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Aging and disease    2018, Vol. 9 Issue (3) : 426-434     DOI: 10.14336/AD.2017.0601
Orginal Article |
Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area
Zhang Sheng1, Zhang Jungen2, Zhang Meixia1, Zhong Genlong1, Chen Zhicai1, Lin Longting3, Lou Min1,*
1Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
2Hangzhou Emergency Medical Center of Zhejiang Province, Hangzhou, China
3The School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
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Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area.

Keywords thrombolysis      prehospital notification      emergency medical service      onset to needle time      door to needle time      clinical outcome     
Corresponding Authors: Lou Min   
About author:

SZ and JZ denote equal first authorship contribution.

Issue Date: 05 June 2018
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Zhang Sheng
Zhang Jungen
Zhang Meixia
Zhong Genlong
Chen Zhicai
Lin Longting
Lou Min
Cite this article:   
Zhang Sheng,Zhang Jungen,Zhang Meixia, et al. Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area[J]. Aging and disease, 2018, 9(3): 426-434.
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Figure 1.  Flow chart of prehospital notification procedures (PNP) and non-PNP. EMS: emergency medical service, ED: emergency department, IVT: intravenous thrombolysis.
Figure 2.  Four-parts durations of DNT in EMS with and without PNP and non-EMS groups. DNT was comprised of four parts: (i) duration in ED; (ii) ED departure to initiation of imaging scan; (iii) duration of imaging scans; (iv) end of imaging scan to initiation of IVT. Significant difference in ED duration part was found between two groups connected by dotted lines. DNT: door-to-needle time, EMS: emergency medical service, ED: emergency department, IVT: intravenous thrombolysis, PNP: prehospital notification procedure.
EMS without PNP
EMS with PNP
Test valuep value
Age, y*68.8 ± 12.573.4 ± 11.366.5 ± 15.4F=2.8100.063
Female, n (%)34 (32.4)14 (38.9)17 (41.5)χ2=1.2560.543
Baseline characteristics
Smoking, n (%)42 (40.0)11 (30.6)12 (29.3)χ2=1.9990.368
Hypertension, n (%)69 (65.7)21 (58.3)27 (65.9)χ2=06930.707
Diabetes mellitus, n (%) &,*22 (21.0)3 (8.3)12 (29.3)χ2=5.2460.073
Atrial fibrillation, n (%)38 (36.2)17 (47.2)14 (34.1)χ2=1.7050.426
Hyperlipidemia, n (%)45 (42.9)17 (47.2)14 (34.1)χ2=1.4710.479
Previous TIA/stroke, n (%) &,24 (22.9)4 (11.1)2 (4.9)χ2=7.8650.020
Baseline NIHSS score,IQR&8.0 (4.0-15.0)14.0 (8.3-18.8)12.0 (6.5-16.5)F=4.1280.018
Baseline SBP, mmHg153.1 ± 19.9156.8 ± 29.2152.5 ± 21.8F=0.4380.646
Baseline DBP, mmHg84.9 ± 11.580.4 ± 11.583.9 ± 13.9F=1.8550.159
Baseline serum glucose, mmol/L&7.8 ± 3.06.6 ± 1.67.1 ± 2.8F=2.2740.106
Receive MRI, n (%)10 (9.5)2 (5.6)0 (0)χ2=4.4210.110
Time tracking information
Onset to needle time,min&,231.3 ± 109.1182.3 ± 98.1174.54 ± 93.0F=5.9090.003
Onset to door time,min&,174.8 ± 105.1130.3 ± 83.4133.2 ± 90.2F=4.2640.016
