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Definitions and Context

5th Edition
2015 UPDATED
January 2015

Only about two-thirds of all patients who seek acute care for stroke symptoms arrive at the emergency department by ambulance (HSF Stroke Report 2014). The remaining patients either drive themselves to the hospital or are brought to hospital by family members or others. These other modes of transportation pose several challenges: 1) it is not safe for a person experiencing stroke symptoms to drive, even if the symptoms start to resolve as reaction times and judgment may be affected, and symptoms may worsen en route; 2) not all hospitals in Canada are equipped to provide urgent stroke care and the public may not know which hospitals they should go to, which potentially delays access to treatment; and, 3) paramedics are able to proceed to an appropriate hospital that is identified as a stroke centre and notify the receiving emergency department of their arrival, which saves valuable time, which could have a direct impact on outcomes.

Following extensive consultation, two timelines have been established to facilitate an effective and efficient response to stroke in Canada within the 4.5 hour-window from symptom onset to administration of thrombolytic therapy. These are:

  1. The pre-hospital phase that starts with stroke symptom onset (or last seen normal or last seen well time) and includes dispatch, paramedic on-scene management and transport times, which ideally should occur as rapidly as possible, and within 3.5 hours or less; and
  2. The emergency department phase after patient arrival to the ED; this includes diagnostic evaluation, diagnosis and consideration of treatment options, which ideally should occur as rapidly as possible, and be achieved in less than 60 minutes

It is important to emphasize that even when the time lapse from stroke symptom onset exceeds 4.5 hours (including pre-hospital time), every attempt should still be made to transport the patient to the closest most appropriate stroke-enabled healthcare facility. This information should be a clear component of any public, patient, or professional education related to the signs of stroke. Refer to Hyperacute Stroke Module, Section 2.1.3 for more information.

Critical Steps in Early Stroke Management

The primary underpinnings of recognition and response requires individuals and healthcare team members to work together to identify stroke as quickly as possible and follow a standardized series of critical steps for stroke survival to maximize treatment options and improve health outcomes.

The critical steps for stroke survival are identified in the Figure below and are applicable to most patients exhibiting the signs of stroke. Individual patient circumstances, geographic issues and resource access will affect the specific steps in early stroke management for each patient; however, the steps outlined in the Figure reflect stroke best practice for the majority of patients exhibiting the signs of stroke or transient ischemic attack (TIA).

Figure: Critical Steps in Early Stroke Management

Critical Steps Stroke Care