This review concluded that use of pre-hospital stroke code was an important intervention to improve the accessibility of the benefits of thrombolysis, especially when combined with educational campaigns to raise awareness. The conclusion seems overly strong given the limitations of the review and available evidence.

To investigate whether a pre-hospital stroke code can enhance time performance in stroke care.

MEDLINE and EMBASE were searched without language restrictions from 1980 to June 2011; search terms were reported. Reference lists of included articles were searched.

Randomised controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies and hospital- and emergency-based registers where pre-hospital stroke code procedures were administered in the field were eligible for inclusion. Studies where patients were transferred from another hospital or where evaluation data were not reported were excluded.

Most studies compared use of a pre-hospital stroke code procedure to standard procedures on the delivery of patients with acute stroke to hospital care. Pre-hospital stroke assessment instruments differed across studies; nearly 50% did not report the use of a standardised screening instrument. Time limits to activate pre-hospital stroke screening procedures ranged from within two to six hours from symptom onset. Approximately half of the studies were conducted in Spain; all studies were in urban areas.

Titles and abstracts were screened by two reviewers; it was unclear whether inclusion criteria were applied to full papers by independent reviewers.

There did not seem to be any systematic assessment of study quality.

The rate of intravenous tissue plasminogen activator (t-PA) treatment in patients with ischaemic stroke was extracted. Comprehensiveness of pre-hospital stroke code procedures was categorised as minimally present (such as lack of hospital pre-notification) or present.

The authors did not state how many reviewers extracted data.

Studies were combined in a narrative synthesis. Study details were summarised in tables.

Nineteen studies (18,217 participants, range 48 to 7,594) met the inclusion criteria. There was only one RCT; most studies used a historical control.

Eighteen of the 19 studies reported a significant increase in the rate of t-PA treatments. Increases ranged from 3.2% to 16%.

Despite its limitations, this review suggested that use of a pre-hospital stroke code was an important intervention to improve the accessibility of the benefits of thrombolysis, especially when implemented together with educational campaigns to optimise the awareness and behaviour of patients and bystanders.

The review addressed a clear question supported by reproducible inclusion criteria. Relevant sources were searched without language restrictions; unpublished studies were not sought. It was not reported that methods to reduce error and bias were used during the entire review process; titles and abstracts were screened in duplicate. There did not appear to be a systematic assessment of the quality of the included studies. Blinding was mentioned in some studies but there was no assessment of the appropriateness of the methods used so risk of bias was unclear.

The authors' conclusion seems overly strong given the limitations of the review and the available evidence. The value of the rate of t-PA treatment alone is questionable without some indication of whether administration of t-PA treatment was appropriate or effective.

Practice: The authors stated that implementation of pre-hospital stroke code procedures was a necessary step to improve stroke outcomes, had a pivotal role in integrating emergency medical services activation and response within stroke systems of care and could save lives and health care resources, especially when educational campaigns were used to optimise awareness and behaviour of patients and bystanders.

Research: The authors stated that further research was needed to identify cost-effective multifaceted strategies to improve acute stroke care and should evaluate the contribution of each component of the strategy; one strategy would not fit all sites because of factors such as availability of human and operational resources across the continuum of acute stroke care.

Italian Health Ministry, Centro Nazionale Prevenzione e Controllo Malattie.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.