Title: PreHOspital Triage for potential stroke patients: lessONs from systems Implemented in response to COVID19 (PHOTONIC)
Funder: Department of Health and Social Care

Abstract: Stroke is a major cause of death and disability in the UK and worldwide. Stroke patients get better care and have better outcomes if treated in a stroke specialist unit, but currently such units also treat many patients who have not had a stroke. During the COVID19 pandemic, some parts of England introduced “prehospital triage” interventions that let hospital-based stroke specialists use digital videoconferencing to communicate remotely with ambulance clinicians to assess suspected stroke patients. These aim to ensure patients are taken to the right service (or stay home, if appropriate). However, little is known about implementing these interventions in different settings, how well they work, their impact on care and outcomes, and whether they provide value for money._x000D_ This proposal builds on the applicants’ current rapid service evaluation of prehospital triage in North Central London (NC London) and East Kent – which focuses on safety, effectiveness, and usability. _x000D_ Our team includes stroke survivors, stroke clinicians and service managers, charities, and researchers. We will study four areas, NC London, East Kent, Maidstone, and Darent Valley, which have recently implemented prehospital triage. _x000D_ _x000D_ First, we will study how prehospital triage is set up, run, and experienced. We will interview patients and carers; stroke, ambulance, and emergency teams; and service and system managers. We will observe oversight and delivery of prehospital triage and study relevant documents. We will ask how the services were put into action, and what helped or hindered this. We will also ask patients and carers how they experienced prehospital triage._x000D_ _x000D_ Second, we will study the impact of prehospital triage on healthcare services, patient outcomes, and value for money. We will use NHS data to analyse:_x000D_ - if more patients are taken to the right healthcare service;_x000D_ - if more patients remain at home and avoid hospital admission;_x000D_ - if patients (stroke and non-stroke) get the right care more quickly, and if there are any adverse effects of prehospital triage;_x000D_ - how well patients do after their stroke; and_x000D_ - if these interventions are good value for money._x000D_ We will compare performance before and after prehospital triage was introduced. We will also compare the areas that are using prehospital triage with other parts of the UK that are not._x000D_ _x000D_ Our study will provide important lessons on how prehospital triage for stroke affects quality of care, patient outcomes, and value for money; it will also support future cooperation between hospital and ambulance systems. Throughout, we will engage with the people leading prehospital triage in monthly meetings, so they can make use of our findings as they develop. We will develop a list of clinicians, politicians, charities, members of the public, and others who make decisions about healthcare and are interested in our research; we will share with them quarterly newsletters and podcasts to describe how our research is going. When we are sure of our findings, we will present them at research conferences and in academic journals, and make accessible summaries and podcasts for stakeholders. Finally, we will run a workshop for people providing stroke and other services, patients and carers, charities, and international experts, to share and develop lessons for services across the UK that might want to introduce prehospital triage.

Lay abstract: BACKGROUND: Stroke is a major cause of death and disability in the UK and worldwide. Rapid access to specialist care for stroke patients saves lives and reduces disability, but up to 50% of patients seen by stroke specialist units do not have stroke. This “stroke mimic” population receives delayed care away from their local care network and drains stroke service resource from managing stroke patients._x000D_ _x000D_ During the COVID19 pandemic, some parts of England introduced “prehospital video triage” services, where hospital stroke specialists communicate with ambulance clinicians to assess suspected stroke patients on scene. These services aim to increase appropriate patient transfer. However, little is known about how such services are implemented, their impact on care, outcomes, patient experience, and cost-effectiveness._x000D_ _x000D_ AIMS AND OBJECTIVES: We will provide robust evidence on how prehospital video triage affects quality of care, patient outcomes, and cost-effectiveness; we will analyse how such services are implemented and experienced by stakeholders including patients, carers, and healthcare professionals and managers. _x000D_ _x000D_ METHODS: We will study four areas (North Central London, East Kent, Maidstone, and Darent Valley), which implemented prehospital video triage services in 2020. _x000D_ 1. Implementation and experiences [months 1-24]: We will use interviews, observations, and documentary analysis to analyse implementation of prehospital video triage, and how patients, carers, and healthcare professionals experience these services. We will use a case study design guided by a conceptual framework addressing implementation of digital innovations, informed by developing findings from a current service evaluation of the NC London and East Kent services._x000D_ 2. Care delivery and outcomes [months 1-22]: We will analyse delivery and outcomes of care using patient-level data. We propose a quasi-experimental design, comparing areas with prehospital triage services against national and regional controls, before and after the introduction of prehospital triage. We will analyse national datasets (Stroke national audit, Hospital Episodes Statistics, Office for National Statistics) and regional data (from ambulance trusts and participating stroke services)._x000D_ 3. Cost-effectiveness [months 1-24]: We will estimate costs (from NHS and personal social services perspectives) and outcomes (life years or quality-adjusted life years). We will use a difference-in-differences design, estimating cost-effectiveness as the difference in cost between comparators divided by the difference in outcomes to give an incremental cost-effectiveness ratio (ICER) per life year saved and per quality-adjusted life year gained._x000D_ 4. Integrating analyses: There will be three key stages of integration: the team will a) ensure qualitative, quantitative, and cost-effectiveness approaches are complementary (months 1-4); b) ensure interim findings are addressing research questions (months 10-12); and c) identify key lessons and finalise strategy to mobilise these, including holding a stakeholder workshop (months 20-24)._x000D_ _x000D_ IMPACT AND DISSEMINATION: This research has potential to reshape care for stroke and other emergency health conditions. To maximise impact, we will build a list of key stakeholders, including patients, clinicians, politicians, charities, and the public. We will share findings at research conferences, in academic journals, and make accessible text and video summaries.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE