Improved Prehospital Triage of Patients With

Stroke in a Specialized Stroke Ambulance

Results of the Pre-Hospital Acute Neurological Therapy and
Optimization of Medical Care in Stroke Study
Matthias Wendt, MD; Martin Ebinger, MD; Alexander Kunz, MD; Michal Rozanski, MD;
Carolin Waldschmidt, MD; Joachim E. Weber, MD; Benjamin Winter, MD; Peter M. Koch, MD;
Erik Freitag; Jenrik Reich; Daniel Schremmer; Heinrich J. Audebert, MD; for the STEMO Consortium*

Background and Purpose—Specialized management of patients with stroke is not available in all hospitals. We evaluated
whether prehospital management in the Stroke Emergency Mobile (STEMO) improves the triage of patients with stroke.
Methods—STEMO is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic
scanner and point-of-care laboratory. We compared the prehospital triage of patients with suspected stroke at dispatcher
level who either received STEMO care or conventional care. We assessed transport destination in patients with different
diagnoses. Status at hospital discharge was used as short-term outcome.
Results—From May 2011 to January 2013, 1804 of 6182 (29%) patients received STEMO care and 4378 of 6182 (71%)
patients conventional care. Two hundred forty-five of 2110 (11.6%) patients with cerebrovascular events were sent to
hospitals without Stroke Unit in conventional care when compared with 48 of 866 (5.5%; P<0.01%) patients in STEMO
care. In patients with ischemic stroke, STEMO care reduced transport to hospitals without Stroke Unit from 10.1% (151
of 1497) to 3.9% (24 of 610; P<0.01). The delivery rate of patients with intracranial hemorrhage to hospitals without
neurosurgery department was 43.0% (65 of 151) in conventional care and 11.3% (7 of 62) in STEMO care (P<0.01).
There was a slight trend toward higher rates of patients discharged home in neurological patients when cared by STEMO
(63.5% versus 60.8%; P=0.096).
Conclusions—The triage of patients with cerebrovascular events to specialized hospitals can be improved by STEMO
ambulances.
Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01382862.   
(Stroke. 2015;46:740-745. DOI: 10.1161/STROKEAHA.114.008159.)
Key Words: ambulances ◼ prehospital emergency care ◼ stroke ◼ triage

See related article, p 610. and causes. For example, initial diagnosis of stroke in an emer-

S pecific management in specialized hospital facilities has

been shown to improve process quality and outcomes in a
variety of diseases.1–3 In the context of neurological disorders,
this applies to the treatment of acute stroke in Stroke Units4 or
of intracranial hemorrhages in hospitals with organized stroke
care or neurosurgery facilities.4,5 Correct prehospital diagnosis is
important because it avoids admissions to nonappropriate hospi-
tals with suboptimal care or leading to time-consuming second-
ary patient transfers. In addition, prehospital diagnostic work-up
can accelerate emergency management by in-advance notifica-
tion of hospital teams.6,7 However, diagnosis of neurological dis-
orders is often difficult for the variety of symptom presentations
gency department yielded a stroke mimic rate of 19%, based on
history and clinical examination only.8 If additional laboratory
findings and a computed tomographic (CT) scan were available,
the stroke mimic rate was only 4%.9 In the prehospital setting
with usually limited diagnostic equipment and neurological
expertise, correct diagnosis is even more difficult. Sensitivity
of stroke diagnosis on the basis of validated prehospital stroke
scores was reported between 74% and 95% with positive pre-
dictive values (PPVs) between 13% and 99%.10 The feasibility
of advanced prehospital neurological work-up, including CT
imaging of the brain and point-of-care laboratory, has recently
been shown in 2 projects using specialized ambulances.11,12 In

Received November 16, 2014; final revision received November 16, 2014; accepted December 10, 2014.
From the Department of Neurology (M.W., M.E., A.K., M.R., C.W., J.E.W., B.W., P.M.K., E.F., J.R., H.J.A.), Center for Stroke Research Berlin (M.E.,
M.R., B.W., H.J.A.), Charité-Universitätsmedizin, Berlin, Germany; and Berliner Feuerwehr, Berlin, Germany (D.S.).
*A list of all STEMO Consortium participants is given in the Appendix.
Correspondence to Matthias Wendt, MD, Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany. E-mail
matthias.wendt@charite.de
© 2015 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.114.008159

