Impact of Prehospital Triage Protocol on Outcomes of Spontaneous Intracerebral Hemorrhage Patients

Background

While prehospital triage protocols for suspected large vessel occlusion (LVO) improve ischemic stroke outcomes, their impact on spontaneous intracerebral hemorrhage (sICH) remains uncertain. We evaluated whether a regional LVO-focused emergency medical service (EMS) transport protocol affected care efficiency and outcomes in sICH patients.

Methods

We conducted a multicenter pre-post implementation cohort study using the Get-With-The-Guidelines-Stroke database in Chicago (April 2017–January 2020).

Included were EMS-transported sICH patients arriving ≤6 hours from last known normal at 8 comprehensive stroke centers (CSCs) and 15 primary stroke centers (PSCs). Primary outcomes were in-hospital mortality and favorable discharge disposition (home/acute rehabilitation). Secondary outcomes included good neurologic outcome (independent ambulation) at discharge and time metrics (symptom-to-arrival, door-to-CT). Interrupted time series (ITS) analysis assessed changes while accounting for temporal trends.

Results

Among 311 sICH patients (111 pre-, 192 post-implementation), there was no difference in in-hospital mortality (12% vs. 9%, p=0.4; ITS level change: −5% [95% CI: −31% to 21%], p=0.68; trend change: 1% [95% CI: −1% to 2%], p=0.34), favorable discharge disposition (58% vs. 64%, p=0.3; ITS level change: −20% [−77% to 38%], p=0.49; trend change: 1% [95% CI: −2% to 4%], p=0.47) or good neurologic outcomes (13% vs. 19%, p=0.4; ITS level change: 11% [−25% to 48%], p=0.53; trend change: −1% [95% CI: −3% to 1%], p=0.37) between pre-post implementation periods. Time metrics (door-to-CT, symptom-to-arrival, symptom-to-CT) showed no significant changes in unadjusted or ITS analyses. The protocol also did not impact CSC admissions rate and inter-hospital transfers in ITS analyses.

Conclusion

Implementation of an LVO-focused EMS transport protocol did not improve outcomes or care efficiency among sICH patients, nor did it affect CSC admission or transfer rates. These findings highlight the need for dedicated prehospital triage strategies specific to sICH, distinct from ischemic stroke pathways.