leading cause of death andthe leading cause of adult disability in the United States.1 Roughly one American suffers a stroke every minute, andone American dies of stroke every 3...

ObjectiveThe aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS).Summary background dataAlthough survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention.MethodsRetrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter.ResultsThere were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS 29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P

BACKGROUND Previous studies have shown that trauma systems decrease morbidity and mortality after injury, but progress in system development has been slow and inconsistent. This study evaluated the progress in 20 state or regional systems following a consultative visit conducted by the Trauma Systems Evaluation and Planning Committee (TSEPC) of the Committee on Trauma, expanding on a previous study published in 2008, which demonstrated significant progress in six systems following consultation. METHODS Twenty trauma systems that underwent TSEPC consultation between 2004 and 2010 were studied. Status was assessed using a set of 16 objective indicators. Baseline scores for 14 regions were calculated during the consultation visit and taken from the 2008 study for the remaining six. Postconsultation status was assessed during facilitated teleconferences. Progress was assessed by comparing changes in indicator scores. RESULTS There was significant improvement in approximately 80% of systems evaluated within 60 months following the consultation. There was no progress in five of six systems reevaluated over 80 months after consultation, and all four systems evaluated over 100 months after consultation showed erosion of progress. Significant improvements were seen in 10 of the 16 individual indicators, with the greatest gains related to system standards, data systems, performance improvement, prehospital triage criteria, and linkages with public health. Consistent with the 2008 study, the two indicators related to financing for the trauma system showed no improvement. CONCLUSION The TSEPC consultation process continues to be associated with improvements in trauma system development in approximately 80% of cases, consistent with the 2008 study, but gains are not self-sustaining. There was a stagnation in progress and a deterioration in total score over time, suggesting that a repeat consultation may be beneficial. System funding remains a challenge and was the area most likely to suffer setbacks over during study period. LEVEL OF EVIDENCE Care management study, level V.

BACKGROUND: Priority dispatch accuracy is a key issue in optimizing the match between patients' medical needs and pre-hospital resources. This study measures the accuracy of a Criteria Based Dispatch (CBD) system, by evaluating discrepancies between dispatch priorities and ambulance crews' severity evaluations. METHODS: This is a retrospective study conducted from January 2011 to December 2011. We ruled that a National Advisory Committee for Aeronautics (NACA) score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/ diseases) should require a priority dispatch with lights and siren (L&S), while NACA scores 3. RESULTS: There were 29,008 primary missions in 2011, 1122 were excluded. Of the 15,749 L&S missions, 12,333 patients had a NACA score 3, leading to an under triage rate of 4.6 %. Sensitivity was 86 % (95 % confidence interval: 85.6-86.4 %), specificity 48 % (47.4-48.6 %), positive predictive value 21.7 % (21.2-22.2 %), and negative predictive value 95.4 % (95.2-95.6 %). CONCLUSION: The rates of over triage and under triage in our CBD are 78 and 4.6 % respectively. The lack of consistent or universal metrics is perhaps the most important limitation in dispatch accuracy research. This is mainly due to the large heterogeneity of dispatch systems and prehospital emergency system.

With the many advances in rapid reperfusion therapy for management of acute ST segment elevation myocardial infarction (STEMI), there is a need to revisit the current plan for prehospital triage (point of entry). Until recently in Boston, and nationwide, there has been a policy that patients with suspected acute MI were brought to the nearest hospital. Then, if ST segment elevation was present, patients were treated with either thrombolytic therapy or primary percutaneous coronary intervention (PCI). Recent data, however, have shown that with advances in interventional devices, techniques and institutional experience, primary PCI is associated with improved outcomes compared with thrombolytic therapy for all patients with STEMI when provided at expert centers with high institutional volumes, with experienced interventional cardiologists as the operators, and with relatively short time to treatment. We describe the rationale for and the implementation of the Boston EMS STEMI Triage Plan and Treatment Registry. Many of the issues that prompted the implementation of the Boston STEMI plan are relevant to all EMS systems. Among these issues are the accuracy of prehospital identification of STEMI patients, the availability of mechanical reperfusion therapy, the appropriate triage of patients with complicated myocardial infarction or shock, as well as the local consensus regarding strength of the evidence favoring mechanical reperfusion. This article describes the history of the Boston EMS STEMI Triage Plan and Treatment Registry and suggests the need for other EMS systems to develop a systematic approach to patients with STEMI.