740
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 Wendt et al   Prehospital Triage With a Stroke Ambulance    741
the Pre-Hospital Acute Neurological Therapy and Optimization
of Medical Care in Stroke (PHANTOM-S) study, patient care in
the Stroke Emergency Mobile (STEMO) was safe, increased the
rate of intravenous thrombolysis in patients with ischemic stroke
and reduced time to treatment.12,13 In the present evaluation, we
investigated whether prehospital care in the STEMO concept
leads to improved delivery of patients with cerebrovascular dis-
eases (CVDs) to appropriate hospitals.
Materials and Methods
Details of PHANTOM-S and the pilot study were previously de-
scribed.12–14 The proportion of patients referred to specialized cen-
ters was a prespecified secondary outcome for several diagnostic
categories.
Stroke Emergency Mobile
STEMO is a specialized ambulance equipped with a CT scanner
(CereTom; NeuroLogica, Danvers, MA), point-of-care laboratory
devices (ABX Micros 60; Horiba Medical, Irvine, CA; CoaguChek
XS Plus, Roche Diagnostics, Mannheim, Germany; i-STAT Portable
Clinical Analyzer; American Screening Corporation, Shreveport, LA)
and teleradiology technology (VIMED-STEMO; MEYTEC GmbH,
Werneuchen, Germany). Teleradiology technology was used for
transmission of CT imaging to a hospital-based neuroradiologist on
call and documentation of readings in the medical report on board.
STEMO is staffed with a neurologist, a paramedic, and a radiology
technician. All participating neurologists have experience of ≥4-year
clinical neurology and a special education in emergency medicine.
In addition to the clinical practice as a physician, this education in-
cludes ≥6-month practice on an intensive care unit, 6-month experi-
ence in anesthesiology or in an emergency department. The radiology
technician is also trained as a paramedic assistant (Rettungssanitäter).
STEMO and the team were based at a fire station close to the city
center of Berlin. The dispatch center communicated with STEMO
via radio connection. The catchment area was defined by a calculated
75% probability of arriving at scene within 16 minutes. This area in-
cluded ≈1 300 000 inhabitants.
Conventional Emergency Medical Services
In Germany, normal ambulances are staffed with ≥1 paramedic
(Rettungsassistent) with a professional training of 2 years. The sec-
ond patient on ambulances is either another paramedic or a paramedic
assistant with an education of ≈3 months (520 hours). Emergency
physicians (Notärzte) are simultaneously deployed in case of criti-
cally ill patients. In Berlin, this applies to patients with stroke only in
the case of decreased level of consciousness or unstable vital param-
eters. The Emergency Medical Services (EMS) in Berlin is organized
and operated by the Berlin Fire Brigade with STEMO as an integrated
specialized ambulance. EMS personnel in Berlin are trained in acute
stroke assessment during professional education and as part of non-
systematic EMS stroke training conducted by various Stroke Units.
A directive of the Chief EMS officer to deliver all suspected patients
with stroke to hospitals with Stroke Units is in place since 2011. The
city of Berlin has a well-established stroke care infrastructure with 14
Stroke Units serving as acute and monitoring stroke units.4
Study Design
From May 2011 to January 2013 (21 months), we compared weeks
with STEMO care (STEMO weeks) and weeks without STEMO care
(control weeks). The acute stroke dispatch was activated in the dis-
patch center in case of a suspected acute stroke with symptom onset
either within 4 hours or unknown. For this purpose, the dispatch cen-
ter used a previously validated algorithm to identify patients with a
high probability for stroke.15 STEMO operated in randomized weeks
from 7:00 am to 11:00 pm all days of the week. For randomization of
study periods, we used 4-week blocks as described in detail before.14
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During STEMO weeks, STEMO (if available) and an additional
