Characterisation of patients treated at the Red Cross field hospital in Kashmir during the first three weeks of operation

Objective

To evaluate the characteristics of patients treated at a field hospital in the first month after a major earthquake.

Methods

Age, sex, diagnosis, and operations performed on patients admitted to the field hospital of the International Committee of the Red Cross in Pakistani Kashmir between 21 October and 10 November 2005 were recorded and the data analysed.

Results

During the three week period of this study, 316 patients were treated at the hospital; 246 were women and children (77.9%). Two thirds were hospitalised, over 90% because of the need for surgery or surgical consultation. Altogether 345 operations were performed on 157 patients. The majority of patients had infected wounds with or without fractures.

Conclusions

Most patients need medical evaluation in consequence of earthquake‐related trauma even weeks after the catastrophe, especially in areas difficult of access.     

How do clinical features help identify paediatric patients with fractures following blunt wrist trauma?

Objective

Wrist injuries are a common presentation to the emergency department (ED). There are no validated decision rules to help clinicians evaluate paediatric wrist trauma. This study aimed to identify which clinical features are diagnostically useful in deciding the need for a wrist radiograph, and then to develop a clinical decision rule.

Methods

This prospective cohort study was carried out in the ED of Sheffield Children''s Hospital. Eligible patients were recruited if presenting within 72 hours following blunt wrist trauma. A standardised data collection form was completed for all patients. The outcome measure was the presence or absence of a fracture. Univariate analysis was performed with the χ² test. Associated variables (p<0.2) were entered into a multivariate model. Classification and regression tree (CART) analysis was used to derive the clinical decision rule.

Results

In total, 227 patients were recruited and 106 children were diagnosed with fractures (47%). Of 10 clinical features analysed, six were found by univariate analysis to be associated with a fracture. CART analysis identified the presence of radial tenderness, focal swelling, or an abnormal supination/pronation as the best discriminatory features. Cross fold validation of this decision rule had a sensitivity of 99.1% (95% confidence interval 94.8% to 100%) and a specificity of 24.0% (17.2% to 32.3%). The radiography rate would be 87%.

Conclusions

Radial tenderness, focal swelling, and abnormal supination/pronation are associated with wrist fractures in children. The clinical decision rule derived from these features had a high sensitivity, but low specificity, and would not substantially alter our current radiography rate. The potential for a clinical decision rule for paediatric wrist trauma appears limited.     

A study of police operated dispatch to acute coronary syndrome cases arising from 112 emergency calls in Aarhus county, Denmark

Background

The accuracy of the Danish police operated "112" emergency call system was studied. Dispatch of the anaesthesiologist staffed mobile emergency care unit (MECU) to acute coronary syndrome (ACS) cases was used as an indicator of accuracy of dispatch to life threatening emergencies.

Methods

This was an observational cohort study of patients given a 112 system report of heart attack and patients with a provisional diagnosis of ACS made on scene by the MECU. Sensitivity, specificity, and positive predictive value with 95% confidence intervals (CI) were calculated.

Results

There were 341 reports of “heart attack” and 205 patients with ACS. Sensitivity was 75% (95% CI 68% to 80%) specificity 90% (89% to 92%) and positive predictive value 45% (40% to 50%).

Conclusion

The accuracy of 112 dispatch of the MECU was found to be moderate. We suggest more training of dispatch staff and medical supervision.     

The effect of working hours on outcome from major trauma

Objective

To determine whether being admitted with major trauma to an emergency department outside rather than within working hours results in an adverse outcome.

Methods

The data were collected from hospitals in England and Wales participating in the Trauma Audit and Research Network (TARN). Data from the TARN database were used. Admission time and discharge status were cross matched, and this was repeated while controlling for Injury Severity Score (ISS) values. Logistic regression was carried out, calculating the effects of Revised Trauma Score (RTS), ISS, age, and time of admission on outcome from major trauma. This allowed observed versus expected mortality rates (Ws) scores to be compared within and outside working hours. As much of the RTS data were missing, this was repeated using the Glasgow Coma Score instead of RTS.

