In our large regional centralised acute stroke system, FAST positive patients collected by ambulance are diverted to one of 3 hyperacute stroke units (HASUs). If onset is >48 hours and/or the patient is unstable (based on pre-specified criteria) they are diverted to the nearest Emergency Department (ED) instead. We sought to determine the diagnoses and clinical characteristics of those excluded and whether treatment for stroke would potentially be delayed.

We extracted data for consecutive patients conveyed by ambulance with suspected stroke to our HASU between 01/08/2015-28/02/2017. Patients for whom our HASU is co-located with their nearest ED were compared with those diverted from out-of-area (OOA). The local cohort provides an unselected population and the OOA cohort were only brought if no exclusions were present or exclusions were not heeded.  

4216 were identified and data were complete for 2571 OOA patients and 924 local patients. 350 (13.6%) of OOA patients and 227 (24.6%) had at least one pathway exclusion present. Of patients with exclusions, 140 (40%) OOA patients and 75 (33%) of local patients had a final diagnosis of stroke with a median onset-to-arrival time of 88 min (IQR: 55-179 min) and 93.5 min (IQR: 64-211 min), respectively. The most common exclusions were FAST negative (but stroke suspected), seizure activity and respiratory rate >30.

Nearly a quarter of suspected strokes meet pathway exclusions and 30-40% of these have a final diagnosis of stroke. Most present in time for hyperacute treatments thus a review of current pathway exclusions may be required.

THE USE OF PRE-HOSPITAL STROKE PATHWAY EXCLUSIONS IN A LARGE UK CENTRALISED ACUTE STROKE SYSTEM: ANALYSIS OF A LARGE LINKED PRE-HOSPITAL AND HOSPITAL DATASET