regular ambulance were simultaneously deployed. The paramedics
on the regular ambulance were able to cancel STEMO before its
arrival based on their first assessment. During non-STEMO weeks
and during STEMO weeks in case of STEMO unavailability, regular
ambulances were deployed. Within this conventional care system, an
emergency physician was coalarmed simultaneously only in case of
reported unstable vital parameters or reduced consciousness.
Patients
All patients with acute stroke dispatch were included, except for pa-
tients aged <18 years. Patients who received regular care were trans-
ported after prehospital assessment to the nearest hospital that seemed
to be appropriate to the EMS staff—except of patients who refused
hospital admission or requested admission to a specific hospital.
Patients who received STEMO care were physically examined by the
STEMO neurologist after arrival. If necessary, point-of-care laborato-
ry including blood count, glucose, electrolytes, international normal-
ized ratio, and creatinine was performed. A CT scan was performed if
indicated for immediate therapeutic decisions or for patient’s triage.
An additional CT angiography was performed whenever additional
information about specific arterial occlusion was requested. Imaging
data were sent via teleradiology to the neuroradiologist on call, who
interpreted these immediately and gave feedback to the STEMO phy-
sician. In difficult cases including decisions about thrombolysis, a
senior neurologist was involved via telephone or videoconferencing.
Thereafter, patients were transported to the nearest appropriate hos-
pital according to the judgment of the emergency physician (again
respecting the patient’s preferences). If STEMO was not available
(in case of a simultaneous alarm or maintenance), patients received
regular care as described for control weeks. In the present analysis,
we compared patients with STEMO deployment (STEMO deployed
regardless of actual STEMO care) and without STEMO deployment
(all patients during control weeks and patients during STEMO weeks
without STEMO deployment). In addition, we determined short-term
outcome as provided by the acute hospital discharge status.
Diagnostic Accuracy of Prehospital Diagnosis
Hospital discharge diagnoses were categorized according to the docu-
mented International Classification of Diseases-Tenth Revision dis-
charge codes into CVDs (G45.x [except G45.4], I60.x, I61.x, I63.x,
and I64.x), other neurological diagnoses (A8.x, A35.x, C70.x, C71.x,
C72.x, F0.x, F1.x, G0.x–G99.x, H46.x–H48.x, H51.x, H53.1–H53.4,
H54.x, H81.x, R25.x–R29.x, R55.x, S00.x–S09.x, and T39.x–T65.x)
and non-neurological diagnoses (all others). Intracranial hemor-
rhage comprises spontaneous intracerebral hemorrhages, traumatic
intracerebral hemorrhages, subdural hematoma, epidural hematoma,
and subarachnoid hemorrhages. Prehospital diagnoses established in
STEMO were compared with final discharge diagnoses. Diagnostic
accuracy was calculated with sensitivity, specificity, PPV, and nega-
tive predictive value.
Data Collection
All patients with stroke dispatch received a deidentified alphanumeric
code by the Dispatch Center. Clinical data were documented by par-
ticipating hospitals in case report forms. The case report forms were
sent to the Center for Stroke Research Berlin. Data were merged us-
ing the alphanumeric code with deidentified databanks provided by
the fire brigade and the Berlin Stroke Registry.16 Information about
demographics, comorbidities (atrial fibrillation and diabetes melli-
tus), discharge diagnosis, and discharge status (in-hospital death, re-
ferral to another hospital and discharge home) were taken from case
report forms. Secondary emergency referral was defined as referral to
another hospital within 2 days from admission. Additional informa-
tion about prehospital diagnosis was retrieved for patients cared on
STEMO from the STEMO documentation system. An independent
Center for Stroke Research Berlin team conducted audits and data
monitoring.
742  Stroke  March 2015

