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Li Y, Ou Q, Lu Y, Shen Z, Li J, Zhang Z, Tai L, Li G, Chen H, Zhang G, Zhang L, Sun X, Qiu J, Wei Y, Zhu S, Wang Z, Sun W, Huang Y. Geographic differences in pharmacotherapy patterns and outcomes of acute ischemic stroke in China. BMC Neurol 2024; 24:64. [PMID: 38360588 PMCID: PMC10868026 DOI: 10.1186/s12883-024-03564-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/06/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Vast economic and healthcare status discrepancies exist among regions in China, contributing to different treatment patterns. This study was aimed to investigate the current status of pharmacotherapy for acute ischemic stroke (AIS) and outcomes in China and explore the geographic variation in stroke care. METHODS This study was a multicenter prospective registry study, which collected the data of patients with AIS from 80 hospitals in 46 cities in 2015-2017 across China. Poor functional outcome defined as a modified Rankin Scale score of 3-6 was assessed at 3 and 12 months. Multivariate logistic regression was used. RESULTS Among 9973 eligible patients, the number of receiving intravenous thrombolysis (IVT), antiplatelet agents, anticoagulants, statin and human urinary kallidinogenase was 429 (4.3%), 9363 (93.9%), 1063 (10.7%), 6828 (74.7%) and 5112 (51.2%), respectively. Multivariable analysis showed IVT use in northeastern was significantly more frequent than in eastern region (OR = 3.17, 95% CI, 2.53-3.99), while the antiplatelets agents use were less frequent (OR = 0.46, 95%CI: 0.38-0.57). The proportions of poor outcomes at 3 and 12 months were 20.7% and 15.8%, respectively. Multivariate analysis showed AIS patients from northeastern and central region had significantly lower risk of poor outcome at month 3 and 12 than those from eastern region (all P < 0.05). CONCLUSIONS There was a low IVT use and a high antiplatelet agent and statin use for AIS in China. The pharmacotherapy and prognosis of AIS had variation by geographic region. TRIAL REGISTRATION This study was registered with ClinicalTrials.gov (NCT02470624).
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Affiliation(s)
- Ying Li
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Qianhua Ou
- Department of medical affairs, Techpool Bio-Pharma Co., LTD, Guangzhou, China
| | - Yuxuan Lu
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Zhiyuan Shen
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Jieyu Li
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Zhuangzhuang Zhang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Liwen Tai
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guozhong Li
- Department of Neurology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Shenyang Military Command, Shenyang, China
| | - Guiru Zhang
- Department of Neurology, Penglai People's Hospital, Penglai, China
| | - Lei Zhang
- Department of Neurology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xuwen Sun
- Department of Neurology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jinhua Qiu
- Department of Neurology, Huizhou First Hospital, Huizhou, China
| | - Yan Wei
- Department of Neurology, Harrison International Peace Hospital, Hengshui, China
| | - Sainan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China
| | - Weiping Sun
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China.
| | - Yining Huang
- Department of Neurology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
- Beijing Key Laboratory of Neurovascular disease discovery, Beijing, China.
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Oostema JA, Nickles A, Allen J, Ibrahim G, Luo Z, Reeves MJ. Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment. Stroke 2024; 55:101-109. [PMID: 38134248 DOI: 10.1161/strokeaha.123.043846] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/25/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care. METHODS This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan's EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes. RESULTS Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2-1.6]), glucose check (1.3 [1.1-1.6]), on-scene time ≤15 minutes (1.6 [1.4-1.9]), hospital prenotification ([2.0 [1.4-2.9]), and intravenous line placement (1.8 [1.5-2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (-9.2 [-10.6 to -7.8] minutes; P<0.001) and thrombolysis (-4.3 [-6.4 to -2.2] minutes; P<0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0-1.2]; P=0.002). CONCLUSIONS Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.
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Affiliation(s)
- J Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Secchia Center (J.A.O.)
| | - Adrienne Nickles
- Michigan Department of Health and Human Services Lifecourse Epidemiology and Genomics Division (A.N., J.A., G.I.)
| | - Justin Allen
- Michigan Department of Health and Human Services Lifecourse Epidemiology and Genomics Division (A.N., J.A., G.I.)
| | - Ghada Ibrahim
- Michigan Department of Health and Human Services Lifecourse Epidemiology and Genomics Division (A.N., J.A., G.I.)
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics Michigan State University College of Human Medicine (Z.L., M.J.R.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics Michigan State University College of Human Medicine (Z.L., M.J.R.)
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Dixon M, Appleton JP, Siriwardena AN, Williams J, Bath PM. A systematic review of ambulance service-based randomised controlled trials in stroke. Neurol Sci 2023; 44:4363-4378. [PMID: 37405524 PMCID: PMC10641071 DOI: 10.1007/s10072-023-06910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood. AIMS To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets. CONCLUSION Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported. REGISTRATION NUMBER PROSPERO 2018CRD42018075803.
