• Martijne H C Duvekot, Bjarty L Garcia, Luuk Dekker, Truc My Nguyen, Ido R van den Wijngaard, Karlijn F de Laat, Els L L M de Schryver, Loet M H Kloos, AerdenLeo A MLAMDepartment of Neurology, Reinier De Graaf Gasthuis, Delft, The Netherlands., Stas A Zylicz, Jan Bosch, Eduard van Belle, Erik W van Zwet, Anouk D Rozeman, Walid Moudrous, Frédérique H Vermeij, Hester F Lingsma, Jeannette Bakker, van DoormaalPieter JanPJDepartment of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands., Adriaan C G M van Es, Aad van der Lugt, WermerMarieke J HMJHDepartment of Neurology, Leiden University Medical Center, Leiden, The Netherlands., DippelDiederik W JDWJDepartment of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands., Henk Kerkhoff, Bob Roozenbeek, Nyika D Kruyt, Esmee Venema, and Leiden Prehospital Stroke Study and PRESTO Investigators.
• Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
• Prehosp Emerg Care. 2023 Jan 1; 27 (5): 630638630-638.

Background And PurposeDirect transportation to a thrombectomy-capable intervention center is beneficial for patients with ischemic stroke due to large vessel occlusion (LVO), but can delay intravenous thrombolytics (IVT). The aim of this modeling study was to estimate the effect of prehospital triage strategies on treatment delays and overtriage in different regions.MethodsWe used data from two prospective cohort studies in the Netherlands: the Leiden Prehospital Stroke Study and the PRESTO study. We included stroke code patients within 6 h from symptom onset. We modeled outcomes of Rapid Arterial oCclusion Evaluation (RACE) scale triage and triage with a personalized decision tool, using drip-and-ship as reference. Main outcomes were overtriage (stroke code patients incorrectly triaged to an intervention center), reduced delay to endovascular thrombectomy (EVT), and delay to IVT.ResultsWe included 1798 stroke code patients from four ambulance regions. Per region, overtriage ranged from 1-13% (RACE triage) and 3-15% (personalized tool). Reduction of delay to EVT varied by region between 24 ± 5 min (n = 6) to 78 ± 3 (n = 2), while IVT delay increased with 5 (n = 5) to 15 min (n = 21) for non-LVO patients. The personalized tool reduced delay to EVT for more patients (25 ± 4 min [n = 8] to 49 ± 13 [n = 5]), while delaying IVT with 3-14 min (8-24 patients). In region C, most EVT patients were treated faster (reduction of delay to EVT 31 ± 6 min (n = 35), with RACE triage and the personalized tool.ConclusionsIn this modeling study, we showed that prehospital triage reduced time to EVT without disproportionate IVT delay, compared to a drip-and-ship strategy. The effect of triage strategies and the associated overtriage varied between regions. Implementation of prehospital triage should therefore be considered on a regional level.

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