Ethics without a Stroke Unit, there were no significant differences in

The study was approved by the Charité Ethics Committee, the Data
Protection Commissioner of the state of Berlin, and data protection
representatives of participating hospitals. Three-month functional
follow-up is not reported in this study because it could only be col-
lected in patients who had given signed informed consent. This was
eventually restricted to patients cared in STEMO making a compari-
son with conventional care impossible.13
Statistical Analysis
Pearson χ2 test or Fisher exact test were used to compare categori-
cal variables. The Mann–Whitney U test was used for comparisons
of continuous variables. A 2-sided significance level of α=0.05 was
used. Standardized plausibility checks were performed under statisti-
cal supervision. All analyses were conducted with IBM-SPSS version
19 statistics software.
Results
A total of 7098 stroke dispatches were activated by the
Dispatch Center of the Berlin Fire Brigade.13 Patient inclusion
is summarized as a flow chart in the Figure. Hospital docu-
mentation was available for 6182 (94%) of 6573 patients with
hospital admission. During STEMO weeks, STEMO could
not be deployed in a high proportion of patients (n=1409;
44%) either because STEMO was already in operation
(n=1288; 91%) or because of maintenance (n=121; 9%). Of
1804 STEMO deployments, 349 (19%) were cancelled before
STEMO arrival. In-hospital data were collected from 28 hos-
pitals. Patient characteristics were well balanced between the 2
groups except for slightly higher rates of atrial fibrillation and
diabetes mellitus in the STEMO group (Table 1). We found an
almost equal proportion of patients with CVD, neurological
but non-CVD patients, and non-neurological patients in both
groups. Table 2 shows transport destinations and short-term
outcomes. With regard to admissions of patients to hospitals
hospital deliveries for patients with non-neurological or neu-
rological but non-CVD diagnoses. For the group of patients
with CVD and the subgroup of patients with ischemic stroke,
we found a significantly lower proportion of patients deliv-
ered to hospitals without Stroke Unit in the STEMO group
(patients with CVD, 5.5% versus 11.6%; P<0.01 and patients
with ischemic stroke, 3.9% versus 10.1%; P<0.01). In the
STEMO group, patients with intracranial hemorrhages were
significantly less frequently delivered to hospitals without
neurosurgery (11.3% versus 43.0%; P<0.01). Secondary
emergency referrals to another hospital were more frequent
in patients with cerebrovascular events and in particular in
patients with intracranial hemorrhages when cared in conven-
tional care. However, these differences did not reach statisti-
cal significance. No differences in outcomes were found in
the group of non-neurological patients. In the groups of all
neurological patients (and those without CVD), there was a
trend toward higher rates of patients discharged home (all neu-
rological patients, 63.5% versus 60.8%; P=0.096 and neuro-
logical patients without CVD, 83.5% versus 79.5%; P=0.08)
in patients with STEMO deployment. Except for patients
with non-CVD neurological diseases, in-hospital mortality
was consistently lower for patients in the STEMO group (not
reaching statistical significance). Prehospital diagnostic accu-
racy on cerebrovascular events revealed a sensitivity of 89%,
specificity 77%, PPV 79%, and negative predictive value 87%
(Tables 3 and 4).
Discussion
Patient care within the STEMO-concept was associated
with more frequent delivery of patients with cerebrovascu-
lar events to appropriate hospitals in particular for patients

Total
deployments
n=7098

STEMO weeks Control weeks

n=3668 n=3430
324 days 455 patients excluded 461 patients excluded 322 days

240 No transport to hospital 273 No transport to hospital

166 No match with hospital 154 No match with hospital
database database
37 Delivery to a hospital with 27 Delivery to a hospital with
< 10 admissions < 10 admissions
9 Prehospital death 3 Prehospital death
3 No information on 4 No information on
Available hospital hospital destination hospital destination Available hospital
documentation documentation
n=3213 n=2969
Conventional care
during STEMO
weeks n=1409
STEMO
Conventional care
deployments
n=4378
n=1804

STEMO
STEMO care
cancellation
n=1455
n=349

Figure. Study flow chart. STEMO indicates Stroke Emergency Mobile.

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 Wendt et al   Prehospital Triage With a Stroke Ambulance    743

Table 1.  Patient Characteristics Table 2.  Transport Destinations and Short-Term Outcome
Conventional STEMO Conventional Care
Care Group Group Group STEMO Group P Value
n=4378 n=1804 P Value
All patients n=4378 n=1804
Demographics  Delivered to hospitals 416 (9.5) 158 (8.8) 0.36
 Age, years, mean (SD) 74.2 (14.9) 73.9 (15.0) 0.51 without neurological
 Sex, men, n (%) 1970 (45.0) 646 (44.1) 0.50 department, n (%)

Risk factors, n (%)  Secondary emergency 185 (4.2) 72 (4.0) 0.64

referral
 Atrial fibrillation 962 (22.0) 440 (24.4) 0.04
 In-hospital mortality, n (%) 173 (4.0) 62 (3.4) 0.34
 Diabetes mellitus 983 (22.5) 451 (25.0) 0.03
 Discharged home, n (%) 2839 (64.8) 1196 (66.3) 0.28
Discharge diagnoses, n (%)
Non-neurological patients n=1210 n=520
 Cerebrovascular 2110 (48.2) 866 (48.0) 0.89
 Delivered to hospitals 226 (18.7) 99 (19.0) 0.86
  
TIA 461 (10.5) 185 (10.3) without neurological
  
Ischemic stroke 1497 (34.2) 610 (33.8) department, n (%)
  
