Table 1 Summary of included studies
Lead author | Year | Country | Sample Size | Study design | Intervention | Prehospital impact | Risk of bias |
|---|---|---|---|---|---|---|---|
Studies targeting EMS dispatch +/− EMS clinicians | |||||||
 Berglund [16] | 2012 | Sweden | 942 suspected stroke patients | RCT | Increased priority stroke dispatch and rapid transport to stroke unit. Meetings and education prior to study. | Dispatch randomised = shorter call to hospital but no change in OST. EMS randomised = no change. | Some concernsa |
 Mohamad [22] | 2016 | Denmark | 476 stroke patients who received thrombolysis and/or thrombectomy | Before and after | EMS dispatch and paramedic training on large vessel occlusion scale and prioritisation | Reduced prehospital delay for thrombectomy but not for thrombolysis (non-significant) | Serious |
 Puolakka [25] | 2016 | Finland | 77 thrombolysis candidates | Prospective cohort study | Dispatch of fire and rescue service to support ambulances with stroke patients | Non-significant decrease in OST | Serious |
 Watkins [26] | 2013 | UK | 464 suspected or confirmed stroke patients | Interrupted time series | 2-hour online training package for dispatchers | No change in call to hospital arrival pre and post implementation, improved recognition of stroke | Moderate |
Studies targeting EMS clinicians only | |||||||
 Frendl [20] | 2009 | USA | 154 suspected stroke patients | Before and after | 1-hour educational presentation with written material | No significant change in OST | Critical |
 Gorchs-Molist [17] | 2020 | Spain | 17,135 suspected stroke patients | Before and after | 6-hours online training | Increased call to hospital time with large % due to OST | Critical |
 Oostema [23] | 2019 | USA | 1805 EMS transported patients | Interrupted time series | 30-minute online training plus case-based feedback | Increased cases < 15 mins OST, no significant change in overall OST or transport time | Serious |
 Puolakka [24] | 2016 | Finland | 289 thrombolysis candidates | Before and after | 45-minute training session with interactive follow up group sessions | 10% reduction in OST, no change in dispatch to hospital time | Moderate |
Studies targeting whole system change | |||||||
 De Luca [19] | 2009 | Italy | 4895 suspected stroke patients | Cluster RCT | Training on stroke emergency care pathway | Reduced dispatch to hospital | Lowa |
 Kendall [21] | 2015 | UK | 351 thrombolysed patients | Before and after | Continuous quality improvement approach | No significant difference in call to door time | Critical |
 Wojner-Alexandrov [18] | 2005 | USA | 1518 suspected stroke patients | Before and after | Monthly multilevel education sessions | Increased OST, transport and overall time | Critical |