Pre-hospital triage for potential stroke patients: a Q&A with Angus Ramsay

Dr Angus Ramsay is part of the Rapid Service Evaluation Team (RSET) – a collaboration between UCL and the Nuffield Trust. His latest RSET research looks at a new NHS service for triaging potential stroke patients before they reach hospital. We spoke to him about why this research is important.

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Published: 23/09/2022

Your research explores a new service for triaging potential stroke patients before they reach hospital. Could you explain how the service works?

It's all about enabling stroke specialist advice earlier on in the care pathway. When ambulance clinicians or paramedics pick up a patient who they think may be having a stroke, they can use their tablet or iPad to connect via video call with the local stroke unit. They speak with a stroke doctor who then assesses the patient and makes a recommendation on whether the patient is having a stroke or not. This determines whether they should be transferred to the local stroke unit. The main ambition is for more patients to be taken to the right place first time and reduce unnecessary pressure on stroke services. One of the big drivers of this service during the early stages of the pandemic was concern that patients were being taken to the wrong place and were thus at greater risk of either spreading or catching Covid-19.

How did you carry out the analysis?

This was a rapid service evaluation and we drew together a number of approaches (rapid literature reviews, qualitative analysis of interviews, observations and documents, and quantitative analysis of data on ambulance journeys and delivery of stroke clinical interventions). We also conducted a survey of paramedics. Our research looked at two places using pre-hospital triage – North Central London and East Kent, both early on in the pandemic.

We drew together researchers from University College London, clinicians from the stroke and ambulance services, and three patient representatives. All of these people were part of the team from the beginning of the project, right through to writing up the findings. I don’t think our work would have been as strong without that kind of collaboration. It ensures that our analysis is grounded in the reality of patient and staff experiences.

What were the key findings?

We found that the triage assessments had a significant impact on the workload of stroke physicians. There was no reduction in their standard workload, but they had to respond to these calls that kept coming up. It acted as a bit of a disrupter to their ongoing processes. A question for sustainability is whether creating a rota to enable a separation of these duties is worth considering. However, staff thought the service worked well for them and they perceived it as safe. Network stability and audio-visual signal was especially important, so that paramedics could connect with stroke doctors appropriately. 

Collaboration between the ambulance and stroke clinical leads was incredibly important, as was training. Paramedics had a very strong preference for active training approaches – having someone physically show them how the triaging service works.

We observed that there was quite a reduction in the governance hurdles that usually exist when implementing change quickly. There was still a lot of work by the local teams to ensure that appropriate processes were gone through, but a lot of that red tape was removed.

What surprised you most in your findings?

It was the speed with which change can be implemented. We have been doing work similar to this for 15 years and sharing lessons from major health system changes and restructures. Almost every time, the final slide with the lessons would say “changes like this take a really long time”. For this service, during the early stages of the pandemic, that just wasn't the case. Services were being transformed in a matter of weeks. Hard decisions were being made and implemented because the NHS was in a state of crisis. It was enabled by strong clinical leadership and a constant focus on safety and quality of patient care.

I'm doubtful that this work would have happened without the pandemic. One of our partners got funding to do a small pilot with a small number of patients back in 2018, but it didn't actually turn into a regular service.

Why is this research important?

We found quite big gaps in the evidence related to this kind of triaging service. You'd often have a description of a single pilot, whereas we were able to look at two pilots that were operating differently.

Like lots of research that will have been going on over the two last years, we are capturing the wider impact of the pandemic – that is, how health services behave in a time of crisis. We could provide assurance to local services that what they were doing was going in the right direction and that there weren’t any glaring issues emerging from our work. It helped inform how they were developing their services. We couldn't take the normal approach of doing some research and gradually coming to a finding two years down the road.

Are there any safety concerns in delivering this triaging service?

Local clinical teams were extremely conscious of risk when introducing a new service so quickly. They were terrified of the idea that they could institute something that resulted in people missing out on life-saving stroke care. So, they were very careful to monitor what was going on if someone was transferred out of the stroke pathway. In hundreds and hundreds of cases now – well over 1,000 in London – there have only been a handful of cases where things could have been done differently, suggesting that it's a pretty safe process.

How could this research impact patients and NHS staff in future?

Stroke patients could get treated in services that are under a lot less strain. A very common impact of the more traditional pathway is that 30% of patients dealt with in stroke units are not actually having a stroke. You end up with what are called outliers – stroke patients who can't actually have a bed in the main ward. They are in a bed elsewhere in the hospital and have to be visited by the stroke team.

Non-stroke patients would also be getting to the right place sooner. Many things like seizures and migraines may present as a potential stroke. It’s the difference between being told by stroke specialists immediately “you're not having a stroke” or alternatively, being rushed to hospital in an ambulance by a paramedic saying “you might be having a stroke”, then having to wait an hour to be told by a stroke specialist that you're not having one. I think the impact on the emotional experience of this is potentially huge.

Is there anything you would change if you were doing the project again?

A major limitation in our project is that we didn't get to interview patients. That's very much the next step in our work. This project was classified as a service evaluation, which meant that we didn't have to go through certain ethics approvals. But to interview patients we would need that approval. I often think audiences feel a bit shortchanged if you haven't been able to look at the patient perspective. It's one of the best ways of understanding how our services are working. But given that we were able to provide lessons from our research quite quickly, I think it's never going to be a satisfactory balance.

What needs to happen next, for both the triaging service and your research?

Lots of places across England are now exploring this kind of triaging intervention, not just for stroke but in areas like cardiac care and paediatrics too. I think it's really important that they take on board the lessons we've identified.

In terms of our research, based on this evaluation, we managed to obtain funds for a two-year project called PHOTONIC, funded by the NIHR health and social care delivery research programme. It addresses many of the limitations that I've talked about. We're going to be looking at pre-hospital triage in four areas: North Central London and East Kent again, as well as two other parts of Kent (Maidstone and Darent Valley). We're interested in how the services are implemented and their impact on patient journeys, care delivery, patient outcomes and value for money. We're going to be able to speak with a much wider range of stakeholders, including stroke and non-stroke patients, but also representatives of the wider system. We'll be using patient level data to really dig into the impact of these services on delivery outcomes and value for money. We'll hopefully be able to deliver even more compelling lessons for interventions like this both in stroke and other care settings.

*To read the full report, Prehospital video triage of potential stroke patients in North Central London and East Kent: rapid mixed-methods service evaluation, please click here.

The Rapid Service Evaluation Team (‘RSET’) comprises health service researchers, health economists and other colleagues from University College London and the Nuffield Trust who have come together to rapidly evaluate new ways of providing and organising care. For more information about the team’s work and projects, please visit the main RSET page.


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