Related Experiment Video
Updated: Dec 5, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
The Effect of a County Prehospital FAST-ED Initiative on Endovascular Treatment Times
Helen Rynor1, Jake Levine1, Joseph Souchak2
1Florida International University Herbert Wertheim College of Medicine, Miami, FL USA.
Insights
Implementing the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) prehospital algorithm significantly reduced door-to-puncture times for acute stroke patients, especially during off-hours. This initiative improved treatment efficiency for emergent large vessel occlusion strokes.
Area of Science:
- Neurology
- Emergency Medicine
- Public Health
Background:
- Timely reperfusion is critical for improving acute stroke outcomes.
- The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) algorithm was implemented in March 2017 by local EMS agencies.
- FAST-ED includes hospital bypass and prehospital activation of the neurointerventional team for suspected strokes.
Purpose of the Study:
- To analyze the impact of the FAST-ED initiative on stroke patient volume, transfers, treatment times, and outcomes.
- To evaluate the FAST-ED tool's predictive ability for large vessel occlusion (LVO) strokes.
- To compare treatment times before and after FAST-ED implementation, considering on- vs. off-hours and field activation.
Main Methods:
- Retrospective analysis of stroke cases managed by EMS from March 2016 to February 2018 (one year pre- and post-FAST-ED).
- Comparison of treatment times (door-to-needle, door-to-puncture) between the pre- and post-FAST-ED periods.
- Analysis of treatment times based on on-hours vs. off-hours and with vs. without prehospital field activation.
Main Results:
- Of 1153 EMS-coded stroke cases, 761 (67%) were confirmed strokes, and 235 (20%) received reperfusion therapy.
- Door-to-puncture (DTP) times improved significantly post-FAST-ED: 17 min overall, 25 min off-hours, and 33 min with field activation.
- FAST-ED scale compliance was 85%; a FAST-ED score cutoff of ≥6 was deemed appropriate for field activation, balancing activations and procedures.
Conclusions:
- The prehospital FAST-ED initiative successfully reduced DTP times, with the most substantial improvements observed during off-hours and with field activation.
- While FAST-ED increased field activations, only one-third of these led to endovascular treatment, suggesting a need for score refinement or further validation.
- The FAST-ED score of ≥6 appears to be a suitable threshold for prehospital activation of the neurointerventional team.
Background:
Acute stroke outcomes depend on timely reperfusion. In 3/2017, local EMS agencies implemented a prehospital triage algorithm with hospital bypass and field activation of the neurointerventional team using the Field Assessment Stroke Triage for Emergency Destination (FAST-ED). A score ≥4 bypasses to a comprehensive stroke center (CSC) and a score ≥6 also has the interventional team field activated off-hours.
Aim:
We analyzed effects of this initiative on volume, acute stroke transfers, treatment times, and outcomes and determined the tool's ability to predict large vessel occlusion.
Methods:
Stroke cases brought to our center by EMS during 3/2016-2/2018 were analyzed, which included one year before and after FAST-ED implementation. Treatment times were compared on- vs. off-hours and to those with field activation.
Results:
Of 1153 patients, 761 (67%) were coded as stroke and 235 (20%) underwent reperfusion. Age, sex, race/ethnicity, stroke severity, length of stay, door-to-needle, and 90-d mRS were comparable between periods. Scale compliance was 85%. Concordance rate of ±1 between EMS and calculated score was 53%. Compared to the previous year, door-to-puncture (DTP) improved by 17 min (p < 0.01) overall, 25 min (p < 0.001) off-hours, and 33 min (p < 0.05) with field activation. A cutoff of 4 vs. 6 would have led to 140% increase in field activations but only 36% increase in procedures.
Conclusions:
This prehospital initiative led to faster DTP by up to 33 min. The highest impact was off-hours with field activation. Only 1/3 of activations led to endovascular treatment. FAST-ED≥6 appears to be appropriate for field activation.