Intracerebral hemorrhage 100 (2.3) 45 (2.5)  Secondary emergency 72 (6.0) 38 (7.3) 0.29
  
Subarachnoid hemorrhage 8 (0.2) 3 (0.2) referrals
  Other cerebrovascular events 44 (1.0) 23 (1.3)  In-hospital mortality, n (%) 63 (5.2) 23 (4.4) 0.49
 Neurological noncerebrovascular 1058 (24.2) 418 (23.2) 0.40  Discharged home, n (%) 913 (75.5) 381 (73.3) 0.34
  
Subdural hematoma 16 (0.4) 5 (0.3) All neurological patients n=3168 n=1284
  Traumatic brain injury 27 (0.6) 9 (0.5)  Delivered to hospitals 190 (6.0) 59 (4.6) 0.07
without neurological
  
Epilepsy 331 (7.6) 129 (7.2)
department, n (%)
  
Syncope 85 (1.9) 37 (2.1)
 Secondary emergency 113 (3.6) 34 (2.6) 0.12
  
Headache 81 (1.9) 45 (2.5) referrals
  
Vertigo 52 (1.2) 17 (0.9)  In-hospital mortality, n (%) 110 (3.5) 39 (3.0) 0.47
  Decreased awareness and 93 (2.1) 41 (2.3)  Discharged home, n (%) 1926 (60.8) 815 (63.5) 0.10
neuropsychological disorders
Noncerebrovascular but n=1058 n=418
  
Movement disorder 24 (0.5) 14 (0.8) neurological patients
  Transient global amnesia 33 (0.8) 8 (0.4)  Delivered to hospitals 63 (6.0) 30 (7.2) 0.38
  Delirium/intoxication (acute 128 (2.9) 46 (2.5) without neurological
confusional state) department, n (%)
  
Mononeuropathy 55 (1.3) 9 (0.5)  Secondary emergency 54 (5.1) 178 (4.3) 0.52
  
Others 133 (3.0) 58 (3.2) referrals

 Non-neurological 1210 (27.6) 520 (28.8) 0.55  In-hospital mortality, n (%) 10 (0.9) 6 (1.4) 0.41

  Ischemic heart disease 34 (0.8) 17 (0.9)  Discharged home, n (%) 841 (79.5) 349 (83.5) 0.08

  Nonischemic heart disease 50 (1.1) 33 (1.8) All cerebrovascular patients n=2110 n=866

  
Dehydration 88 (2.0) 41 (2.3)  Delivered to hospitals 245 (11.6) 48 (5.5) <0.01
without Stroke Unit, n (%)
  
Infection 225 (5.1) 104 (5.8)
 Secondary emergency 59 (2.8) 16 (1.8) 0.13
  
Metabolic disorders 155 (3.5) 56 (3.1) referrals
  
Hypertension/hypotension 81 (1.9) 37 (2.1)  In-hospital mortality, n (%) 100 (4.7) 33 (3.8) 0.27
  
Dyspnoea/COPD 16 (0.4) 3 (0.2)  Discharged home, n (%) 1085 (51.4) 466 (53.8) 0.24
  
Frailty 23 (0.5) 8 (0.4) Patients with ischemic n=1497 n=610
  Noncentral nervous malignoma 33 (0.8) 17 (0.9) stroke
  Nonorganic psychiatric disorders 64 (1.5) 26 (1.4)  Delivered to hospitals 151 (10.1) 24 (3.9) <0.01
  
Others 441 (10.1) 178 (9.9) without Stroke Unit, n (%)

COPD indicates chronic obstructive pulmonary disease; STEMO, Stroke  Secondary emergency 33 (2.2) 11 (1.8) 0.56
Emergency Mobile; and TIA, transient ischemic attack. referrals
 In-hospital mortality, n (%) 81 (5.4) 28 (4.6) 0.44
 Discharged home, n (%) 642 (42.9) 279 (45,7) 0.23
with ischemic strokes or intracranial hemorrhages. There Patients with intracranial n=151 n=62
was no statistically significant difference in short-term out- hemorrhages*
comes, but the observed trends toward better outcome in  Delivered to hospitals 65 (43.0) 7 (11.3) <0.01
the STEMO group are in line with previously established without neurosurgery
evidence.4 STEMO care reduced the inadequate delivery of department, n (%)
patients with ischemic stroke to a hospital without Stroke (Continued)

