3.3 Emergency care pathways

Stroke specific training for ambulance, emergency services, and other involved medical staff is often part of a wider effort of developing and implementing new, more efficient emergency care pathways on a national or regional level. Examples of stroke care pathways introduced in Europe and their impact (if published) are listed in Table 11.

Table 11: examples of European stroke care pathways




Stroke care pathway

Austria Tyrolian stroke pathway, introduced in 2009, covering pathway from symptom onset to rehabilitation, led to less in-hospital delay (median nationwide door-to-needle time decreased from 49 min in 2010 to 44 min in 2013) and increased thrombolysis rate (from 12.9% in 2010 to 16.8% in 2013[209])
Finland “Helsinki Model” including ambulance pre-notification of stroke team, led to less in-hospital delay[210]

Re-organisation of in-hospital treatment pathway with shifting stroke care from neurologists/internist to emergency doctors, led to less in-hospital delay[211]

France Re-organisation of regional stroke care pathway (North of France region) centralised emergency service directs patients to closest SU, direct admission to radiology department, led to increased thrombolysis rate[212]
Hungary Lysis Alarm Program with ambulance pre-notification, led to less in-hospital delay and increased thrombolysis rate[213]
Italy Stroke Code system: screening by ambulance and pre-notification of hospital, impact: increased thrombolysis rate[214], still only 20% of stroke pat arrive with code[193]
Portugal Via verde do AVC, describes pre- and in-hospital pathways, implemented in 2005, no improvement in stroke mortality rates[215], but higher thrombolysis rates with activated stroke code[216]
Spain Stroke Code system, higher thrombolysis rate in Barcelona hospital[217-219]
UK Stroke screening by ambulance using validated tools such as FAST and pre- notification and transport to hospital with acute specialist stroke services[220]

Ambulance stroke screening and pre- notification of the assigned hospital are a central part of most of the pathways listed above. They were found to improve thrombolysis rates, especially when combined with educational campaigns to optimise awareness and behaviour of patients and bystanders[214].

The key measure to assess delays in hospital is how long it takes for someone to get treatment after arriving – the door- to-needle time (DNT). This measure can be used to assess how efficient in-hospital emergency pathways and protocols for stroke are.

Large inequalities in DNTs were found between countries, but particularly also between different centres within the same country. In Slovenian centres 60% of thrombolysed patients achieved DNTs under 60 min, while only 19% did in Slovakian centres[222].

Data from Croatia, the Czech Republic, Estonia, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Turkey revealed large variations between centres[223]: in some centres, the chance of imaging within 25 minutes of arrival was 93% compared to 3% in other centres.

Long transport times between the place of admission and a CT scanner was the main explanation given, pointing to a need to further re-organise stroke services.

Data from the Stroke Knowledge Network Netherlands showed similar variations between hospitals, but also a general reduction in DNTs as hospital routines improved[224].

The International Safe Implementation of Thrombolysis in Stroke Registry with predominantly European data reported that patient volume was the strongest predictor of DNT times[225].

Example from Finland: The “Helsinki Model” involved several system improvements[…] at Helsinki University Central Hospital in Finland between 1998 and 2011, including ambulance pre-notification, direct triage to CT scanner transport, and administration of thrombolysis directly in the CT suite. In-hospital delays as analysed with annual median door-to-needle time were reduced from 105 minutes in 1998 to 20 minutes in 2011[210]. Those system changes were successfully replicated at The Royal Melbourne Hospital in Australia bringing DNT down to 25 minutes.[221]

Example from Italy: Stroke Program in Siena Province includes direct transfer by ambulance or helicopter with medical assistance on board, stroke code notification, mean door-toneedle time 48 minutes, thrombolysis with possible rescue thrombectomy, stroke unit care equipped with 6 semi-intensive and 10 less intensive care beds with multidisciplinary team. The Programme has received an award from the Joint Commission Italian Network in 2016. [9]

Examples from Greece[9]: Case 1 (Region of Thrace): urgent transport to a rural hospital (Komotini General Hospital- onset to ER time: 35 min) – emergency department: immediate assessment by internist and CT scan, transport to University Hospital of Alexandroupolis (60Km distance): immediate assessment by the stroke team – iv. thrombolysis – transfer to stroke unit bed (available bed in cardiovascular intensive care unit). Case 2 (from Attikon University Hospital, Athens): 28-year old female with acute (onset to ER time: 125 min) right MCA infarction (NIHSS score 16 points) due to a proximal right M1MCA occlusion disclosed by TCD and CTA. The door to needle time for iv. thrombolysis was 24 min. The patient had substantial improvement (NIHSS 9 points). A second CTA disclosed a residual clot in M2MCA- transfer to the angiography suite to undergo mechanical thrombectomy. The door to groin time was 102 min. Complete recanalisation was achieved using a stent retriever (groin to recanalisation time 32 min). The patient’s neurological status further improved (NIHSS-score 1)