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Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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Riera-López N, Aranda-Aguilar F, Gorchs-Molist M, Iglesias-Vázquez JA. Effect of the COVID-19 pandemic on advanced life support units' prehospital management of the stroke code in four Spanish regions: an observational study. BMC Emerg Med 2023; 23:116. [PMID: 37794327 PMCID: PMC10552388 DOI: 10.1186/s12873-023-00886-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Stroke is the most common time-dependent pathology that pre-hospital emergency medical services (EMS) are confronted with. Prioritisation of ambulance dispatch, initial actions and early pre-notification have a major impact on mortality and disability. The COVID-19 pandemic has led to disruptions in the operation of EMS due to the implementation of self-protection measures and increased demand for care. It is crucial to evaluate what has happened to draw the necessary conclusions and propose changes to improve the system's strength for the future. The study aims to compare prehospital time and neuroprotective care metrics for acute stroke patients during the first wave of COVID-19 and the same periods in the years before and after. METHODS Analytical, observational, multicentre study conducted in the autonomous communities of Andalusia, Catalonia, Galicia, and Madrid in the pre-COVID-19 (2019), "first wave" of COVID-19 (2020) and post-COVID-19 (2021) periods. Consecutive non-randomized sampling. Descriptive statistical analysis and hypothesis testing to compare the three time periods, with two by two post-hoc comparisons, and multivariate analysis. RESULTS A total of 1,709 patients were analysed. During 2020 there was a significant increase in attendance time of 1.8 min compared to 2019, which was not recovered in 2021. The time of symptom onset was recorded in 82.8% of cases, and 83.3% of patients were referred to specialized stroke centres. Neuroprotective measures (airway, blood glucose, temperature, and blood pressure) were performed in 43.6% of patients. CONCLUSION During the first wave of COVID-19, the on-scene times of pre-hospital emergency teams increased while keeping the same levels of neuroprotection measures as in the previous and subsequent years. It shows the resilience of EMS under challenging circumstances such as those experienced during the pandemic.
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Devlin S, Bury G. Paramedic recognition of posterior circulation stroke: a vignette and focus group study. Br Paramed J 2023; 8:1-9. [PMID: 37674916 PMCID: PMC10477819 DOI: 10.29045/14784726.2023.9.8.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Introduction The main pre-hospital screening tool used for stroke in Ireland and the United Kingdom is the FAST (face, arms, speech, time) test. However, posterior circulation stroke (PCS) patients may be FAST negative on exam, presenting with sudden dizziness, headaches, visual problems, nausea and vomiting and balance/co-ordination problems. There is a lack of research into paramedic recognition of PCS, and this study sought to evaluate recognition rates among paramedics (Ps) and advanced paramedics (APs) in Ireland. Methods A cross-sectional sequential exploratory design was chosen. An anonymous online survey was carried out, which informed focus group discussions. The survey contained six clinical vignettes, two of which were PCS presentations. Correct diagnosis, hospital destination and type of pre-alert were recorded. Focus groups were chaired by an independent moderator via Zoom. Recordings were transcribed and thematic analysis was carried out to create codes and themes. Results One hundred and fifty-one staff members (91 Ps, 60 APs) completed the survey (response rate 40%). Of these, 67% did not recognise PCS symptoms and 77% did not choose to transport to a stroke unit. For those correctly suspecting PCS, 42% requested resus at the stroke unit and 18% requested resus in the local emergency department (ED). Two focus groups of four practitioners (n = 8) took place. Three main themes were created: (1) comfort levels with posterior stroke, with subthemes of recognition and personal experiences; (2) education, with subthemes of clinical practice guideline (CPG) issues and training issues; and (3) hospital factors, with subthemes of pre-alerting and disconnect between hospital and emergency medical services. Participants were uncomfortable with PCS recognition and bypassing their local ED. More training was called for, with a dedicated CPG. Relationships with hospital staff affected willingness to pre-alert. Conclusions In this sample group, recognition of PCS and onward transfer to a stroke unit was low. Focus groups showed that practitioners were uncomfortable recognising PCS and bypassing a local ED without adequate training and a dedicated CPG. Relationships with hospital staff also affected pre-alert decisions.
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Affiliation(s)
- Shane Devlin
- National Ambulance Service, Ireland; University College Dublin ORCID iD: https://orcid.org/0000-0003-3528-769X
| | - Gerard Bury
- University College Dublin ORCID iD: https://orcid.org/0000-0002-4441-6724
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Mavragani A, Amorim Reis LH, Marquering H, Zwinderman AH, Delgado Olabarriaga S. Perceptions of a Secure Cloud-Based Solution for Data Sharing During Acute Stroke Care: Qualitative Interview Study. JMIR Form Res 2022; 6:e40061. [PMID: 36563043 PMCID: PMC9823575 DOI: 10.2196/40061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Acute stroke care demands fast procedures performed through the collaboration of multiple professionals across multiple organizations. Cloud computing and the wide adoption of electronic medical records (EMRs) enable health care systems to improve data availability and facilitate sharing among professionals. However, designing a secure and privacy-preserving EMR cloud-based application is challenging because it must dynamically control the access to the patient's EMR according to the needs for data during treatment. OBJECTIVE We developed a prototype of a secure EMR cloud-based application. The application explores the security features offered by the eHealth cloud-based framework created by the Advanced Secure Cloud Encrypted Platform for Internationally Orchestrated Solutions in Health Care Horizon 2020 project. This study aimed to collect impressions, challenges, and improvements for the prototype when applied to the use case of secure data sharing among acute care teams during emergency treatment in the Netherlands. METHODS We conducted 14 semistructured interviews with medical professionals with 4 prominent roles in acute care: emergency call centers, ambulance services, emergency hospitals, and general practitioner clinics. We used in-depth interviews to capture their perspectives about the application's design and functions and its use in a simulated acute care event. We used thematic analysis of interview transcripts. Participants were recruited until the collected data reached thematic saturation. RESULTS The participants' perceptions and feedback are presented as 5 themes identified from the interviews: current challenges (theme 1), quality of the shared EMR data (theme 2), integrity and auditability of the EMR data (theme 3), usefulness and functionality of the application (theme 4), and trust and acceptance of the technology (theme 5). The results reinforced the current challenges in patient data sharing during acute stroke care. Moreover, from the user point of view, we expressed the challenges of adopting the Advanced Secure Cloud Encrypted Platform for Internationally Orchestrated Solutions in Health Care Acute Stroke Care application in a real scenario and provided suggestions for improving the proposed technology's acceptability. CONCLUSIONS This study has endorsed a system that supports data sharing among acute care professionals with efficiency, but without compromising the security and privacy of the patient. This explorative study identified several significant barriers to and improvement opportunities for the future acceptance and adoption of the proposed system. Moreover, the study results highlight that the desired digital transformation should consider integrating the already existing systems instead of requesting migration to a new centralized system.
