Paramedics will take stroke patients directly to the CT scanner on arrival at hospital, using a standard checklist to coordinate rapid delivery of clot-busting drugs. This matters because the speed of treatment for major disabling strokes directly determines how much brain damage a patient suffers. Current delays happen between ambulance crews, emergency departments, and radiology teams—each handoff costs precious minutes. The programme also tackles a second, linked problem: deciding which patients should be sent to specialist centres for intra-arterial clot removal, a procedure that is not yet routinely available across England. If the enhanced paramedic protocol works, it could cut treatment times nationwide without requiring new buildings or expensive equipment—just better coordination and a clear checklist. The second strand will produce a mathematical model showing how the NHS could best organise a national intra-arterial therapy service, including which hospitals should provide it and how patients should be redirected. Together, the two strands aim to make the entire emergency stroke pathway faster, more consistent, and more cost-effective for the NHS.
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The programme comprises two interconnected strands of work focused on improving the effectiveness, efficiency and speed of the early management of patients with acute stroke and major disabling symptoms. A key focus of our work will be improving and integrating working between pre-hospital (ambulance paramedics, general practitioners) and hospital teams (Emergency Department, Acute Stroke, Radiology, Neuroradiology) to achieve more rapid delivery of intravenous thrombolysis for major disabling strokes (objective 1) and define the role of intra-arterial thrombectomy in the management of major disabling stroke (objective 2). Objective 1 will develop and evaluate a novel enhanced paramedic protocol to expedite immediate brain imaging and drive forward the hospital assessment of stroke patients who can benefit from rapid treatment, specifically thrombolytic therapy. Paramedics will pre-notify the hospital team with details that justify urgent imaging, transfer the patient directly to the scan room on arrival and use a standard checklist to co-ordinate rapid delivery of thrombolysis if indicated. The objective consists of six phases. Output from the pre-trial phases 1-3 (months 0-20) will be a systematic review of enhanced paramedic roles, qualitative description of professional and public views to shape the intervention, training materials and a tested protocol. Phase 4 (months 21 – 54) will evaluate the enhanced protocol by cluster randomized controlled trial across three regions (North East, North West and South Wales) and qualitative examination of professional and public experiences. Phase 5 (months 24–60) is a within-trial economic evaluation to estimate cost-effectiveness of the enhanced protocol versus usual care. If the enhanced protocol is effective and affordable, dissemination of results and training materials would quickly lead to wider adoption (phase 6; months 55-60). Objective 2 will determine the clinical effectiveness, costs, cost effectiveness and affordability of delivering intra-arterial therapy (IAT) for acute ischaemic stroke patients to the English population. We will model alternative means of provision of (IAT) for stroke across NHS services as part of the cost effectiveness/affordability analyses. Objective two will increase understanding of the evidence of IATs effectiveness, how effectiveness might vary across patient groups, the requirements for and barriers to providing an acute intra-arterial stroke therapy nationally across the NHS. This information will then be used to develop a model that can be used to explore how such a service would best be organised. The model reflects the complete patient pathway and will include the enhanced role of paramedics outlined in objective one in the potential redirection of suitable patients to centres providing acute intra-arterial therapy. As a model of effective and cost-effectiveness, the outputs will include the resource implications from an NHS perspective. The objective consists of five phases: (months 0-12) a conceptual model of care pathways intra-arterial therapy and an understanding of the feasibility and requirements of providing a 24hr IA service obtained from a survey of stakeholders; (months 13-36) creating a validated mathematical model capable of running simulations of a population of stroke patients; (months 25-30) consulting with stakeholders about possible configurations of service provision; (months 37-54) modelling and reporting on the configurations being considered and consulting on and disseminating the results of the objective (months 48-60). The two objectives each address a critical and under-researched area of the emergency care pathway of patients with acute stroke symptoms. Each involves the evaluation of potentially large changes in services and by addressing them in one programme of work facilitates joined-up thinking about the wider implications of change to a service both individually and collecti
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