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744  Stroke  March 2015
Table 2.  Continued
Conventional Care
Group STEMO Group
 Secondary emergency 19 (12.6) 3 (4.8)
referrals
 In-hospital mortality, n (%) 20 (13.2) 6 (9.7)
 Discharged home, n (%) 50 (33.1) 18 (29.0)
STEMO indicates Stroke Emergency Mobile.
*Consisting of spontaneous intracerebral hemorrhages, traumatic
intracerebral hemorrhages, subdural and epidural hematoma, and subarachnoid
hemorrhages.
Unit by >50% and of patients with intracranial hemorrhage to
a hospital without neurosurgery by >60% (relative risk reduc-
tion). This may be the consequence of improved prehospital
diagnosis or of better persuasion of patients by emergency
physicians. Secondary referrals of patients with cerebrovas-
cular events were higher in conventional care. However, the
majority of patients with cerebrovascular events delivered to
a hospital without Stroke Unit remained in the hospital of
primary delivery, despite recommendations that all patients
with acute stroke should be treated on a Stroke Unit.17 This
indicates that primary delivery is crucial for the place of
acute care. The results of the STEMO prehospital diagnostic
accuracy on cerebrovascular events (sensitivity, 89%; speci-
ficity, 77%; PPV, 79%; and negative predictive value, 87%)
compare well with the validation results of the Recognition
of Stroke in the Emergency Room (ROSIER) scale (sensitiv-
ity, 93%; specificity, 83%; PPV, 90%; and negative predic-
tive value, 88%).18 With shorter observation time, affirmation
of a stroke diagnosis is often more difficult, particularly in
most frequent stroke mimics of Todd paresis or migrainous
aura. Rather than a single factor, the combination of prese-
lection via the dispatch center, specialist neurological assess-
ment, diagnostic support with CT, as well as point-of-care
laboratory, and telemedicine all add to diagnostic accuracy.
Of note, the specialization of the emergency team on board
the STEMO did not result in poorer outcomes in patients
with non-neurological diseases. Admission rates of patients
with ischemic stroke to a primary stroke center vary between
regions. Data from the United States show that only 55% of
patients have access to a primary stroke center within 60 min-
utes, and only 28% of patients with stroke in New Zealand
were managed on a Stroke Unit.19,20 These low rates may be
a consequence of the shortage of hospitals with specialized
departments. However, even after implementation of a pre-
hospital stroke triage policy in the Chicago metropolitan area
Table 3.  Test Parameters for Prehospital Stroke
Diagnosis Validated Against Final Discharge Diagnosis of
Cerebrovascular Events*
True-positives
False-positives
True-negatives
False-negatives
*Cerebrovascular events include ischemic or hemorrhagic stroke and
transient ischemic attacks.
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Table 4.  95% CI for Prehospital Stroke Diagnosis Validated
Against Final Discharge Diagnosis of Cerebrovascular Events*
P Value 95% CI
0.09 Estimated Value Lower Limit Upper Limit
Sensitivity 0.89 0.86 0.91
0.47 Specificity 0.77 0.73 0.80
0.56 Positive predictive value 0.79 0.76 0.82
Negative predictive value 0.87 0.85 0.90
CI indicates confidence interval.
*Cerebrovascular events include ischemic or hemorrhagic stroke and
transient ischemic attacks.
with 17 primary stroke centers, the admission rate of patients
with ischemic stroke to these stroke centers was only 81.1%.21
Although it is difficult to compare these data with ours, the
96% correct admission rate for this group of patients reflects
a clear improvement when compared with conventional care.
Hence, the STEMO concept offers additional potentials on
top of increased thrombolysis rate and reduction of onset-to-
treatment time.11–13,22 Although improved outcomes could not
be proved on the basis of hospital discharge data alone, there
is established evidence that patients with stroke benefit from
treatment in organized stroke care.23 The advantages of this
specialized ambulance have to be weighed against the costs
of the project, including expenses for investments, staff, and
consumables. This is currently under investigation in another