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Affiliation(s)
| | | | - Henk Marquering
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Aeilko H Zwinderman
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Oostema JA, Nickles A, Luo Z, Reeves MJ. Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry. J Am Heart Assoc 2022; 12:e026834. [PMID: 36537345 PMCID: PMC9973590 DOI: 10.1161/jaha.122.026834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.
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Affiliation(s)
- J. Adam Oostema
- Department of Emergency MedicineMichigan State University College of Human Medicine, Secchia CenterGrand RapidsMI
| | - Adrienne Nickles
- Michigan Department of Health and Human Services, Lifecourse Epidemiology and Genomics DivisionLansingMI
| | - Zhehui Luo
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State University College of Human MedicineEast LansingMI
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Desai A, Zumbo A, Giordano M, Morandini P, Laino ME, Azzolini E, Fabbri A, Marcheselli S, Giotta Lucifero A, Luzzi S, Voza A. Word2vec Word Embedding-Based Artificial Intelligence Model in the Triage of Patients with Suspected Diagnosis of Major Ischemic Stroke: A Feasibility Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15295. [PMID: 36430014 PMCID: PMC9691077 DOI: 10.3390/ijerph192215295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The possible benefits of using semantic language models in the early diagnosis of major ischemic stroke (MIS) based on artificial intelligence (AI) are still underestimated. The present study strives to assay the feasibility of the word2vec word embedding-based model in decreasing the risk of false negatives during the triage of patients with suspected MIS in the emergency department (ED). METHODS The main ICD-9 codes related to MIS were used for the 7-year retrospective data collection of patients managed at the ED with a suspected diagnosis of stroke. The data underwent "tokenization" and "lemmatization". The word2vec word-embedding algorithm was used for text data vectorization. RESULTS Out of 648 MIS, the word2vec algorithm successfully identified 83.9% of them, with an area under the curve of 93.1%. CONCLUSIONS Natural language processing (NLP)-based models in triage have the potential to improve the early detection of MIS and to actively support the clinical staff.
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Affiliation(s)
- Antonio Desai
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| | - Aurora Zumbo
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Internal Medicine, Humanitas Research Hospital, 20089 Milan, Italy
| | - Mauro Giordano
- Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Pierandrea Morandini
- Artificial Intelligence Center, Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy
| | - Maria Elena Laino
- Department of Radiology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Elena Azzolini
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Health Directorate, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
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Devlin S. Not so FAST: pre-hospital posterior circulation stroke. Br Paramed J 2022; 7:24-28. [DOI: 10.29045/14784726.2022.06.7.1.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Posterior circulation strokes account for 20% of ischaemic strokes, but may present differently to their anterior circulation counterparts. Patients may not exhibit unilateral facial weakness, speech disturbances and unilateral limb weakness, but instead present
with more vague symptoms of sudden headache, dizziness, loss of balance and visual problems. This case describes a patient displaying signs and symptoms of a posterior stroke, but who eluded the FAST (face, arm, speech, time) test.Case presentation: An ambulance was called for a
60-year-old man who had a sudden onset of generalised weakness, diaphoresis and one episode of emesis at home in rural Ireland. He had a history of hypertension, hypercholesterolaemia, angina and a coronary stent placed 4 months previously. Cardiac, respiratory, abdominal, urinary and gastrointestinal
exams were unremarkable. Vital signs and 12-lead electrocardiogram were normal. He was FAST negative on exam. Due to persistent dizziness, further neurological exams were carried out, showing a left visual field neglect, new nystagmus, left-sided dysmetria on finger-to-nose and heel-to-shin
tests and he was unable to walk unassisted upon standing. A posterior circulation stroke was suspected, and the nearest stroke unit was pre-alerted en route. A rapid assessment and computed tomography took place at hospital, with timely thrombolysis with tissue plasminogen activator. The patient
subsequently had a full neurological recovery.Conclusion: This case describes a patient displaying signs and symptoms of a posterior circulation stroke albeit being FAST negative on exam. There is potential here to improve our recognition of posterior stroke in the pre-hospital
field by including additional neurological exams to the FAST test. Use of ‘BEFAST’ (balance, eyes, face, arm, speech, time), the finger-to-nose test, and the ‘5 Ds’ and ‘DANISH’ mnemonics may help increase recognition of these subtle presentations.