Results

In total, 5.2% of people admitted "out of hours" died, compared with 5.3% of people within working hours, and 12.2% of people admitted outside working hours had an ISS score greater than 15, compared with 10.1% admitted within working hours. Outcome in cases with comparable ISS values were very similar (31.1% of cases with ISS >15 died out of hours, compared with 33.5% inside working hours.) The subgroup of data with missing RTS values had a significantly increased risk of death. Therefore, GCS was used to calculate severity adjusted odds of death instead of RTS. However, with either model, Ws scores were identical (both 0%) within and outside working hours.

Conclusions

Out of hours admission does not in itself have an adverse effect on outcome from major trauma.     

Validation of a diagnostic reminder system in emergency medicine: a multi-centre study

Background

Diagnostic error is a significant problem in emergency medicine, where initial clinical assessment and decision making is often based on incomplete clinical information. Traditional computerised diagnostic systems have been of limited use in the acute setting, mainly due to the need for lengthy system consultation. We evaluated a novel web‐based reminder system, which provides rapid diagnostic advice to users based on free text search terms.

Methods

Clinical data collected from patients presenting to three emergency departments with acute medical problems were entered into the diagnostic system. The displayed results were assessed against the final discharge diagnoses for patients who were admitted to hospital (diagnostic accuracy) and against a set of “appropriate” diagnoses for each case provided by an expert panel (potential utility).

Results

Data were collected from 594 patients (53.4% of screened attendances). Mean age was 49.4 years (95% CI 47.7 to 51.1) and the majority had significant past illnesses. Most were assessed first by junior doctors (70%) and 266/594 (44.6%) were admitted to hospital. Overall, the diagnostic system displayed the final discharge diagnosis in 95% of inpatients and 90% of “must‐not‐miss” diagnoses suggested by the expert panel. The discharge diagnosis appeared within the first 10 suggestions in 78% of cases.

Conclusions

The Isabel diagnostic aid has been shown to be of potential use in reminding junior doctors of key diagnoses in the emergency department. The effects of its widespread use on decision making and diagnostic error can be clarified by evaluating its impact on routine clinical decision making.     

Patient self assessment of pregnancy status in the emergency department

Objectives

Pregnancy tests are often performed routinely for female emergency department (ED) patients of reproductive age. One major reason is a perception that patients are unreliable in predicting their own pregnancy status. We hypothesised that patients could reliably predict that they were not pregnant.

Methods

The study used a prospective cohort design, in an urban academic ED, from January 19 to May 19, 2004. All patients for whom a pregnancy test was ordered were asked about their sexual history as well as two additional questions: “Do you think you might be pregnant?” and “Is there any chance you could be pregnant?” Patients with already documented pregnancies were excluded.

Results

A total of 474 patients had pregnancy tests performed that met inclusion criteria. Eleven (2.3%) tests were positive. Among patients who answered no to both questions (337), one test (0.3%) was positive (negative predictive value (NPV) 99.7%, likelihood ratio (LR) 0.13 (95% CI, 0.02 to 0.82)). The other historical factor with a high NPV (100%) was not being sexually active (LR not calculable). All pregnancies occurred in patients with gastrointestinal or genitourinary as the chief complaint: this comprised only 56% of the presentations for which tests were ordered.

Conclusion

Sexual history and self assessment can be used as a highly effective predictor of a patient not being pregnant. Given the risks of missed pregnancy in the ED, and low monetary and time cost of pregnancy tests, frequent testing is still recommended in most instances.     

Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the ambulance service to a diabetes specialist nurse team

Objectives

To evaluate the effectiveness of ambulance crew referral of patients treated for acute hypoglycaemia, to a diabetes specialist nurse (DSN) team. Patients were assessed by the ambulance service and did not attend an emergency department.

