The rate of thrombolytic therapy for acute ischaemic stroke in Australia is low (ie, <3%), suggesting limited access of patients to this valuable, cost-effective treatment.

Started in 2006, the Pre-hospital Acute Stroke Triage (PAST) protocol is a systems redesign project which resulted in improved patient access to tissue plasminogen activator (tPA) therapy. The goal was to increase access to tPA for acute stroke patients in a rural catchment area using innovative pre-hospital clinical assessment methods and patient transport arrangements. The protocol was developed in collaboration with the Ambulance Service of New South Wales and features a new pre-hospital assessment tool and a transport decision matrix that makes use of road and combined road/air transfers to speed up patient transport to the community hospital (John Hunter Hospital). To ensure appropriate use of the protocol, paramedics were provided an overview on stroke and underwent training on implementation of the protocol.

The transport decision matrix allowed rural paramedics from the catchment area to readily identify patients who could be transported to the community hospital within the narrow, 3-hour window of open-label tPA therapy. As a result, six patients transported following the PAST protocol received tPA therapy, a substantial improvement from the year prior to its implementation, during which none of more than 200 acute stroke patients in the catchment area received tPA.

During its implementation between April and September 2009, the protocol was activated 11 times for either ischaemic stroke, transient ischaemic attack, intracerebral haemorrhage or stroke mimic. Six of the patients transported under the protocol received tPA, giving a number-needed-to-transport-in-order-to-treat of 2.