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 287] [Impact Index Per Article: 143.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Dylla L, Rice JD, Poisson SN, Monte AA, Higgins HM, Ginde AA, Herson PS. Analysis of Stroke Care Among 2019-2020 National Emergency Medical Services Information System Encounters. J Stroke Cerebrovasc Dis 2022; 31:106278. [PMID: 34998044 PMCID: PMC8851983 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/07/2021] [Accepted: 12/17/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Emergency Medicine Service (EMS) providers play a pivotal role in early identification and initiation of treatment for stroke. The objective of this study is to characterize nationwide EMS practices for suspected stroke and assess for gender-based differences in compliance with American Stroke Association (ASA) guidelines. MATERIALS AND METHODS Using the 2019-2020 National Emergency Medical Services Information System (NEMSIS) Datasets, we identified encounters with an EMS designated primary impression of stroke. We characterized patient characteristics and EMS practices and assessed compliance with eight metrics for "guideline-concordant" care. Multivariable logistic regression modeled the association between gender and the primary outcome (guideline-concordant care), adjusted for age, EMS level of service, EMS geographical region, region type (i.e. urban or rural), and year. RESULTS Of 693,177 encounters with a primary impression of stroke, overall compliance with each performance metric ranged from 18% (providing supplemental oxygen when the pulse oximetry is less than 94%) to 76% (less than 90sec from incoming call to EMS dispatch). 2,382 (0.39%) encounters were fully guideline-concordant. Women were significantly less likely than men to receive guideline-concordant care (adjusted OR 0.82, 95% CI 0.75-0.89; 0.36% women, 0.43% men with guideline-concordant care). CONCLUSIONS A minority of patients received prehospital stroke care that was documented to be compliant with ASA guidelines. Women were less likely to receive fully guideline-compliant care compared to men, after controlling for confounders, although the difference was small and of uncertain climical importance. Further studies are needed to evaluate the underlying reasons for this disparity, its impact on patient outcomes, and to identify potential targeted interventions to improve prehospital stroke care.
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Affiliation(s)
- Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora CO, USA.
| | - John D Rice
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora CO, USA.
| | - Sharon N Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora CO, USA.
| | - Andrew A Monte
- Department of Emergency Medicine and Pharmaceutical Sciences, University of Colorado School of Medicine, Aurora CO, USA.
| | - Hannah M Higgins
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora CO, USA.
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine.
| | - Paco S Herson
- (7)Department of Neurological Surgery, The Ohio State University, Columbus OH, USA.
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Dowbiggin PL, Infinger AE, Purick GT, Swanson DR, Asimos A, Rhoten JB, VonCannon S, Dometrovich M, Studnek JR. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. PREHOSP EMERG CARE 2021; 26:333-338. [PMID: 34524065 DOI: 10.1080/10903127.2021.1979701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00-2.52) and negative likelihood ratio 0.34 (95% CI 0.25-0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70-0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.
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Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26 Suppl 2, Advancing Legal Epidemiology:S19-S28. [PMID: 32004219 DOI: 10.1097/phh.0000000000001126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Approximately 800 000 strokes occur annually in the United States. Stroke systems of care policies addressing prehospital and in-hospital care have been proposed to improve access to time-sensitive, lifesaving treatments for stroke. Policy surveillance of stroke systems of care laws supported by best available evidence could reveal potential strengths and weaknesses in how stroke care delivery is regulated across the nation. DESIGN This study linked the results of an early evidence assessment of 15 stroke systems of care policy interventions supported by best available evidence to a legal data set of the body of law in effect on January 1, 2018, for the 50 states and Washington, District of Columbia. RESULTS As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 type of stroke center. Thirty states recognizing stroke centers also had evidence-supported prehospital policy interventions authorized in law. Four states authorized 10 or more of 15 evidence-supported policy interventions. Some combinations of prehospital and in-hospital policy interventions were more prevalent than other combinations. CONCLUSION The analysis revealed that many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. This study provides a baseline for ongoing policy surveillance and serves as a basis for subsequent stroke systems of care policy implementation and policy impact studies.
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14
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Polineni SP, Perez EJ, Wang K, Gutierrez CM, Walker J, Foster D, Dong C, Asdaghi N, Romano JG, Sacco RL, Rundek T. Sex and Race-Ethnic Disparities in Door-to-CT Time in Acute Ischemic Stroke: The Florida Stroke Registry. J Am Heart Assoc 2021; 10:e017543. [PMID: 33787282 PMCID: PMC8174374 DOI: 10.1161/jaha.120.017543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Less than 40% of acute stroke patients have computed tomography (CT) imaging performed within 25 minutes of hospital arrival. We aimed to examine the race‐ethnic and sex differences in door‐to‐CT (DTCT) ≤25 minutes in the FSR (Florida Stroke Registry). Methods and Results Data were collected from 2010 to 2018 for 63 265 patients with acute ischemic stroke from the FSR and secondary analysis was performed on 15 877 patients with intravenous tissue plasminogen activator‐treated ischemic stroke. Generalized estimating equation models were used to determine predictors of DTCT ≤25. DTCT ≤25 was achieved in 56% of cases of suspected acute stroke, improving from 36% in 2010 to 72% in 2018. Women (odds ratio [OR], 0.90; 95% CI, 0.87–0.93) and Black (OR, 0.88; CI, 0.84–0.94) patients who had strokes were less likely, and Hispanic patients more likely (OR, 1.07; CI, 1.01–1.14), to achieve DTCT ≤25. In a secondary analysis among intravenous tissue plasminogen activator‐treated patients, 81% of patients achieved DTCT ≤25. In this subgroup, women were less likely to receive DTCT ≤25 (0.85, 0.77–0.94) whereas no significant differences were observed by race or ethnicity. Conclusions In the FSR, there was considerable improvement in acute stroke care metric DTCT ≤25 in 2018 in comparison to 2010. However, sex and race‐ethnic disparities persist and require further efforts to improve performance and reduce these disparities.
