Prehospital time efficiency in the Portuguese Stroke Fast-Track pathway: a nationwide observational study

Abstract

Background: Timely prehospital management is critical to improve acute stroke outcomes by minimising time to reperfusion. Despite Stroke Fast-Track pathways, reductions in system response times remain limited. This study aimed to describe system response times from emergency call to hospital arrival within the Portuguese nationwide Stroke Fast-Track pathway and to identify patient-level, geographic, and structural determinants of prehospital timeliness.

Methods: In this cross-sectional study, data from the National Prospective Stroke Fast-Track Registry (Portugal), 2017 to 2023, were analysed. Cases meeting stroke pathway activation criteria were included to assess the interval between emergency call and hospital arrival (system response time). Associations between demographic, clinical, geographic, structural, temporal factors and system response time were evaluated using multivariable generalised linear models; results reported as adjusted estimates with 95% confidence intervals (CIs).

Results: A total of 32,506 patients were included. Median system response time was 61 minutes (IQR 49-77); only 48% of cases met the national target of call-to-hospital arrival within 60 minutes. Paradoxically, lower emergency vehicle density and lower stroke unit availability per 100,000 inhabitants were independently associated with shorter adjusted system response times (reductions of 4-8 minutes and 5 minutes, respectively, compared with highest-availability categories). Higher population density was also independently associated with shorter times (1minute reduction per unit increase in log population/km²; 95% CI: -1.68 to -0.42; p = 0.001). These inverse associations suggest that, in high-resource settings, dispatch complexity may offset proximity advantages.

Conclusions: In a nationwide stroke network, simple resource availability does not predict faster prehospital response. Operational factors may influence prehospital stroke performance. Pathway optimisation should address emergency network organization.

Keywords: Acute stroke; Critical pathways; Early identification; Prehospital delay.