背景:本邦の救急医療機関は初期から3次の3種に分類されている。救急隊員による現場での重症度評価とそれに基づく搬送先の選定(prehospital triage,以下PTと略す)は,本邦の救急医療の重要な要素をなしており,PTは常に正確であることが求められている。目的:東京消防庁におけるPTの有用性と限界について,医療施設における診断と転帰とを考慮して検討する。方法:1997年から3年間に東京消防庁が慶應義塾大学病院(2次・3次救急医療施設,軽症から重症までのすべての救急患者を救急部門が受け入れている)に搬送した全救急搬送患者を対象に,傷病分類(内因性・外因性),PTによる重症度分類(重症・非重症)によって各々2群に分類し,PTの評価と救急室における転帰(ICU・CCUに入院したか否か)とを比較した。さらに,ICU・CCU入院例を対象として入院30日後の累積死亡率を調査し,PTと傷病とが死亡率に影響しているか否かを検討した。結果:3年間の救急搬送患者は15620人であった。このうちPTで重症と判断された患者は1152人(7.4%)であった。一方,内因性は9587人(61.4%),外因性は5763人(36.9%)であった。PTにおける重症患者の頻度は内因性よりも外因性で高かったが(odds ratio=0.52, 95% CI: 0.46-0.59), ICU・CCUに入院した患者は外因性よりも内因性に多かった(3.07, 2.61-3.61)。 ICU・CCUに入院した患者の30日後の累積死亡率は,外因性より内因性が高値で(17.6%, 6.0%, p=0.0003), PTにおける重症が非重症よりも高値であり(27.4%, 12.1%, p

Two papers in this month’s issue of EMJ systematically examine the validity of triage systems for adults and children1, while Tsai et al analyse the performance of prehospital triage criteria in Taiwan.2 Few emergency physicians have the luxury of being able to see all patients immediately and thus not needing triage. Firstly, before we can find a good triage system, we need to consider why we triage. The underlying principle of triage is a utilitarian ethic of maximising the overall good, originally described in the military setting: ‘those who are dangerously wounded should receive the first attention, without regard to rank or distinction’.3 It presupposes that the patient with an ankle sprain does not benefit from waiting while the patient with ST elevation myocardial infarction (STEMI) is seen before him, but the population as a whole …

Introduction: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been used successfully to increase survival in patients suffering from out-of-hospital cardiac arrest (OHCA). However, few OHCA patients can benefit from E-CPR since this procedure is only performed in dedicated centers. Prehospital triage systems have helped decrease mortality from other acute conditions, by directly transporting patients to dedicated centers, often bypassing primary care centers. Our study aimed to quantify the possible impact of a prehospital triage system on the proportion of E-CPR eligible patients transported to E-CPR centers. Methods: We used a registry of adult OHCA collected between 2010 and 2015 from the city of Montréal, Canada. Included patients were adults with non-traumatic witnessed OHCA refractory to 15 minutes of resuscitation. Using this cohort, we created 3 scenarios in which potential E-CPR candidates could be redirected to E-CPR centers. We used strict eligibility criteria in our first pair (e.g. age Results: A total of 3136 patients (2054 men and 982 women) with a mean age of 69 years (standard deviation 15) were included. In each simulation, prehospital redirection would have significantly increased the proportion of patients transported to an E-CPR center (pair 1: 1.3% vs 3.8%, pConclusion: In an urban setting, a prehospital triage system could triple the number of patients with refractory OHCA who would have an access to E-CPR. This implies that centers with E-CPR capability should prepare themselves accordingly for such a system to effectively improve survival following OHCA.

During the last 30 yrs, there has a been remarkable reduction in severe TBI mortality from 50% to 25%. To ensure further improvement in TBI related mortality and to minimize related morbidity, formalization of further protocols to reduce delays in triage, transfer and treatment of patients should be implemented. Neurointensivists and Neurosurgeons have a long held belief that a decrease in the time between injury and definitive care improves the outcome.

The goal of trauma triage is to get the right patient to the right place at the right time. In an attempt to achieve this objective numerous authors have developed a variety of prehospital triage tools. Comparative evaluation to determine which of the currently developed triage tools has the greatest predictive power has been prevented mainly because of the varying definitions of major trauma. The use of small data sets and the absence of model validation techniques have also prevented the true worth of these triage tools from being accurately determined. The aim of this article is to critically appraise the major prehospital triage tools.

The management of the critically injured patient in the intensive care unit is the focus of this paper, in particular, the pitfalls attendant in the diagnosis and treatment of specific injuries. The past two decades have seen great advances in the care of the injured patient, both in the prehospital triage and transport and in the intensive care unit. More than ever, the outcome of these patients, both in terms of morbidity and mortality, is very dependent on a solid understanding of the pathophysiology of certain disease states and also of the evolution of certain injuries. Attention to detail is critical and an awareness of the pitfalls is essential, if one is to be successful in avoiding preventable morbidity and mortality. This article addresses pitfalls in judgement and also in specific management of specific injury patterns that will aid in better management of the severely injured patient.