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Affiliation(s)
- Sai P Polineni
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | - Kefeng Wang
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | | | | | - Chuanhui Dong
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Negar Asdaghi
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Jose G Romano
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Ralph L Sacco
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Tatjana Rundek
- Department of Neurology University of Miami Miller School of Medicine Miami FL
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15
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Dowbiggin PL, Infinger AI, Purick G, Swanson DR, Studnek JR. Inter-Rater Reliability of the FAST-ED in the Out-of-Hospital Setting. PREHOSP EMERG CARE 2021:1-8. [PMID: 33205683 DOI: 10.1080/10903127.2020.1852350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 10/23/2022]
Abstract
Introduction: Patients experiencing a large vessel occlusion stroke (LVOS) may require endovascular-capable centers and benefit from direct transport to such facilities, creating a need for an accurate prehospital assessment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a secondary scale to identify LVOS. Currently, there is limited prospective evidence validating the use of the FAST-ED in the prehospital environment. This study aimed to evaluate the inter-rater reliability of the FAST-ED between patient care providers in the prehospital setting.Methods: This prospective study was conducted between 4/1/2018 and 7/1/2018 in a single municipal EMS agency that staffs two providers per ambulance with at least one being a paramedic. Patients were included based on paramedic impression that the patient was both having a stroke and greater than 18 years old. Each provider independently performed and documented a FAST-ED assessment on eligible patients. Data analysis consisted of performing inter-rater reliability using Cohen's Kappa on the FAST-ED score between primary and secondary providers. The FAST-ED was analyzed on an item level, an aggregate level (cumulative of all items), and using the defined cut point of ≥4. A sub-analysis determined if inter-rater reliability changed across provider certification.Results: There were 231 patients included in this analysis with an average age of 68.5 years and 135 (58.4%) female. Inter-rater reliability varied across individual items in the scale from 90.1% agreement to 82.5%. When analyzing inter-rater reliability of the aggregate FAST-ED score, the scale demonstrated 70.1% agreement (Kappa 0.66), considered substantial agreement. FAST-ED scores were analyzed using a cut point of ≥4. When using this cut point, there was 92.2% (Kappa 0.81) agreement between primary and secondary caregiver, demonstrating almost perfect agreement. Agreement was substantial across provider certifications including paramedics and EMTS.Conclusion: This study demonstrated high inter-rater reliability of the FAST-ED scale when performed in the prehospital setting on patients suspected of having a stroke. There were minimal differences in reliability based on provider certification, and item level analysis indicated substantial inter-rater reliability.
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Oostema JA, Chassee T, Baer W, Edberg A, Reeves MJ. Accuracy and Implications of Hemorrhagic Stroke Recognition by Emergency Medical Services. PREHOSP EMERG CARE 2020; 25:796-801. [PMID: 33026277 DOI: 10.1080/10903127.2020.1831669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hemorrhagic stroke is a medical emergency that requires rapid identification and treatment. Despite playing a critical role in the emergency response to hemorrhagic stroke patients, a minimal amount is known about the quality of emergency medical services (EMS) care for this condition. The objectives of this study were to quantify EMS hemorrhagic stroke recognition, identify predictors of accurate EMS recognition, and examine associations between EMS recognition, quality of prehospital care, and patient outcomes. Methods: Consecutive EMS-transported hemorrhagic strokes were identified from medical records at 4 primary stroke centers. Data regarding prehospital care were abstracted from EMS records and linked to in-hospital data. Clinical predictors of accurate EMS recognition were examined using logistic regression. EMS performance measure compliance and hospital outcomes were also compared among EMS recognized and unrecognized hemorrhagic strokes. Results: Over 24 months, EMS-transported 188 hemorrhagic stroke patients; 108 (57.4%) were recognized by EMS. Recognized cases had higher rates of stroke scale documentation (84.3% vs. 20.0%, p < 0.001); multivariable logistic regression confirmed a strong independent relationship between stroke scale documentation and recognition (adjusted OR 15.1 [5.6 to 40.7]). Recognized cases also had shorter on-scene times (15.5 vs. 21 min, p < 0.001) and door-to-computed tomography (DTCT) acquisition times (20 vs. 47 min, p < 0.001). Conclusions: Among EMS-transported hemorrhagic stroke cases, stroke screen documentation was strongly associated with EMS stroke recognition, which was in turn associated with higher quality of EMS care and faster computed tomography (CT) scans upon emergency department arrival.
