Prehospital triage of patients with suspected acute stroke (PRESTO-2): protocol for a controlled before-and-after intervention trial

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BACKGROUND: Prehospital triage of suspected stroke patients aims to reduce onset-to-groin time by eliminating the need for interhospital transfers for patients with ischaemic stroke caused by an LVO eligible for EVT, thereby improving long-term functional outcome. We aim to evaluate the implementation of a novel decision support tool, the Stroke Triage App (STA), which provides personalised triage advice by integrating stroke severity, onset time, GPS-based driving times, hospital-specific workflow metrics and time-dependent treatment effects. STUDY DESIGN: PRESTO-2 is a multicentre controlled before-and-after intervention trial. The study aims to evaluate the outcomes before and after implementation of prehospital triage with the STA in 1 acute-care region in the south-west of the Netherlands, compared with a control region. The STA is a smartphone-based application that uses an integrated decision model to estimate the probability of good functional outcome after 3 months (mRS score 0-2) under 2 strategies: transportation to the nearest primary stroke centre or transportation to the more distant intervention centre. Paramedics will use the STA for suspected stroke patients with a positive FAST test of 1 point or more. STUDY ENDPOINTS: The primary outcome is onset-to-groin time. Effects will be estimated using difference-in-differences linear regression analysis. Secondary outcomes include the onset-to-needle time, 3-month functional outcome, proportion of patients treated with IVT and EVT within guideline-recommended time windows, overtriage and undertriage, ambulance utilisation, compliance and adherence to triage advice. SUMMARY: The PRESTO-2 study uses a pragmatic and efficient design for implementation studies, and is expected to provide insights into the optimisation of prehospital stroke care pathways and the challenges associated with integration of novel digital health technologies in existing clinical practice. These findings may inform scientists and clinicians to more efficiently design studies and organise stroke care pathways.

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