Methods

For a 3 month period patients were referred from two areas of West Yorkshire by the ambulance service to specialist diabetes teams. The DSNs contacted the patients within 7 days by telephone and arranged further review if necessary. Satisfaction questionnaires were sent to patients.

Results

Thirty eight patients were referred and all were reviewed by telephone; 30 (79%) also required a clinic review appointment. Warning signs of hypoglycaemia were identified by 21 (55%) patients, but 14 (37%) had none (three had incomplete data). Twelve patients had had a self‐treated episode in the previous 6 months; nine patients had had three or more. Fifteen (39%) patients had called an emergency ambulance for similar reasons in the previous 6 months (27 “999” calls). Twenty patients (53%) had their drug treatment altered at a clinic appointment and 14 (37%) required ongoing review. Twenty six patients returned the satisfaction questionnaire; of these 88% agreed or strongly agreed that they had improved their understanding of hypoglycaemia and 73% felt more able to treat a hypoglycaemic episode in the future. Patient satisfaction with this care pathway was high.

Conclusions

The ambulance service can coordinate successful referral of patients with episodes of acute hypoglycaemia to a DSN‐led service. Patients often required treatment review. They valued this service and felt more confident managing their diabetes.     

Estimating the rate of re-expansion of spontaneous pneumothorax by a formula derived from computed tomography volumetry studies

Background

Available evidence suggesting that the rate of re‐expansion of spontaneous pneumothorax is 1.25%/day is based on a small sample and mathematical modelling‐based estimates.

Aim

To estimate the rate of re‐expansion of spontaneous pneumothoraces by a formula derived from computed tomography volumetry studies.

Methods

This retrospective study included adult patients with spontaneous pneumothorax, identified from patient management databases, who were treated conservatively. Medical records were reviewed to confirm that no intervention such as aspiration or catheter drainage had occurred. Radiographs were reviewed independently by two researchers and measured according to the method described by Collins et al. Their formula was used to estimate pneumothorax size on each date. The rate of re‐expansion was defined as the change in size (%)/number of days between radiographs. Patients were excluded if they did not have at least two radiographs taken, at least 1 day apart. Data were analysed using cluster analysis by patient to minimise the effect of repeated measures from an individual patient.

Results

88 episodes were identified in 57 patients. 82% were men and the patients had a median age of 22 years. The average rate of re‐expansion was 2.2%/day (95% confidence interval 1.4% to 3.0%), but varied between −7.5% and 13.4%/day.

Conclusion

Spontaneous pneumothoraces treated conservatively re‐expand at an average rate of 2.2%/day.A few studies have explored the rate of resolution of spontaneous pneumothoraces, and all have had small sample sizes. Current “best evidence” derives from the report of Kircher and Swartel,¹ who used a mathematical approach based on the area (not volume) of the collapsed lung on a radiograph compared with the area of the hemithorax and serial radiographs to estimate that pneumothoraces re‐expanded at a rate of 1.25%/day when treated with bed rest. Recently, more sophisticated methods for estimating the volume of a pneumothorax have been developed using radiographic thoracic gas volume measurement² and helical computed tomography,³ but no studies have investigated the rate of re‐expansion of pneumothoraces using these methods.We investigated the rate of re‐expansion of spontaneous pneumothoraces in patients treated conservatively.     

Oxygen alert cards and controlled oxygen: preventing emergency admissions at risk of hypercapnic acidosis receiving high inspired oxygen concentrations in ambulances and A&E departments

Background

Appropriate resuscitation of hypoxic patients is fundamental in emergency admissions. To achieve this, it is standard practice of ambulance staff to administer high concentrations of oxygen to patients who may be in respiratory distress. A proportion of patients with chronic respiratory disease will become hypercapnic on this.

