Target: tPA

      Since 1963, local governments in Japan have had to establish emergency medical services. These governments manage fire stations as part of their emergency medical systems, and anyone can call an ambulance free of charge by dialing 1-1-9. Most governments use a one-tier system: Usually, the fire department dispatches the EMS team in an ambulance after receiving an emergency call. However, in some areas another ambulance, carrying a team that includes a doctor from a local hospital, may also arrive at the scene.

   In Japan, medical facilities are divided into three categories (primary, secondary, tertiary) from the standpoint of emergency care. Primary emergency medical facilities receive patients who are not in serious condition--who can walk in for treatment and do not need hospitalization, such as patients with flu or diarrhea. Secondary medical facilities receive patients who cannot walk on their own and need hospitalization, but who are not in critical condition, such as those with pneumonia, appendicitis or fractures. Tertiary medical facilities, such as lifesaving emergency centers, receive patients in critical conditions, such as patients in shock, unconsciousness, hypoxia, acute myocardial infarction or with severe multiple trauma.

   When a central fire station receives an emergency call, the nearest substation dispatches an EMS team in an ambulance. The EMS team consists of three members: one driver and two emergency medical technicians and/or emergency lifesaving technicians. Emergency lifesaving technicians can secure airways with instruments, secure peripheral venous access and administer 1 mg of epinephrine intravenously for patients with cardiopulmonary arrest after obtaining permission from doctors by telephone. When the EMT team accepts a patient into an ambulance, they must select and transport to a medical facility that agrees to treat the patient. The medical facility can deny acceptance of the emergency patient for various reasons: All beds are fully occupied, they have no specialist for the patient's problem or the physician on duty is too busy to treat any other patients. In this case, the EMT team cannot move until they can find a medical facility that agrees to receive the patient.

   Recombinant tissue plasminogen activator (tPA) can dissolve thrombi during an ischemic stroke. tPA must be administered intravenously within the first three hours of the event to reduce the mortality and morbidity of cerebral ischemia.¹ Accordingly, early detection, dispatch, delivery and location are important in the prehospital setting.²

   Although stroke mortality is decreasing in Japan, it is still the third-leading cause of death, and the number of patients with strokes is increasing as the population ages.³ tPA could not be used for ischemic stroke until 2005, when it was approved by the Ministry of Health, Labour and Welfare. In 2007, guidelines for the prehospital management of stroke were published by the Japanese Society of Emergency Medicine, to which most Japanese emergency medical services belong. Due to a lack of stroke specialists in many communities, some hospitals cannot be prepared to provide intravenous thrombolytic therapy around the clock, and time lost transporting patients to tertiary centers may mitigate the benefits of thrombolysis.⁴ Accordingly, candidates for tPA with ischemic stroke should be transported directly to a proper medical facility.

   The difficulty of clinically diagnosing stroke in the prehospital and primary care settings has been evaluated;^5,6 however, the quality of prehospital management provided by the emergency medical system has not. Therefore, our study investigated whether local EMS provided proper management of candidates for tPA for ischemic stroke.

METHODS