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patients and in delivering experimental stroke therapy.31,32 C. Air Medical Transport Air medical (helicopter) transport for patients with acute stroke appears beneficial, although the data are limited. Helicopters may extend the range of thrombolytic therapy to rural areas.33 They could deliver teams to administer tPA and subsequently transfer treated patients,34 expand enrollment for acute stroke studies,35 and facilitate early definitive diagnosis and operative intervention in nontraumatic intracranial hemorrhage.36 It is important to note that helicopter transfer of stroke patients for potential thrombolysis is cost-effective for a wide range of system variables.37 Protocols for the use of air medical transfer from facilities unable to provide acute stroke care should be developed in advance. Air medical transfer should be considered for patients who cannot receive treatment locally and who could reach a treating facility within the available time window.33,38 In addition, telemedicine may be used as a way to bring stroke expertise to patients in rural or small hospitals. Preliminary data suggest that such electronic methods may be increasingly useful.39–43 D. Conclusions and Recommendations Public educational programs likely will increase the proportion of patients with stroke who will utilize EMS as their first contact with the healthcare system. This trend should be encouraged. In response, EMS should have protocols in place to rapidly assess, treat, and transport patients. The objectives of the EMS phase of stroke care are as follows: (1) rapid identification of stroke as the cause of the patient’s findings, (2) elimination of comorbid conditions that could mimic stroke, (3) stabilization, (4) rapid transportation of the patient to the closest appropriate ED, and (5) notification of the receiving institution about impending arrival of a patient with suspected stroke. Such steps are especially critical for the use of time-dependent therapies. Community and physician educational programs on acute stroke treatment appear to enhance the use of recombinant tPA (rtPA), and these programs should be encouraged. Strategies such as telemedicine or air medical transport (helicopter) may provide access to specialized stroke care when it is not available locally. Such approaches may increase the number of patients who can be treated, especially in rural or otherwise underserved areas. To maximize therapeutic options, treatment guidelines and transfer protocols should be established in advance to ensure orderly patient transition from a prehospital to a hospital environment. The recommendations that follow were not included in the previous guidelines. Class I Recommendations 1. Activation of the 9-1-1 system by patients or other members of the public is strongly supported because it speeds treatment of stroke (Class I, Level of Evidence B). 9-1-1 Dispatchers should make stroke a priority dispatch. 2. To increase the number of patients who can be seen and treated within the first few hours after stroke, educational programs to increase public awareness of stroke are recommended (Class I, Level of Evidence B). 3. To increase the number of patients who are treated, educational programs for physicians, hospital personnel, and EMS personnel also are recommended (Class I, Level of Evidence B). 4. Brief assessments by EMS personnel as outlined in Tables 3 and 5 are recommended (Class I, Level of Evidence B). 5. The use of a stroke identification algorithm such as the Los Angeles or Cincinnati screens is encouraged (Class I, Level of Evidence B). 6. The panel recommends that EMS personnel begin the initial management of stroke in the field, as outlined in Table 3 (Class I, Level of Evidence B). The development of stroke protocols to be used by EMS personnel is strongly encouraged. 7. Patients should be transported rapidly for evaluation and treatment to the closest institution that provides emergency stroke care as described in the statement (Class I, Level of Evidence B). In some instances, this may involve air evacuation. EMS personnel should notify the receiving ED so that the appropriate resources may be mobilized. Class II Recommendation 1. Telemedicine can be an effective method to provide
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