Strokes: progressive stroke pathway

7. Transfer to Hospital

Most patients with symptoms of acute stroke will be transferred to hospital by the Scottish Ambulance Service (SAS). In general, SAS transport patients with suspected hyperacute stroke to the nearest hospital which can provide thrombolysis (Acute Stroke Centre).

Transfer to hospital is a vital part of a progressive stroke pathway. There are important opportunities to:

• Improve pre-hospital diagnostic accuracy including assessment of eligibility for hyperacute treatments, enabling possible bypass of the local Acute Stroke Centre (sometimes referred to as a spoke hospital in the thrombectomy pathway) to a Comprehensive Stroke Centre (sometimes referred to as a thrombectomy hub).
• Provide receiving clinicians with information to enable quick decision making upon arrival at hospital.

7.1 Improving pre-hospital assessment

It is important to continue providing training and support to ambulance crews in the use of pre-hospital clinical assessment tools and to explore the use of more detailed tools or technologies which might improve diagnostic accuracy and triage for stroke, TIA and the identification of people potentially suitable for thrombolysis and thrombectomy.

Improving pre-hospital assessment of people who would benefit from hyperacute treatment will reduce time to treatment by ensuring that they can be quickly placed on the pathway for the most appropriate treatment.

It is also important that ambulance crews have the capacity to seek advice from stroke specialists to support with triage and diagnosis while a patient is being transferred. This can be provided via telestroke services. For example, there have been pilot projects indicating that providing ambulance crews with access to specialist support via a Professional to Professional audio and/or video call can enhance the pre hospital diagnostic accuracy and decision making with respect to TIA and stroke.

7.2 Pre-Alert

Ensuring that appropriate information is available to clinicians receiving the patient at the hospital enables quicker decision making and enables timely access to imaging and treatment upon arrival.

Pre-alert refers to the sharing of information about a patient with the hospital during transfer by an ambulance crew. Through our review process, hospital clinicians highlighted the vital importance of the pre-alert including patient identifiers such as the CHI number, name and date of birth. Despite this, the reviews identified that there is variation in appropriate pre-alerting of patients with stroke, and of the information included with the pre-alert.

At present, there is a lack of timely data available from NHS boards and sites, concerning the number of patients with suspected hyperacute stroke that are pre-alerted by SAS. This in turn means that there is no robust measure to ensure the correct patients are being taken to the most suitable hospital, and then placed on the most appropriate pathway. It is therefore important to have access to better information about pre-alerting across Scotland, to address variation and to improve pre-alerting in general.

7.3 Recommendations

1. To improve pre-hospital assessment ambulance crews should continue to be trained and supported in the use of pre-hospital clinical assessment tools.

2. The use of more detailed tools or technologies, which might improve diagnostic accuracy and triage for stroke, TIA and the identification of people potentially suitable for thrombolysis and thrombectomy, should be explored.

3. Telestroke systems should be available for use in ambulances and air transport to enable professional-to-professional calls to support ambulance crews in decision making regarding hyperacute stroke.

4. A single communication platform should facilitate voice, data and video communication between paramedics, ambulance control, stroke physicians in ASCs and CSCs, stroke nurses and interventional radiologists.

5. Communication of patient identifiers during pre-alert should be enabled to support timely decision making and improve time to treatment upon arrival at hospital.

6. A mechanism should be developed to provide routine feedback of confirmed diagnosis and treatment pathway to SAS to support staff development and improve performance and patient pathways.