Houston Paramedic and Emergency Stroke Treatment and Outcomes Study (HoPSTO)

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Abstract
Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines. Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study. Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department-Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase (P<0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% (P=0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post- tissue plasminogen activator hemorrhage (3.7%) reported. A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window. Stroke center development supports safe thrombolytic practice in community settings.