Objectives and methods

A scheme was agreed between the authors'' hospital and the local ambulance service, whereby patients with a history of previous hypercapnic acidosis with a Pao₂ >10.0 kPa—indicating that oxygen may have worsened the hypercapnia—are issued with “O₂ Alert” cards and a 24% Venturi mask. The patients are instructed to show these to ambulance and A&E staff who will then use the mask to avoid excessive oxygenation. The scheme was launched in 2001 and this paper present the results of an audit of the scheme in 2004.

Results

A total of 18 patients were issued with cards, and 14 were readmitted on 69 occasions. Sufficient documentation for auditing purposes was available for 52 of the 69 episodes. Of these audited admissions, 63% were managed in the ambulance, in line with card‐holder protocol. This figure rose to 94% in the accident and emergency department.

Conclusion

These data support the usability of such a scheme to prevent iatrogenic hypercapnia in emergency admissions.     

Motor vehicle trauma: analysis of injury profiles by road-user category

Background

Vehicle accidents in Greece are among the leading causes of death and the primary one in young people. The mechanism of injury influences the patterns of injury in victims of vehicle accidents.

Objective

Identification and analysis of injury profiles of motor‐vehicle trauma patients in a Greek level I trauma centre, by road‐user category.

Patients and methods

The trauma registry data of Herakleion University Hospital of adult trauma patients admitted to the hospital after a vehicle accident between 1997 and 2000 were retrospectively examined. Patients were grouped based on the mechanism of injury into three road‐user categories: car occupants, motorcyclists, and pedestrians.

Results

Of 730 consecutive patients, 444 were motorcyclists (60.8%), 209 were car occupants (28.7%), and 77 were pedestrians (10.5%). Young men constituted the majority of injured motorcyclists whereas older patients (p = 0.0001) and women (p = 0.0001) represented a substantial proportion of the injured pedestrians. With regard to the spectrum of injuries in the groups, craniocerebral injuries were significantly more frequent in motorcyclists and pedestrians (p = 0.0001); abdominal (p = 0.009) and spinal cord trauma (p = 0.007) in car occupants; and pelvic injuries (p = 0.0001) in pedestrians. Although the car occupants had the highest Injury Severity Score (ISS) (p = 0.04), the pedestrians had the poorest outcome with substantially higher mortality (p = 0.007) than the other two groups.

Conclusions

The results reveal a clear association between different road‐user categories and age and sex incidence patterns, as well as outcomes and injury profiles. Recognition of these features would be useful in designing effective prevention strategies and in comprehensive prehospital and inhospital treatment of motor‐vehicle trauma patients.     

Anxiety disorder in patients with non-specific chest pain in the emergency setting

Objectives

Many patients who have been discharged from the emergency department (ED) with a diagnosis of “non‐specific chest pain” (NSCP) have anxiety disorder (AD), a commonly missed entity in acute care. The objective of this study was to delineate characteristic properties that could enhance recognition of AD in ED patients admitted with NSCP.

Methods

All patients between 18 and 65 years of age diagnosed with NSCP were enrolled. The Hospital Anxiety and Depression Scale (HADS) anxiety subscale was used as a screening test for AD. The patients with high HADS scores (⩾10) were evaluated by a psychiatrist for AD.

Results

In total, 157 patients were enrolled in the study. HADS scores were found to be "high" (⩾10) in 49 patients (31.2%). Patients with high HADS scores had a higher frequency of associated symptoms (p = 0.004). Dizziness or lightheadedness, chills or hot flushes, and fear of dying were found to have been reported more frequently by patients with high anxiety scores. Of the group with high score, 33 patients (67.3%) were interviewed by a psychiatrist, and 23 (69.7%) of these patients were diagnosed with AD. Associated symptoms were described by 21 patients with AD (91.3%). Of those with AD, 18 (78.3%) had been previously admitted to the ED with chest pain. Atypical chest pain was described by 21 patients (91.3%).

Conclusions

Physicians should always consider AD in patients presenting to the ED with chest pain after ruling out organic aetiology. Patients'' definition of atypical pain, recurrent admissions to ED, and presence of associated symptoms such as dizziness, chills or hot flushes, and fear of dying could aid in considering AD.     

