Raffaele Ornello, MD

Middleton S, Dale S, Cheung NW, Cadilhac DA, Grimshaw JM, Levi C, et al. Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial. Stroke. 2019;50:1346–1355.

The implementation of rapid and effective treatment of stroke in the emergency department (ED) is key to improving outcomes. However, establishing the best evidence-based ED protocol of stroke care is difficult.

In the T3 trial, which was performed in Australia, the authors tested the implementation of a nurse-initiated ED stroke care protocol, which included adequate triage, treatment of fever, hyperglycemia, and swallowing difficulties, and rapid transfer to stroke units (hence the 3 T’s of the trial name). The protocol was implemented by educational strategies and strict follow-up.

At the end of the 3-year trial period, there was no improvement of patient outcomes or of ED clinical behavior; this surprising result might be explained by the suboptimal implementation of ED stroke processes of care, but also by the general improvement of stroke care in recent years, which was independent of the trial.

Besides, the challenging environment and unpredictability of the ED might have limited the attention paid to stroke patients; the authors reminded that in acute stroke care units, which are easier to organize compared with the ED, the implementation of stroke care protocols was effective.

The result of the T3 trial endorses a more direct pathway of stroke patients to stroke care units, even bypassing the ED.