🧠 Stroke Handover: What They Actually Need

Pre-alert & handover priorities from the stroke team's side of the door

1

Time points — exact, unrounded

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Thrombolysis/thrombectomy eligibility is a clock. Vague times get rounded down by the team to the safest assumption — which often means a treatable patient gets excluded.
  • Last known well — actual clock time, not "this morning." If estimated, give a range and say it's estimated.
  • Wake-up strokes: both time last seen normal AND time found abnormal — these are different data points and both matter for MRI-based pathway decisions.
  • Your on-scene time and time of departure — not the call time, not the dispatch time.
  • If the time is genuinely unclear (found on floor, unwitnessed), say so plainly — don't guess and present it as fact.
Downstream effect: Inside 4.5h → thrombolysis is on the table. Outside that but within ~24h with salvageable tissue on CT perfusion → thrombectomy may still be possible, thrombolysis usually isn't. Outside all windows → management shifts to secondary prevention and rehab only — no acute reperfusion therapy. A vague timeline can shut a door an exact one would have opened.
2

A clean, reproducible exam

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FAST positive/negative alone is too coarse. They need findings they can compare against their own exam on arrival.
  • Limb weakness: drift vs no movement against gravity vs no movement at all — and which side.
  • Speech: dysarthria (slurred but words right) vs expressive dysphasia (can't find words) vs receptive (doesn't understand) — these localise differently, don't lump them as "speech was off."
  • Gaze deviation / visual field deficit if testable in transit.
  • Trend since you arrived: improving, worsening, fluctuating. This single fact can change the pathway more than the baseline severity does.
FindingWhy it matters
Pure sensory deficitLower stroke probability — flag if isolated
Gaze palsy + dense hemiplegiaLarge vessel occlusion suspicion — thrombectomy pathway
Improving rapidlyMay be TIA — still needs urgent assessment, different urgency framing
Downstream effect: Limb severity and speech type feed the NIHSS score, which gates trial-based eligibility cutoffs and predicts haemorrhage risk vs benefit. Gaze deviation + dense hemiplegia raises suspicion of large vessel occlusion — triggers CTA and thrombectomy team activation, not just thrombolysis. Rapid improvement may get reclassified as TIA, sometimes avoiding thrombolysis risk for a deficit that's resolving anyway; worsening escalates urgency and can prompt repeat imaging.
3

Anticoagulation — precise, not generic

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"On blood thinners" is functionally useless to them. The specific drug changes the thrombolysis decision outright.
  • Critical Drug name — DOAC (which one) vs warfarin vs antiplatelet only.
  • Last dose time — DOACs have a narrow window where thrombolysis becomes unsafe.
  • If warfarin: INR if known or available from records.
  • Don't say "blood thinners" if you can find the actual box, app, or dosette — it's worth the extra 60 seconds.
Downstream effect: DOAC within its active window usually rules out thrombolysis outright (bleeding risk) — patient gets redirected to thrombectomy-only if eligible, or supportive care if not. Warfarin with a high INR carries the same exclusion logic, but it's reversible and checkable, so the actual number matters, not just the drug name. Antiplatelet-only (aspirin/clopidogrel) usually doesn't exclude thrombolysis — getting this distinction right avoids ruling someone out who didn't need to be.
4

Background that changes management

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Not a generic PMH dump — specifically the contraindication-screening and outcome-relevant facts.
  • Previous stroke/TIA — and roughly when (recent = higher bleed risk relevance).
  • Recent surgery, GI bleed, or trauma — direct thrombolysis contraindications.
  • Baseline functional status — independent vs needs care/residential. This is outcome-relevant, not just colour — it affects whether aggressive treatment changes anything meaningful for that patient.
  • Seizure at onset — relevant differential, worth flagging explicitly.
Downstream effect: Recent surgery, GI bleed, or trauma are hard contraindications to thrombolysis regardless of how good a candidate the patient otherwise looks. Baseline functional status isn't a box-tick — it's an actual input to the team's risk-benefit judgment on whether aggressive treatment changes anything meaningful for that person. Seizure at onset can mimic stroke (postictal Todd's paresis), which can shift the differential and the imaging ordered.
5

