Analysis of national database showed only half of suspected stroke patients in Thailand were transported by ALS ambulance. A median total prehospital time was approximately 30 minutes which was mainly occupied by transportation, response and scene times. Although, there was good performance of dispatch, activation and scene times, only half of operations met the target KPI of RT.
Current recommendation for prehospital management for suspected stroke patients includes early recognition of signs/symptoms, immediate activation of EMS system, response with high level EMS ambulance, applying prehospital stroke screening tools and finally rapid transporting of the patients to stroke center (3, 14–16). Our results indicated only half of suspected stroke subjects who called EMS system were transported to receiving hospital by ALS ambulances. The percentage was significantly lower than previous studies in the developed countries (17–19). This was caused by limited number and distribution of ALS ambulances across Thailand. Therefore, lower level ambulances were deployed instead, and stroke screening tools at prehospital phase might not be used. Moreover, inconsistent level of phone triage was also found across regions of Thailand and this might reflect differences of phone triage and dispatch protocol. There were evidences which supported that early recognition of stroke and prearrival notification by EMS personnel improved time and quality of stroke care at receiving hospital (20–22). Therefore, training EMT and FR to access stroke signs/symptom with supervision by standardized direct medical command via tele-consultation might be an area for improvement if the number of ALS ambulances are difficult to increase.
The results showed median total prehospital time was approximately 30 minutes which corresponded to previous studies (17–19, 23–26). Our result also revealed high percentage of dispatch and activation ≤ 2 minutes (13, 14). However, our median RT was longer than recommendation and other studies (3, 14, 16–19, 23, 25), and only half of subjects experienced RT ≤ 8 minutes. Although, short dispatch and activation time pointed out prompt ambulances were available, but long RT also indicated ambulances took a long time to reach to patients. This might be the result of long distance from parking to scene (Tables 1 and 2), traffic and geographic problem. Therefore, exploring abundance/distribution of patients might be required to improve reallocating EMS service for suspected stroke patients.
Most of our total prehospital time was spent for travelling from parking to scene and from scene to hospital, which differed from previous studies (18, 19, 25) that most of prehospital time was occupied at scene. This might be due to general concept of EMS system which is implemented in Thailand is scoop and run model. Patients are initially evaluated at scene and, then provided necessary medical intervention, before transporting to the nearest hospital. Most interventions for stroke protocol (e.g., EKG, intravenous assessment, blood collection, etcetera) primarily begin at ED of receiving hospital. Therefore, our scene time was very short. However, this finding also supported extension and continuation of stroke protocol between prehospital and hospital care should be implemented to complete stroke chain of survival (3, 14–16).
The strength of this study included we used a national database which represented all EMS operations across Thailand. In addition, this dataset contained low number of missing time information and this decreased selection bias. However, limitations were also identified. This database did not contain clinical important factors (e.g., last seen normal time interval, facility of receiving hospitals, diagnosis and outcomes, etcetera). Therefore, the scope of this study included only prehospital phase of suspected stroke patients.