Sahlgrenska University Hospital (SU) in Gothenburg, Sweden, is actually three separate hospitals with separate emergency departments and stroke units. Together, they serve a population of approximately 700,000 inhabitants. The present study was performed at one of these three stroke units, SU/Östra, which has 32 in-patient beds and treats approximately 500 stroke patients a year. The patients are treated at the unit for the whole of their hospital stay, both in the acute phase and throughout rehabilitation.
In September 2008, a collaboration project between the EMS system and the hospital was started. The aim of the project was to determine whether selected stroke patients could be identified in the ambulance and be admitted directly to a stroke ward without passing through the ED.
Before the project started, the EMS nurses participated in a 3-hour education course on stroke and stroke symptoms. At the start, the project only involved 2 ambulances, but, in 2009, the project gradually expanded and, by November 2009, most of the 19 ambulances in the area were taking part in the project. In all ambulances, a nurse was on duty at all times. The EMS nurse recorded an ECG, took a blood sample for plasma glucose, measured blood pressure, oxygen saturation (POX), body temperature with an ear-lobe probe and respiratory rate. If plasma glucose was less than 4 mmol/L, the patient was treated with 30% glucose intravenously in the ambulance.
A protocol was used and inclusion and exclusion criteria were registered.
The inclusion criteria were acute onset of a neurological deficit, such as a sudden problem of speaking or a sudden weakness in the face, arm, or leg.
The exclusion criteria were a) patients who met the criteria for i.v. thrombolysis (symptoms for less than 3 hours and under 80 years of age), b) ischemic ST changes on the ECG, c) plasma glucose of 22 mmol/L or more, d) body temperature of 39 degrees Celsius or more, e) POX below 90%, f) systolic blood pressure below 100 mmHg, g) heart rate below 50 or above 100 beats per minute, h) respiratory rate over 25 breaths per minute or i) low consciousness defined as Glasgow Coma Scale of 14 or below. These exclusion criteria were based on the Medical Emergency Triage and Treatment System (METTS) triage system .
If a patient met the criteria for direct admission, the EMS nurse contacted a co-ordinator at the stroke unit who double-checked that the inclusion and exclusion criteria had been met and then decided whether or not the patient could be admitted directly to the ward. The co-ordinator was either a nurse or an assistant nurse, so no physician was involved in the decision to admit the patient.
During the study period, direct admission was possible Monday through Friday between 8 am and 4 pm.
All consecutive patients who were admitted directly to the stroke unit between 15 September 2008 and 2 November 2009 were included in the study and formed the direct admission group.
A control group was recruited from consecutive patients who came to the ED by ambulance during the same time period as the direct admission group, on weekdays (Monday through Friday) between 7 am and 6 pm, met the same inclusion and exclusion criteria and where the physician on duty suspected acute stroke and the patient was admitted to the same stroke unit. The patients in the control group all arrived in ambulances not involved in the direct admission project and were therefore not considered for direct admission. The time for inclusion in the control group was extended to 7 am until 6 pm in order to increase the sample size.
Data were collected retrospectively from the patients’ medical charts and ambulance charts.
An historical reference group was used for the power calculation. It consisted of consecutive patients who came to the ED by ambulance between 1 January and 31 August 2008 on weekdays (Monday through Friday) between 8 am and 4 pm, met the same exclusion criteria according to METTS and were hospitalised with a discharge diagnosis of acute stroke.
This group consisted of 90 patients; 46 men (51%) and 44 women. Their median age was 80 years, Inter quartile range (IQ range): 70–87 years). The median time spent at the emergency ward was 334 minutes (IQ range 245–444 minutes) and the mean delay at the emergency ward was 368 minutes. We estimated the mean time from the onset of the emergency call to arrival at the emergency ward as 40 minutes. The mean time from calling for an ambulance to arrival at the stroke unit was therefore 408 minutes in the historical control group.
Based on experience from fast tracking in acute coronary syndrome (9), we hypothesised that the mean delay from the emergency call to arrival at the stroke unit in the direct admission group would be 60 minutes. If this hypothesis was true, 10 patients in each group would be required (p < 0.05) with 80% power to show a significant shortening of time from the emergency call to arrival at the stroke unit.
All analyses were performed using the SAS© software. Differences in proportions were analysed with Fisher’s exact test. For continuous variables, the Mann–Whitney U test was used.
All tests were two-tailed. P-values of less than 0.05 were considered significant.
According to the criteria set by the Swedish Ethical Review Board, this study was classified as a quality project and evaluation by the Ethical Review Board was therefore not required.
The study was approved by the hospital management committee and informed consent was obtained from all patients included in the project.