Background: The extent to which severely injured patients receive definitive care at trauma centers is determined by the accuracy of prehospital major trauma criteria in predicting severe injuries and by the level of compliance with these triage instructions by prehospital providers. This study was conducted to evaluate the level of compliance with triage criteria in an established trauma system. Methods: The study involved a retrospective analysis of the 1995 Maryland statewide prehospital ambulance data. Prehospital providers in Maryland are instructed to consider transporting patients meeting any of the three nonexclusive major trauma criteria-physiology, injury, and mechanism-to designated trauma centers. Compliance with these criteria was defined as the proportion of patients transported to designated trauma centers among those meeting prehospital triage criteria as documented on the ambulance trip report. Special emphasis was placed on differences in the levels of compliance by age of the trauma patients. Results : A total of 32,950 transports were analyzed. Patients meeting injury criteria were most likely to be transported to trauma centers (86%), followed by those meeting mechanism criteria (46%), and physiology criteria (34%). When the level of compliance was stratified by age, there was no age difference in the level of compliance for patients meeting injury criteria (90.5% for patients aged 0-54 years vs. 88.7% for patients aged 55+ years; p = 0.197). For older patients meeting physiology criteria only or for those meeting mechanism criteria only, however, compliance was differentially low. For patients meeting physiology criteria only, the compliance was 40.3% for patients aged 0 to 54 years and 23.9% for patients aged 55 years and older (p = 0.0001); for patients meeting mechanism criteria only, compliance was 47.0% for patients aged 0 to 54 years and 39.7% for patients aged 55+ years (p = 0.002). Conclusion: The majority of patients meeting prehospital major trauma criteria were transported to designated trauma centers. Patients meeting only physiology criteria, however, were much less likely to be transported to trauma centers, and there was a differentially low compliance for elderly trauma patients meeting physiology criteria alone. The causes and consequences of lower compliance with triage instructions for the elderly population deserve further investigation.

In the field of non–ST-segment acute coronary syndromes, the evidence from recent randomized controlled trials favors early invasive management in high-risk patients. However, data from the recent ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) trial and from several large “real-world” registries suggest that the benefit may be modest. In contrast, in the field of ST-segment elevation myocardial infarction, mechanical reperfusion with primary percutaneous coronary intervention (PCI) has been shown to be superior to thrombolytic therapy. Therefore, efforts should be directed to the organization of regional networks aimed at prehospital triage and swift transfer of patients to dedicated PCI centers with experienced staff and high-volume interventional operators.

INTRODUCTION: Regionalization of stroke care is occurring nationwide, but evidence-based criteria for prehospital triage to comprehensive stroke centers are lacking. We assessed the hypothesis that a prehospital clinical decision rule can identify a group of patients more likely to require comprehensive stroke services--those with an increased risk of in-hospital mortality, ICH, or SAH. METHODS: This study represents a retrospective cohort of patients seen by an urban EMS system from 2000-2003. Subjects were included if they had either a prehospital diagnosis of “stroke/TIA” or a prehospital diagnosis of “decreased level of consciousness” or “headache” and signs and symptoms suggestive of a cerebrovascular event. The primary outcome was a composite of in-hospital mortality, ICH, or SAH. Multivariate logistic regression was used to derive a clinical prediction rule. RESULTS: In 1682 subjects, the discharge diagnoses included TIA (n = 282, 17%), ischemic stroke (n = 433, 26%), ICH (n = 102, 6%), and SAH (n = 30, 2%). There were 221 patients (13%) who experienced the primary outcome: 67 (4%) with non-fatal ICH or SAH and 154 (9%) who died. Using GCS score alone, the area under ROC curve was 0.72, and GCS ≤ 10 resulted in a sensitivity of 0.48 (95%CI 0.42, 0.55) and specificity of 0.88 (95%CI 0.87, 0.90). A six-point prehospital stroke triage score (PSTS) was also derived: nausea/vomiting (1 point), systolic BP ≥ 175 (1 point), GCS 7-10 (2 points) and GCS 3-6 (4 points). The area under ROC curve for the PSTS was 0.74. Test characteristics for PSTS and GCS were similar (Table). CONCLUSION: GCS alone performed similarly to a six-point clinical decision rule for the prehospital identification of patients at increased risk of death, ICH or SAH. GCS has potential utility as a criterion for the prehospital triage to comprehensive stroke centers.