analysis of the PHANTOM-S trial. Strengths of the study are
the high number of patients with participation of 28 hospitals.
A limitation of the study is that we could only compare the
concept of specialized prehospital care in 1 ambulance with
conventional care in multiple regular ambulances. To avoid
a selection bias, we did include all patients with STEMO
deployment in the STEMO group although the STEMO oper-
ation was cancelled in a substantial number of patients in this
group (19%). Misallocation rates were even lower in patients
who were eventually cared by STEMO (3.2% in patients with
ischemic stroke and 8.9% in patients with intracranial hemor-
rhage). Another limitation of the study is the unavailability of
diagnostic accuracy in conventional care because prehospital
paramedic assessment is not regularly documented as diagno-
sis in the Berlin EMS system. In addition, generalizability of
the STEMO system to other healthcare systems has not been
shown yet. For example, it may be difficult to train vascu-
lar neurologists in emergency medicine in countries without
emergency physicians working in EMS. Finally, we are not
able to provide functional outcome results as the study meth-
odology did not allow the collection of long-term outcome.
Conclusions
The STEMO concept improves the triage of patients with
cerebrovascular events in the prehospital setting. Additional
611 studies are needed to show that this observation holds true in
162 other areas and translates into improved patients outcomes.
529
76 Appendix
STEMO Consortium: Berliner Feuerwehr, Berlin,
Germany; BRAHMS GmbH, Hennigsdorf, Germany;
 Wendt et al   Prehospital Triage With a Stroke Ambulance    745
Charité-Universitätsmedizin Berlin, Berlin, Germany;
MEYTEC GmbH, Werneuchen, Germany.
Acknowledgments
We thank all participating paramedics and radiographers for out-
standing team work. We are grateful to Kerstin Bollweg for data col-
lection and management in cooperating hospitals.
Sources of Funding
The research leading to these results has received funding from the
Zukunftsfonds Berlin with cofunding by the European Union (within
the European regional development funds), the Federal Ministry of
Education and Research via the grant Center for Stroke Research
Berlin (01 EO 0801).
Disclosures
Dr Audebert reports receiving speaker honoraria from BMS,
Lundbeck Pharma, Pfizer, Sanofi, EVER Neuropharma, and
Boehringer Ingelheim. He has a consultant or advisory relationship
to Roche Diagnostics, Lundbeck Pharma, and Bayer Vital. The other
authors report no conflicts.
References
1. Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy
TD, et al. A clinical trial of a chest-pain observation unit for patients
with unstable angina. Chest Pain Evaluation in the Emergency Room
(CHEER) Investigators. N Engl J Med. 1998;339:1882–1888. doi:
10.1056/NEJM199812243392603.
2. Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, et al.
Randomised controlled trial and economic evaluation of a chest pain
observation unit compared with routine care. BMJ. 2004;328:254. doi:
10.1136/bmj.37956.664236.EE.
3. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston
BL, et al. A national evaluation of the effect of trauma-center care on mor-
tality. N Engl J Med. 2006;354:366–378. doi: 10.1056/NEJMsa052049.
4. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit)
care for stroke. Cochrane Database Syst Rev. 2013;9:CD000197.
5. Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A,
Mitchell PM; STICH II Investigators. Early surgery versus initial con-
servative treatment in patients with spontaneous supratentorial lobar
intracerebral haematomas (STICH II): a randomised trial. Lancet.
2013;382:397–408. doi: 10.1016/S0140-6736(13)60986-1.
6. Meretoja A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste
M. Reducing in-hospital delay to 20 minutes in stroke thrombolysis.
Neurology. 2012;79:306–313. doi: 10.1212/WNL.0b013e31825d6011.
7. Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Prehospital
stroke care: new prospects for treatment and clinical research. Neurology.
2013;81:501–508. doi: 10.1212/WNL.0b013e31829e0fdd.
8. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke
in the emergency department. Implications for acute stroke trials. Arch
Neurol. 1995;52:1119–1122.