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Oostema JA, Nickles A, Reeves MJ. A Comparison of Probabilistic and Deterministic Match Strategies for Linking Prehospital and in-Hospital Stroke Registry Data. J Stroke Cerebrovasc Dis 2020; 29:105151. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/12/2020] [Indexed: 01/01/2023] Open
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18
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Gorchs-Molist M, Solà-Muñoz S, Enjo-Perez I, Querol-Gil M, Carrera-Giraldo D, Nicolàs-Arfelis JM, Jiménez-Fàbrega FX, Pérez de la Ossa N. An Online Training Intervention on Prehospital Stroke Codes in Catalonia to Improve the Knowledge, Pre-Notification Compliance and Time Performance of Emergency Medical Services Professionals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176183. [PMID: 32858885 PMCID: PMC7503298 DOI: 10.3390/ijerph17176183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 01/19/2023]
Abstract
Strokes are a time-dependent medical emergency. The training of emergency medical service (EMS) professionals is essential to ensure the activation of stroke codes with pre-notification, as well as a rapid transfer to achieve early therapy. New assessment scales for the detection of patients with suspected large vessel occlusion ensures earlier access to endovascular therapy. The aim of this study was to evaluate the impact on an online training intervention focused on the Rapid Arterial oCclusion Evaluation (RACE) scoring of EMS professionals based on the prehospital stroke code in Catalonia from 2014 to 2018 in a pre–post intervention study. All Catalonian EMS professionals and the clinical records from primary stroke patients were included. The Kirkpatrick model guided the evaluation of the intervention. Data were collected on the knowledge on stroke recognition and management, pre-notification compliance, activated stroke codes and time performance of EMS professionals. Knowledge improved significatively in most items and across all categories, reaching a global achievement of 82%. Pre-notification compliance also improved significantly and remained high in the long-term. Increasingly higher notification of RACE scores were recorded from 60% at baseline to 96.3% in 2018, and increased on-site clinical care time and global time were also observed. Therefore, the online training intervention was effective for increasing EMS professionals’ knowledge and pre-notification compliance upon stroke code activation, and the wide adoption of a new prehospital scale for the assessment of stroke severity (i.e., the RACE scale) was achieved.
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Affiliation(s)
- Montse Gorchs-Molist
- Catalonian Emergency Medical System, 08908 L’Hospitalet de Llobregat, Spain; (S.S.-M.); (M.Q.-G.); (F.X.J.-F.)
- School of Medicine and Healthcare Sciences, University of Barcelona, 08036 Barcelona, Spain;
- Correspondence: (M.G.-M.); (I.E.-P.)
| | - Silvia Solà-Muñoz
- Catalonian Emergency Medical System, 08908 L’Hospitalet de Llobregat, Spain; (S.S.-M.); (M.Q.-G.); (F.X.J.-F.)
| | - Iago Enjo-Perez
- School of Medicine and Healthcare Sciences, University of Barcelona, 08036 Barcelona, Spain;
- Correspondence: (M.G.-M.); (I.E.-P.)
| | - Marisol Querol-Gil
- Catalonian Emergency Medical System, 08908 L’Hospitalet de Llobregat, Spain; (S.S.-M.); (M.Q.-G.); (F.X.J.-F.)
| | - David Carrera-Giraldo
- Departament of Neurosurgery, University Hospital Doctor Negrín, 35010 Las Palmas de Gran Canarias, Spain;
| | | | - Francesc Xavier Jiménez-Fàbrega
- Catalonian Emergency Medical System, 08908 L’Hospitalet de Llobregat, Spain; (S.S.-M.); (M.Q.-G.); (F.X.J.-F.)
- School of Medicine and Healthcare Sciences, University of Barcelona, 08036 Barcelona, Spain;
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Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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Li T, Cushman JT, Shah MN, Kelly AG, Rich DQ, Jones CMC. Prehospital time intervals and management of ischemic stroke patients. Am J Emerg Med 2020; 42:127-131. [PMID: 32059935 DOI: 10.1016/j.ajem.2020.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 02/06/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Quantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED). METHODS Acute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed. RESULTS Data from 870 patients were analyzed. Median total prehospital time was 39 min and comprised the following: chute time: 1 min; response time: 9 min; on-scene time: 15 min; and transport time: 14 min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9 min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene. CONCLUSIONS On-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.
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Affiliation(s)
- Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States of America.
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America; Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Adam G Kelly
- Department of Neurology, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America
| | - David Q Rich
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America; Department of Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America; Department of Environmental Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America; Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, United States of America
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Oostema JA, Chassee T, Baer W, Edberg A, Reeves MJ. Brief Educational Intervention Improves Emergency Medical Services Stroke Recognition. Stroke 2020; 50:1193-1200. [PMID: 30917754 PMCID: PMC6476674 DOI: 10.1161/strokeaha.118.023885] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Recognition of stroke symptoms and hospital prenotification by emergency medical services (EMS) facilitate rapid stroke treatment; however, one-third of patients with stroke are unrecognized by EMS. To promote stroke recognition and quality measure compliant prehospital stroke care, we deployed a 30-minute online EMS educational module coupled with a performance feedback system in a single Michigan county. Methods- During a 24-month study period, a registry of consecutive EMS-transported suspected or unrecognized stroke cases was utilized to perform an interrupted time series analysis of the impact of the EMS education and feedback intervention. For each agency, we compared EMS stroke recognition and quality measure compliance rates, as well as emergency department performance and hospital outcomes during 12 preintervention months with performance in the remaining study months. Results- A total of 1805 EMS-transported cases met inclusion criteria; 1235 (68.4%) of these had ischemic or hemorrhagic strokes or transient ischemic attacks. There were no trends toward improvement in any outcome before the intervention. After the intervention, the EMS stroke recognition rate increased from 63.8% to 69.5% ( P=0.037). Prenotification increased from 60.9% to 77.3% ( P<0.001). Among patients with ischemic stroke/transient ischemic attack, there was a trend toward higher rates of tPA (tissue-type plasminogen activator) delivery (13.9%-17.7%; P=0.096) and a significant increase in tPA delivery within 45 minutes (5.7%-8.9%; P=0.042) after intervention. However, improvements in EMS recognition were limited to the first 3 months following intervention. Conclusions- A brief educational intervention was associated with improved EMS stroke recognition, hospital prenotification, and faster tPA delivery. Gains were primarily observed immediately following education and were not sustained through provision of performance feedback to paramedics.
