• Henry Zhao, Lauren Pesavento, Skye Coote, Edrich Rodrigues, Patrick Salvaris, Karen Smith, Stephen Bernard, Michael Stephenson, Leonid Churilov, Nawaf Yassi, Stephen M Davis, and Campbell Bruce C V BCV From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.
• From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of Emergency Medicine, University of Western Australia, Australia (K.S., S.B.). zhaohdr@live.com.
• Stroke. 2018 Apr 1; 49 (4): 945-951.

Background And PurposeClinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability and reliability.MethodsThe ACT-FAST algorithm consists of (1) unilateral arm drift to stretcher <10 seconds, (2) severe language deficit (if right arm is weak) or gaze deviation/hemineglect assessed by simple shoulder tap test (if left arm is weak), and (3) eligibility and stroke mimic screen. ACT-FAST examination steps were retrospectively validated, and then prospectively validated by paramedics transporting culturally and linguistically diverse patients with suspected stroke in the emergency department, for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy.ResultsIn retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST algorithm (n=60) assessed by paramedics showed high overall accuracy (91.7%), sensitivity (85.7%), specificity (93.5%), and positive predictive value (80%) for recognition of endovascular-eligible LVO.ConclusionsThe 3-step ACT-FAST algorithm shows higher specificity and reliability than existing scales for clinical LVO recognition, despite requiring just 2 examination steps. The inclusion of an eligibility step allowed recognition of endovascular-eligible patients with high accuracy. Using a sequential algorithmic approach eliminates scoring confusion and reduces assessment time. Future studies will test whether field application of ACT-FAST by paramedics to bypass suspected patients with LVO directly to endovascular-capable centers can reduce delays to endovascular thrombectomy.© 2018 American Heart Association, Inc.

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