Pre-alert quality

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They would much rather stand a team down on a lower-confidence call than be scrambling one when you roll through the door.
  • Call it early — even on a borderline FAST-positive.
  • One clear sentence: who, what's wrong, since when, why you think it's stroke.
  • Update en route if the picture changes (improving/deteriorating) — don't let the original call stand if it's stale by arrival.
Downstream effect: Doesn't change drug eligibility, but it changes whether the CT scanner, stroke physician, and thrombolysis kit are ready the second you arrive — every minute saved here is minutes preserved inside the treatment window itself.
6

🗺️ NWAS Greater Manchester pathway — where to go, when

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This is the actual operational layer on top of everything above — it decides the destination and whether RED Stroke Standby applies, before any hospital team even gets involved.
FAST positive — query stroke
If in line with JRCALC guidelines, consider HASU. Alternatively, Clinical Incident Hub for advice (Advanced Paramedic, callsign CH183).
< 9 hours since LKW
→ Nearest Hyper-Acute Stroke Unit
9–48 hours since LKW
→ Nearest Hyper-Acute Stroke Unit
Over 48 hours since LKW
→ Transport to local ED
Exception: Cheshire & Mersey area — suspected stroke patients still go to nearest HASU.
FAST negative, query stroke / Query TIA
→ Follow NWAS clinical procedures — local ED
Exception: Cheshire & Mersey — suspected TIA patients attend nearest HASU.
GM only — on anticoagulation (rivaroxaban, edoxaban, apixaban, warfarin or similar)
Yes → RED Stroke Standby. Use ASHICE, include name and DOB.
No → No pre-alert needed.
Downstream effect: The 9-hour and 48-hour cutoffs aren't the thrombolysis 4.5h window itself — they're the destination-triage cutoffs NWAS uses to decide whether the patient needs the HASU's hyperacute capability at all, vs a local ED. Inside 9h, the patient may still be a thrombectomy/thrombolysis candidate by the time imaging is done, so the nearest HASU keeps every option open. The anticoagulation trigger for RED Stroke Standby exists specifically because GM HASUs want advance warning to have reversal agents and imaging slots ready — it's the same logic as the bleeding-risk exclusion, just applied earlier, at dispatch.
Pathway exclusions (these patients don't follow this stroke pathway — manage per usual NWAS procedures and transport to nearest appropriate ED):
  • Age < 16
  • A — Airway requiring intervention
  • B — Assisted breathing using IPPV/BVM ventilation
  • C — Hypotension/bradycardia unresponsive to treatment
  • D — GCS 7 or less, BM <4.0
  • Any seizure activity reported during or causing the event

CAL

  • Blackpool Victoria
  • Cumberland Infirmary
  • Furness General
  • Royal Blackburn
  • Royal Lancaster Infirmary
  • Royal Preston

CAM

  • Aintree
  • Arrowe Park
  • Countess of Chester
  • Leighton
  • Whiston (Facetime Triage)

GM

  • Fairfield (0645–2245)
  • Salford Royal
  • Stepping Hill (0645–2245)
HASUs are 24h unless stated. GM note: Wythenshawe ED catchment patients continue to Manchester Royal Infirmary ED; NMGH/Oldham ED catchment continues to Fairfield ED.
Treatment considerations on scene
  • "Time is Brain" — minimise on-scene time, target <15 minutes
  • Cannulate unaffected arm if clinically appropriate
  • Bring a witness to accompany the patient where possible
  • Document last seen well time if onset is not known
  • Patient kept nil by mouth
  • 12-lead if clinically appropriate, document any irregular heart rate — not required to diagnose stroke, don't delay on scene for it

📞 Pre-alert template

"Pre-alerting a suspected stroke. [Age/sex], [time] since last known well. [Key deficit — e.g. right-sided weakness + expressive dysphasia], [stable/improving/worsening]. On [anticoag, if any — drug + last dose]. ETA [X] mins."
GM RED Stroke Standby (anticoagulated patient) → use ASHICE format instead, and include name + DOB explicitly.