Announcing the emergent patient in the emergency department: a randomised trial

Objective

To determine which of three commonly used methods for notifying medical staff of the arrival of an emergent case to the triage area of an emergency department (ED) is optimal.

Methods

Prospective, randomised trial. Patients arriving with conditions rated as emergencies (triage category 2) were randomised to one of three notification arms: by microphone, by telephone, or by computer. The proportion of patients seen by a doctor within 10 minutes of arrival to the ED in each arm was compared.

Results

A total of 1000 patients were enrolled. The proportion seen within 10 minutes for patients announced by microphone was significantly greater than those announced by telephone or computer (67.0% v 63.2% v 57.3%, respectively; χ² 6.30, p = 0.04). No method achieved the benchmark proportion of 80% of patients seen within 10 minutes of arrival.

Conclusions

A microphone announcement heard by overhead speakers should be incorporated with other strategies to improve the timeliness of medical assessment of emergent cases.     

Validation of the Paediatric Triage Tape

Introduction

The Paediatric Triage Tape (PTT) is an easy to use major incident primary triage tool, based upon a modification of the Triage Sieve. The purpose of this study was to prospectively validate the PTT for use in paediatric major incidents.

Methods

A database of children presenting the Trauma Unit of the Red Cross Children''s Hospital, Cape Town, was developed over a nine month period. Each child was triaged using the PTT, and had an Injury Severity Score (ISS) calculated. Additionally, the New Injury Severity Score (NISS) was calculated, and the presence of interventions that may occur to the children (“Garner criteria”) was documented. The sensitivity, specificity, overtriage, and undertriage rates were calculated.

Results

3461 children were entered into the database. For identifying children with an ISS of over 15, the PTT had a sensitivity of 37.8%, specificity of 98.6%, overtriage rate of 38.8%, and an undertriage rate of 3.5%. Against the NISS and Garner criteria, the results were comparable.

Conclusion

The PTT has poor sensitivity at identifying immediate priority children by these criteria. Specificity (the ability to identify non‐T1 patients) is excellent, and the overtriage and undertriage rates are within the range deemed unavoidable by the American College of Surgeons.     

Triage rapid initial assessment by doctor (TRIAD) improves waiting time and processing time of the emergency department

Aim

To evaluate the effect of triage rapid initial assessment by doctor (TRIAD) on waiting time and processing time of an emergency department (ED) without extra staff.

Method

A senior emergency doctor was put into triage instead of a consultation cubicle for seven shifts of 9 hours each. All the patients were assessed and necessary interventions started at the time of triage. Waiting time and processing time of various categories of patients were compared with a control group that was sampled during the week before the trial period.

Results

In total, there were 1310 cases in the trial period and 1355 controls. Over a quarter (27%) of the patients received triage doctor interventions. The average waiting time was reduced by 38% and the average processing time by 23%. Patients without triage intervention also had a 24% shorter waiting time because of overall improvement in efficiency. Trauma patients and patients needing radiography particularly benefited from the new system. The waiting time and processing time of category 4 and 5 patients improved significantly as a result of more efficient processing of more urgent cases.

Conclusion

The waiting time and processing time of the ED were greatly reduced by TRIAD without extra manpower.     

Ocular injuries in patients with major trauma

Aim

To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures.

Methods

A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39 073 patients with major trauma.

Results

Of the 39 073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs).

