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Better Outcomes with Prehospital Stroke Thrombolysis

April 22, 2014

Better Outcomes with Prehospital Stroke Thrombolysis

  1. Daniel J. Pallin, MD, MPH

In a German study, time to thrombolysis was faster when treatment was provided by neurologists in a specially-equipped ambulance than in the ED.

  1. Daniel J. Pallin, MD, MPH

Investigators in Germany compared time to thrombolysis between stroke patients receiving routine care in an emergency department and those evaluated in the prehospital setting by a special ambulance called “stroke emergency mobile” or STEMO. The STEMO was staffed by a neurologist and was equipped with a mobile computed tomography scanner and a point-of-care laboratory.

The unit of randomization was the week, with the STEMO responding when available during intervention weeks; 1804 STEMO responses were compared with 2969 routine cases. Of note, 1409 patients during STEMO weeks received routine care because the STEMO was not available.

With STEMO care, call-to-thrombolysis time was 25 minutes shorter; rates of thrombolysis were 13% higher (92% vs. 79%); and hemorrhage, mortality, and functional outcomes were similar to those with routine care.

Comment

These results seem impressive. On the other hand, randomizing by week instead of by patient means that this study could not really determine if outcomes were better with STEMO because some patients did not get STEMO care during STEMO weeks, so it is possible that easier-to-treat patients received STEMO care. Also, this study does not account for the opportunity costs of a neurologist and a CT scanner being continuously available to service just one patient at a time; the authors state that a formal economic analysis is forthcoming. The 25-minute reduction in time to thrombolysis was not accompanied by any measurable outcome benefit, and one wonders if a similar time improvement could be achieved by stroke center designation, which is likely a more cost-effective way of improving care.

  • Disclosures for Daniel J. Pallin, MD, MPH at time of publication Grant / research support NIH Leadership positions Society for Academic Emergency Medicine (Co-Chair, Scientific Ssubcommittee of Program Committee)

Citation(s):

Reader Comments (3)

michael power Physician, Geriatrics, Ulster hospital Belfast

Interesting study and deserves further research using a more rigorous design. The costings will be interesting.
I do feel though that there are so many areas still struggling with delivering lysis in hospital and that should still be the priority to get right.
Can't believe Dr Vardakas comment 'Is there really a physician who cares if thrombolysis is administered faster?' ...

Konstantinos Vardakas, MD, PhD Physician, Internal Medicine, Iaso General Hospital

Sometimes I am completely shocked by the decisions of editors to publish articles. For a disease that accounts for millions of deaths in the developed world, we are looking to provide faster treatment with something that increases mortality (thrombolysis) according to recent Cochrane reviews. Is there really a physician who cares if thrombolysis is administered faster? And on what cost? On the contrary, how many physicians want their patients to live longer?

Anders L Nielsen (MD, MPA, MPH) Physician, Internal Medicine, University of the Westindies

Agree with Dr Pallin’s comments however the thinking that ‘one wonders if a similar time improvement could be achieved by stroke center designation, which is likely a more cost-effective way of improving care’ needs some more consideration. I am of the opinion that the comparison was done between the prehospital option and the specialized units/centers (as stated in the paper ‘Berlin has an established stroke care infrastructure with 14 stroke units’). Hence if you have stroke units/centers further improvements might be possible using the prehospital option but obviously it comes with a not insignificant opportunity cost. However if one does not have a stroke unit/center I agree that a much more cost-effective solution is to improve care by establishing a stroke unit/center.

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