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Affiliation(s)
- J Adam Oostema
- From the Department of Emergency Medicine, Michigan State University College of Human Medicine, Secchia Center, Grand Rapids (J.A.O.)
| | - Todd Chassee
- Kent County Emergency Medical Services, Grand Rapids, MI (T.C.)
| | - William Baer
- Department of Research and Innovation, Mercy Health St. Mary's Hospital, Grand Rapids, MI (W.B.)
| | - Allison Edberg
- Department of Emergency Medicine, Metro Health Hospital, Wyoming, MI (A.E.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, MI (M.J.R.)
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Pap R, Lockwood C, Stephenson M, Simpson P. Indicators to measure prehospital care quality: a scoping review. ACTA ACUST UNITED AC 2019; 16:2192-2223. [PMID: 30439748 DOI: 10.11124/jbisrir-2017-003742] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The purpose of this scoping review was to locate, examine and describe the literature on indicators used to measure prehospital care quality. INTRODUCTION The performance of ambulance services and quality of prehospital care has traditionally been measured using simple indicators, such as response time intervals, based on low-level evidence. The discipline of paramedicine has evolved significantly over the last few decades. Consequently, the validity of utilizing such measures as holistic prehospital care quality indicators (QIs) has been challenged. There is growing interest in finding new and more significant ways to measure prehospital care quality. INCLUSION CRITERIA This scoping review examined the concepts of prehospital care quality and QIs developed for ambulance services. This review considered primary and secondary research in any paradigm and utilizing any methods, as well as text and opinion research. METHODS Joanna Briggs Institute methodology for conducting scoping reviews was employed. Separate searches were conducted for two review questions; review question 1 addressed the definition of prehospital care quality and review question 2 addressed characteristics of QIs in the context of prehospital care. The following databases were searched: PubMed, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. The searches were limited to publications from January 1, 2000 to the day of the search (April 16, 2017). Non-English articles were excluded. To supplement the above, searches for gray literature were performed, experts in the field of study were consulted and applicable websites were perused. RESULTS Review question 1: Nine articles were included. These originated mostly from England (n = 3, 33.3%) and the USA (n = 3, 33.3%). Only one study specifically aimed at defining prehospital care quality. Five articles (55.5%) described attributes specific to prehospital care quality and four (44.4%) articles considered generic healthcare quality attributes to be applicable to the prehospital context. A total of 17 attributes were identified. The most common attributes were Clinical effectiveness (n = 17, 100%), Efficiency (n = 7, 77.8%), Equitability (n = 7, 77.8%) and Safety (n = 6, 66.7%). Timeliness and Accessibility were referred to by four and three (44.4% and 33.3%) articles, respectively.Review question 2: Thirty articles were included. The predominant source of articles was research literature (n = 23; 76.7%) originating mostly from the USA (n = 13; 43.3%). The most frequently applied QI development method was a form of consensus process (n = 15; 50%). A total of 526 QIs were identified. Of these, 283 (53.8%) were categorized as Clinical and 243 (46.2%) as System/Organizational QIs. Within these categories respectively, QIs related to Out-of-hospital cardiac arrest (n = 57; 10.8%) and Time intervals (n = 75; 14.3%) contributed the most. The most commonly addressed prehospital care quality attributes were Appropriateness (n = 250, 47.5%), Clinical effectiveness (n = 174, 33.1%) and Accessibility (n = 124, 23.6%). Most QIs were process indicators (n = 386, 73.4%). CONCLUSION Whilst there is paucity in research aiming to specifically define prehospital care quality, the attributes of generic healthcare quality definitions appear to be accepted and applicable to the prehospital context. There is growing interest in developing prehospital care QIs. However, there is a need for validation of existing QIs and de novo development addressing broader aspects of prehospital care.
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Affiliation(s)
- Robin Pap
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,School of Science and Health, Western Sydney University, Sydney, Australia
| | - Craig Lockwood
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Matthew Stephenson
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Paul Simpson
- School of Science and Health, Western Sydney University, Sydney, Australia
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Hansen G, Bal S, Schellenberg KL, Alcock S, Ghrooda E. Prehospital Management of Acute Stroke in Rural versus Urban Responders. J Neurosci Rural Pract 2019; 8:S33-S36. [PMID: 28936069 PMCID: PMC5602258 DOI: 10.4103/jnrp.jnrp_2_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: Stroke guideline compliance of rural Canadian prehospital emergency medical services (EMS) care in acute stroke is unknown. In this quality assurance study, we sought to compare rural and urban care by prehospital EMS evaluation/management indicators from patients assessed at an urban Canadian stroke center. Materials and Methods: One hundred adult patients were randomly selected from the stroke registry. Patients were transported through Rural EMS bypass protocols or urban EMS protocols (both bypass and direct) to our stroke center between January and December 2013. Patients were excluded if they were first evaluated at any other health center. Prehospital care was assessed using ten indicators for EMS evaluation/management, as recommended by acute stroke guidelines. Results: Compliance with acute stroke EMS evaluation/management indicators were statistically similar for both groups, except administrating a prehospital diagnostic tool (rural 31.8 vs. urban 70.3%; P = 0.002). Unlike urban EMS, rural EMS did not routinely document scene time. Conclusion: Rural EMS responders’ compliance to prehospital stroke evaluation/management was similar to urban EMS responders. Growth areas for both groups may be with prehospital stroke diagnostic tool utilization, whereas rural EMS responders may also improve with scene time documentation.