Conclusion

The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.Worldwide, an estimated 1.6 million people are blind as a result of eye injuries, and a further 19 million have monocular blindness or low vision due to eye trauma.¹ Eye injuries in association with major trauma are particularly important as these injuries have a high risk of threatening vision.² Even minor eye injuries can cause considerable morbidity³ and time lost from work.⁴Eye injuries in association with major trauma can pose diagnostic difficulties, as patients with a reduced conscious level may not report visual symptoms, and assessment of the eye can be awkward in a supine patient. Eye injuries may be associated with facial injuries: in patients with periorbital haematomas and swelling, it may not be possible to see the eye properly at the initial examination. Treating life‐threatening injuries will be the immediate priority in a patient with multiple injuries, but the potential for vision loss due to ocular trauma should not be forgotten.Although penetrating eye injuries from road traffic accidents (RTAs) have decreased considerably after seatbelt legislation in 1983 and the introduction of laminated windscreens,^5,6 little is known about the current epidemiology of ocular injuries in patients with major trauma in the UK. To investigate this group of patients, we performed a retrospective analysis of a UK trauma database, looking at the incidence of ocular injuries with major trauma, and their association with facial fractures.     

Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study

Background

The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs.

Objectives

To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost‐effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department.

Method

In this Belgian prospective, double‐blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result.

Results

The prevalence of protective anti‐tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost‐effective tool for patients presenting with a tetanus‐prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (€10.58/patient with the TQS versus €11.34/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to €8.31.

Conclusion

In selected patients, the TQS is a cost‐effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result.     

The anion gap does not accurately screen for lactic acidosis in emergency department patients

Introduction

Lactic acidosis portends a poor prognosis in trauma, sepsis, and other shock states and is useful for triaging and resuscitating emergency department (ED) patients. The authors sought to determine whether the AG is a reliable screen for lactic acidosis when applied specifically in the ED setting.

Methods

The authors performed a retrospective cohort study over a seven month period. Subjects were all ED patients that had a serum lactate obtained. Sensitivity analyses of the AG for detecting presence of lactic acidosis were calculated for the traditional AG normal value (AG <12) and for the lower AG normal value when using newer ion selective electrode assays (AG <6).

Results

Serum lactate levels were ordered in the ED on 440 occasions. 137 samples were excluded by protocol. Using an AG cutoff of 12, the sensitivity for detecting lactic acidosis was 58.2%, specificity was 81.0%, and the negative predictive value was 89.7%. Using the AG cutoff of 6, the sensitivity was 93.2%, the specificity was 17.3%, and the negative predictive value was 91.8%.

Conclusions

The traditional definition of AG >12 was insensitive for the presence of lactic acidosis. Using the revised AG of >6 is more sensitive but non‐specific for lactic acidosis. The authors conclude that employing the AG as a screen for LA may be inappropriate in ED patients. Instead, they recommend ordering a serum lactate immediately upon suspicion of a shock state. A prospective study to confirm these findings is needed.     

Early stroke care in Italy--a steep way ahead: an observational study

Objectives

To measure the performance of selected Italian emergency medical system (EMS) dispatch centres managing calls for patients suffering from stroke. Data on outcome and on early treatment in the ED were collected.

Methods

Prospective data collection for a trimester from interventions for a suspected stroke in 13 EMS dispatch centres over five Italian regions.

Results

Altogether, 1041 calls for a suspected stroke were analysed. Mean intervals of the sequential phases were 2.3±2 minutes between call and ambulance dispatch, 8.4±5.5 minutes to reach the patient, 14.5±8.5 minutes on the scene, and 40.2±16.2 minutes between call and arrival at the ED. Interventions were performed in 56% of cases by a basic life support (BLS) crew, advanced life support (ALS) crews intervened in 28% of cases, and a combination of ALS and BLS in the remaining 16%. Mean diagnostic interval was 99±85 minutes between emergency system call and the first CT scan. This was performed 71±27 minutes after ED admission. Only 1.6% were admitted to a stroke unit. One month outcome according to GCS was good recovery in 32%, moderate disability in 28%, severe disability in 14%, and death in 25% of the patients.

Conclusions

Mean times show a rapid response of the selected EMS dispatch centres to calls for a suspected stroke. Nevertheless, mean times of the ED phase are still unacceptable according to international guidelines such as Brain Attack Coalition and American Stroke Association guidelines. Efforts should be spent to reduce the time between the arrival and the CT scan and more patients should be admitted to a stroke unit.