Door to needle time,min*,56.6 ± 18.351.9 ± 23.841.3 ± 10.7F=10.395<0.001
Door to imaging time, min*,30.4 ± 15.725.8 ± 12.318.1 ± 6.6F=12.469<0.001
Duration in ED, min*,20.9 ± 14.416.1 ± 9.59.2 ± 5.5F=14.455<0.001
ED departure to initiation of imaging scan, min9.5 ± 5.79.6 ± 5.08.9 ± 4.0F=0.2330.792
Duration of imaging scans, min9.7 ± 5.49.3 ± 4.98.3 ± 2.8F=1.3360.265
End of imaging scan to initiation of IVT, min16.4 ± 9.116.9 ± 12.615.0 ±8.0F=0.4630.630
Neurological outcomes
Good outcome, n (%)58 (55.2)15 (41.7)26 (63.4)χ2=3.726p=0.155
HT, n (%)36 (34.3)11 (30.6)14 (34.1)χ2=0.177p=0.915
HI, n (%)24 (22.9)6 (16.7)10 (24.4)χ2=0.781p=0.941
PH, n (%)8 (7.6)3 (8.3)3 (7.3)χ2=0.781p=0.941
sHT, n (%)1 (1.0)2 (5.6)1 (2.4)χ2=2.657p=0.265
Death, n (%)12 (11.4)6 (17.1)3 (7.5)χ2=1.698p=0.428
Table 1  Univariate comparisons among patients transferred by EMS with or without PNP, and other means of transportation (non-EMS).
Poor outcome
Good outcome
Test valuep value
Age, y72.2 ± 12.166.6 ± 13.4t=2.9080.004
Female, n (%)31 (37.3)34 (34.3)χ2=0.1780.673
Baseline characteristics
Smoking, n (%)29 (34.9)36 (36.4)χ2=0.0400.842
Hypertension, n (%)55 (66.3)62 (62.6)χ2=0.2600.610
Diabetes, n (%)14 (16.9)23 (23.2)χ2=1.1290.288
Atrial fibrillation, n (%)35 (42.2)34 (34.3)χ2=1.1740.278
Hyperlipidemia, n (%)32 (38.6)44 (44.4)χ2=0.6440.422
TIA/stroke history, n (%)14 (16.9)16 (16.2)χ2=0.0160.898
Baseline NIHSS score, IQR14.0 (12.0-19.0)5.0 (3.0-10.0)Z= -5.923<0.001
Baseline SBP, mmHg154.2 ± 21.5153.4 ± 23.2t=0.2380.812
Baseline DBP, mmHg84.4 ± 11.483.3 ± 12.8t=0.6340.527
baseline serum glucose, mmol/L7.6 ± 3.27.3 ± 2.5t=0.6860.494
Transferred by EMS, n (%)36 (43.4)41 (41.4)χ2=0.0710.790
EMS with PNP, n (%)15 (18.1)26 (26.3)χ2=1.7350.188
Time tracking information
Onset to needle time, min228.5 ± 115.9192.4 ± 95.1Z=2.1460.032
Onset to door time, min174.1 ± 106.6142.0 ± 91.6t=2.1830.030
Door to needle time, min54.4 ± 21.450.4 ± 16.9t=1.4350.154
Door to imaging time, min27.9 ± 15.025.8 ± 13.8t=0.9990.319
Duration in ED, min18.4 ± 13.616.5 ± 12.3t=1.0060.316
ED departure to initiation of imaging scan, min9.5 ± 5.19.3 ± 5.3t=0.2660.790
Duration of imaging scans, min9.8 ± 5.18.9 ± 4.6t=1.1210.264
End of imaging scan to initiation of IVT, min16.8 ± 10.115.7 ± 9.2t=0.7870.433
Table 2  Univariate comparisons between patients with or without good outcome.
Model 1OR95% CIp value
Baseline NIHSS0.8120.760-0.868<0.001
TIA / stroke history1.7320.628-4.7800.289
Model 2OR95% CIp value
Baseline NIHSS0.8130.760-0.869<0.001
TIA / stroke history1.7900.645-4.9700.264
EMS without PNP1.2360.481-3.1770.661
EMS with PNP2.6131.062-6.4270.036
Model 3OR95% CIp value
Baseline NIHSS score0.8180.765-0.874<0.001
TIA / stroke history1.2940.444-3.7670.636
EMS without PNP0.8970.326-2.4690.834
EMS with PNP1.7850.684-4.6530.236
Onset to needle time0.9940.990-0.9980.001
Table 3  Multivariate regression analysis for good outcome.
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