9. Kothari RU, Brott T, Broderick JP, Hamilton CA. Emergency physicians.
Accuracy in the diagnosis of stroke. Stroke. 1995;26:2238–2241.
Downloaded from http://stroke.ahajournals.org/ by guest on March 28, 2016
10. Brandler ES, Sharma M, Sinert RH, Levine SR. Prehospital stroke scales
in urban environments: a systematic review. Neurology. 2014;82:2241–
2249. doi: 10.1212/WNL.0000000000000523.
11. Kostopoulos P, Walter S, Haass A, Papanagiotou P, Roth C, Yilmaz
U, et al. Mobile stroke unit for diagnosis-based triage of persons
with suspected stroke. Neurology. 2012;78:1849–1852. doi: 10.1212/
WNL.0b013e318258f773.
12. Weber JE, Ebinger M, Rozanski M, Waldschmidt C, Wendt M, Winter
B, et al; STEMO-Consortium. Prehospital thrombolysis in acute stroke:
results of the PHANTOM-S pilot study. Neurology. 2013;80:163–168.
doi: 10.1212/WNL.0b013e31827b90e5.
13. Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski
M, et al; STEMO Consortium. Effect of the use of ambulance-based
thrombolysis on time to thrombolysis in acute ischemic stroke: a ran-
domized clinical trial. JAMA. 2014;311:1622–1631. doi: 10.1001/
jama.2014.2850.
14. Ebinger M, Rozanski M, Waldschmidt C, Weber J, Wendt M, Winter B,
et al; STEMO-Consortium. PHANTOM-S: the prehospital acute neuro-
logical therapy and optimization of medical care in stroke patients-study.
Int J Stroke. 2012;7:348–353. doi: 10.1111/j.1747-4949.2011.00756.x.
15. Krebes S, Ebinger M, Baumann AM, Kellner PA, Rozanski M, Doepp
F, et al. Development and validation of a dispatcher identification algo-
rithm for stroke emergencies. Stroke. 2012;43:776–781. doi: 10.1161/
STROKEAHA.111.634980.
16. Koennecke HC, Walter G. Berliner Schlaganfallregister 2012
[in German]. http://www.aerztekammerberlin.de/10arzt/40_
Qualitaetssicherung/30_QM_Massnahmen_nach_Themen/30_
BerlinerSchlaganfallregister/04_2012/BSR_Gesamtbericht_2012.pdf.
Accessed May 30, 2014.
17. Norrving B; International Society of Internal Medicine; European
Stroke Council; International Stroke Society; WHO Regional Office for
European. The 2006 Helsingborg Consensus Conference on European
Stroke Strategies: Summary of conference proceedings and background
to the 2nd Helsingborg Declaration. Int J Stroke. 2007;2:139–143. doi:
10.1111/j.1747-4949.2007.00109.x.
18. Nor AM, Davis J, Sen B, Shipsey D, Louw SJ, Dyker AG, et al. The
Recognition of Stroke in the Emergency Room (ROSIER) scale: devel-
opment and validation of a stroke recognition instrument. Lancet Neurol.
2005;4:727–734. doi: 10.1016/S1474-4422(05)70201-5.
19. Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA,
Lyden PD, et al. ACCESS: acute cerebrovascular care in emergency
stroke systems. Arch Neurol. 2010;67:1210–1218. doi: 10.1001/
archneurol.2010.250.
20. Child N, Fink J, Jones S, Voges K, Vivian M, Barber PA. New Zealand
National Acute Stroke Services Audit: acute stroke care delivery in New
Zealand. N Z Med J. 2012;125:44–51.
21. Prabhakaran S, O’Neill K, Stein-Spencer L, Walter J, Alberts MJ.
Prehospital triage to primary stroke centers and rate of stroke
thrombolysis. JAMA Neurol. 2013;70:1126–1132. doi: 10.1001/
jamaneurol.2013.293.
22. Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen
T, et al. Diagnosis and treatment of patients with stroke in a mobile
stroke unit versus in hospital: a randomised controlled trial. Lancet
Neurol. 2012;11:397–404. doi: 10.1016/S1474-4422(12)70057-1.
23. Langhorne P, Fearon P, Ronning OM, Kaste M, Palomaki H, Vemmos K,
et al; Stroke Unit Trialists’ Collaboration. Stroke unit care benefits patients
with intracerebral hemorrhage: systematic review and meta-analysis.
Stroke. 2013;44:3044–3049. doi: 10.1161/STROKEAHA.113.001564.
Improved Prehospital Triage of Patients With Stroke in a Specialized Stroke Ambulance:
Results of the Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care
in Stroke Study
Matthias Wendt, Martin Ebinger, Alexander Kunz, Michal Rozanski, Carolin Waldschmidt,
Joachim E. Weber, Benjamin Winter, Peter M. Koch, Erik Freitag, Jenrik Reich, Daniel
Schremmer and Heinrich J. Audebert
for the STEMO Consortium

Stroke. 2015;46:740-745; originally published online January 29, 2015;

doi: 10.1161/STROKEAHA.114.008159
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