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Original Investigation
September 3, 2019

Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Neurology, University Hospital of the Saarland, Homburg, Germany
  • 2Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
  • 3Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
  • 4Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany
  • 5Department of Neurology, Klinikum Saarbrücken, Saarbrücken, Germany
  • 6Department of Radiology, Klinikum Saarbrücken, Saarbrücken, Germany
  • 7Department of Neurology, Caritas-Klinikum Saarbrücken St Theresia, Saarbrücken, Germany
  • 8Medizinische Klinik, Kreiskrankenhaus St Ingbert, St Ingbert, Germany
  • 9Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
  • 10Statistical Consultant, Ingelheim, Germany
  • 11Department of Neuroscience, Faculty of Medical Science, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, Southend University Hospital, Southend-on-Sea, United Kingdom
  • 12Zweckverband für Rettungsdienst und Feuerwehralarmierung, Saar, Germany
JAMA Neurol. Published online September 3, 2019. doi:10.1001/jamaneurol.2019.2829
Key Points

Question  How does optimized prehospital management featuring a clinical score compare with management in a mobile stroke unit (MSU) in triaging patients with stroke to hospitals providing or not providing neurointerventional treatment?

Findings  In this randomized clinical trial involving 116 patients, a protocol that included the use of the Los Angeles Motor Scale resulted in accurate triage decisions for 37 of 53 patients, whereas an MSU with imaging enabled accurate triage decisions for 63 of 63 patients, a significant difference.

Meaning  Depending on the health care environment, both management optimized by a clinical score and deployment of an MSU can be beneficial in triage decision-making.

Abstract

Importance  Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem.

Objective  To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment.

Design, Setting, and Participants  In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients.

Interventions  Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities).

Main Outcomes and Measures  The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others).

Results  A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different.

Conclusions and Relevance  Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients.

Trial Registration  ClinicalTrials.gov identifier: NCT02465346

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