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Original research
Stroke care: initial data from a county-based bypass protocol for patients with acute stroke
  1. Syed F Zaidi1,
  2. Julie Shawver2,
  3. Aixa Espinosa Morales1,
  4. Hisham Salahuddin1,
  5. Gretchen Tietjen1,
  6. David Lindstrom2,
  7. Brent Parquette3,
  8. Andrea Adams4,
  9. Andrea Korsnack1,
  10. Mouhammad A Jumaa1
  1. 1Department of Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
  2. 2Promedica Toledo Hospital, Toledo, Ohio, USA
  3. 3Lucas County EMS, Toledo, Ohio, USA
  4. 4Mercy St Vincent Hospital Toledo, Toledo, Ohio, USA
  1. Correspondence to Dr Mouhammad A Jumaa, Department of Neurology, University of Toledo Medical Center, 3000 Arlington Ave, Toledo, OH 43614, USA; mjumaa{at}


Background Early identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes.

Objective To describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio.

Method All county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months.

Results An increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05).

Conclusions Our results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

  • Stroke
  • Standards

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