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

Autor:	Helwig SA; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Ragoschke-Schumm A; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Schwindling L; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Kettner M; Department of Neurology, University Hospital of the Saarland, Homburg, Germany.; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany., Roumia S; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany., Kulikovski J; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany., Keller I; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Manitz M; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Martens D; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Grün D; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Walter S; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Lesmeister M; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Ewen K; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Brand J; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Fousse M; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Kauffmann J; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Zimmer VC; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Mathur S; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Bertsch T; Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany., Guldner J; Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany., Magull-Seltenreich A; Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany., Binder A; Department of Neurology, Klinikum Saarbrücken, Saarbrücken, Germany., Spüntrup E; Department of Radiology, Klinikum Saarbrücken, Saarbrücken, Germany., Chatzikonstantinou A; Department of Neurology, Caritas-Klinikum Saarbrücken St Theresia, Saarbrücken, Germany., Adam O; Medizinische Klinik, Kreiskrankenhaus St Ingbert, St Ingbert, Germany., Kronfeld K; Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany., Liu Y; Department of Neurology, University Hospital of the Saarland, Homburg, Germany., Ruckes C; Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany., Schumacher H; Statistical Consultant, Ingelheim, Germany., Grunwald IQ; Department of Neuroscience, Faculty of Medical Science, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, Southend University Hospital, Southend-on-Sea, United Kingdom., Yilmaz U; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany., Schlechtriemen T; Department of Neurology, University Hospital of the Saarland, Homburg, Germany.; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany.; Zweckverband für Rettungsdienst und Feuerwehralarmierung, Saar, Germany., Reith W; Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany., Fassbender K; Department of Neurology, University Hospital of the Saarland, Homburg, Germany.
Jazyk:	angličtina
Zdroj:	JAMA neurology [JAMA Neurol] 2019 Dec 01; Vol. 76 (12), pp. 1484-1492.
DOI:	10.1001/jamaneurol.2019.2829
Abstrakt:	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.
Databáze:	MEDLINE
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