Transforming guidelines in routine practice.

Transforming Guidelines in Routine Practice To the Editor: We have read with great interest the AHA/ASA guidelines on the early management of acute stroke patients,1,2 and we wish to report our experience as regards to the role of Emergency Medical Services (ES) personnel in the management of acute stroke patients. In order to evaluate the role of training on the accesses to our University Hospital Emergency Department Stroke Unit (EDSU), we compared the practice of a study group of ES personnel pertaining to our suburban area, randomly selected to be trained in the use of an Emergency Clinical Pathway (ECP), with that of a nontrained ES control group3. During the training, the ES personnel was taught to consider as appropriate cases for EDSU referral those with a focal neurological deficit of 6 hours of onset, aged 80 years. Over a 6-month period, 32% (1181/3585) of all cases hospitalized for a suspected stroke were performed by the ES service; the diagnosis of stroke was confirmed in 66% (780/1181) of cases. Trained ES personnel referred to our hospital 63% (88/140) of all confirmed appropriate strokes, as compared with 37% (52/140) of appropriate cases referred by the nontrained ES personnel. Mean times from dispatch to hospital admission were respectively 37 19 minutes and 49 14 minutes. Finally, appropriate stroke cases admitted to the EDSU were 76% (67/88) of those selected by trained ES, and 17% (9/52) of those selected by nontrained ES. In summary, training ES personnel to recognize stroke signs and symptoms and to rapidly screen main inclusion criteria (age and timing) for recombinant tissue plasminogen activator treatment can increase the number of cases suitable for pharmacological reperfusion, as well as the appropriateness of accesses to stroke units.