# Prehospital stroke triage in Denmark: a retrospective observational study of emergency medical services handling confirmed stroke cases not admitted directly to a stroke unit

## TL;DR

This study examines how emergency medical services in Denmark handle stroke cases that are not directly sent to a stroke unit, finding that most patients are consulted with a neurologist but some are rejected due to various reasons.

## Contribution

The study provides new insights into prehospital stroke triage practices and reasons for non-referral to stroke units in Denmark.

## Key findings

- 86% of patients were consulted with a neurologist, with older patients and typical stroke symptoms more likely to be consulted.
- 34% of consulted patients had documented reasons for rejection, including being outside the thrombolysis time window and atypical symptoms.

## Abstract

Early identification and correct triage of stroke in the prehospital setting are essential for timely treatment and improved outcomes. In Region Zealand, Denmark, ambulance personnel are instructed to consult a neurologist when stroke is suspected to facilitate direct admission to a specialised stroke unit. However, little is known about what happens when emergency medical service (EMS) dispatchers correctly suspect stroke, but the patient is not admitted directly to a stroke unit. This includes whether a consultation with a neurologist occurs and on what basis patients are rejected. The primary aim was to determine how often ambulance personnel consulted with a neurologist and examine documented reasons for not referring patients directly to a stroke unit. The secondary aim was to describe symptom presentation in these patients.

This retrospective observational study linked prehospital ambulance records, Computer-Aided Dispatch data, and the Danish Stroke Register. The prehospital medical record by ambulance personnel was reviewed for each case to examine the decision-making during ambulance responses using a predefined instrument. The study included patients ≥ 18 years who were initially suspected of having a stroke by the EMS dispatcher, were not transported directly to a stroke unit, and a stroke diagnose in the Danish Stroke Register corresponding to the same clinical event from January 2021 to September 2024 in Region Zealand, Denmark. Descriptive statistics were used to summarise findings.

Of the 680 patients included, 583 (86%) were consulted with a neurologist. Patients consulted with a neurologist were older (median 77 vs. 74 years; p = 0.021) and more often exhibited typical stroke symptoms such as paresis and aphasia. Reasons for neurologist rejection were documented in 201 out of 583 consulted patients (34%) and included being outside the thrombolysis time window (19%), contraindications to thrombolysis (15%), few or atypical stroke symptoms (14%), or lack of suspicion of stroke (12%).

While most patients were consulted with a neurologist, a notable proportion were not despite instructions. Reasons for rejection was documented in 34% of patients and included being outside the thrombolysis time window, contraindications, or atypical symptoms. These findings highlight the need to review triage instructions.