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Affiliation(s)
- Gregory Hansen
- Department of Pediatrics, Division of Critical Care, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Division of Neurology, University of Calgary, Calgary, Alberta T2N 2T9, Canada
| | - Kerri Lynn Schellenberg
- Department of Medicine, Division of Neurology, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
| | - Susan Alcock
- Department of Medicine, Health Sciences Centre, Section of Neurology, University of Manitoba, Winnipeg, Manitoba R3A 1R9, Canada
| | - Esseddeeg Ghrooda
- Department of Medicine, Health Sciences Centre, Section of Neurology, University of Manitoba, Winnipeg, Manitoba R3A 1R9, Canada
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Abstract
BACKGROUND Research suggests that there is a delay in recognizing unique stroke symptoms in women by both healthcare professionals and the general population. The purpose of this review was to identify and summarize the most relevant literature regarding recognition and assessment of unique stroke symptoms in women. METHODS Literature review using PubMed, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar was used to search literature describing unique stroke symptoms. RESULTS Unique stroke symptoms, female sex, and race are associated with delayed recognition, treatment, misdiagnosis, and outcomes. Women experience unique symptoms of nausea/vomiting, headache, dizziness, and cognitive dysfunction more often than men. Stroke assessment tools and registries recognize 1 to 4 of the 11 unique stroke symptoms in women, no study directly assesses the sensitivity and specificity of these unique symptoms, and all studies included women and men. Conclusions and Nursing Implications: Current assessment tools and registries are not sensitive and specific to measuring unique stroke symptoms in women. Accurately identifying unique stroke symptoms in women may reduce presentation and treatment time, minimizing misdiagnoses and poor patient outcomes.
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DiBiasio EL, Jayaraman MV, Oliver L, Paolucci G, Clark M, Watkins C, DeLisi K, Wilks A, Yaghi S, Hemendinger M, Baird GL, Oostema JA, McTaggart RA. Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols. J Neurointerv Surg 2018; 12:370-373. [DOI: 10.1136/neurintsurg-2018-014108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/10/2018] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Abstract
BackgroundFollowing the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs.PurposeWe developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge.MethodsWe assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models.ResultsTraining was provided for 179 EMS providers throughout the state.Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%–88%, P<0.0001). Each of the 10 questions was individually assessed and all showed significant gains in EMS knowledge after training (P<0.0001).ConclusionsA brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.
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Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med 2018; 33:501-507. [PMID: 30156180 DOI: 10.1017/s1049023x18000766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IntroductionIschemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.Hypothesis/ProblemThis study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED). METHODS A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers. RESULTS Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159). CONCLUSIONS Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ. LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to providing prehospital care to ischemic stroke patients: predictors and impact on care. Prehosp Disaster Med. 2018;33(5):501-507.
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English SW, Rabinstein AA, Mandrekar J, Klaas JP. Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale. J Stroke Cerebrovasc Dis 2018; 27:919-925. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/20/2017] [Accepted: 10/29/2017] [Indexed: 01/19/2023] Open
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Oostema JA, Chassee T, Reeves M. Emergency Dispatcher Stroke Recognition: Associations with Downstream Care. PREHOSP EMERG CARE 2018; 22:466-471. [PMID: 29336708 DOI: 10.1080/10903127.2017.1405131] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE As the first point of contact for patients activating emergency medical services (EMS), emergency dispatchers have the earliest opportunity to recognize stroke. We sought to quantify dispatcher stroke recognition and its relationships with EMS stroke recognition and response speed. METHODS We assembled a cohort of consecutive EMS-transported patients with a dispatcher suspected stroke or a hospital discharge diagnosis of stroke or transient ischemic attack (TIA). Dispatcher sensitivity and positive predictive value (PPV) for stroke recognition were calculated. Multivariable logistic regression analysis was used to determine predictors of dispatcher recognition and relationships between dispatcher recognition and downstream care. RESULTS During a 12-month period, 601 patients met inclusion criteria. Dispatchers suspected stroke in 229/324 (sensitivity = 70.7% [65.5 to 75.4%]) confirmed stroke/TIA cases and correctly assigned a suspected stroke label in 229/506 cases (PPV = 45.3% [41.0 to 49.6%]). Dispatchers had higher odds of recognizing ischemic strokes (aOR 3.4 [1.4 to 8.5]) and lower odds of recognizing patients with visual deficits (aOR = 0.4 [0.2 to 0.9]) or vomiting (aOR = 0.3 [0.1 to 0.9]). Dispatcher suspected stroke cases received more on-scene stroke screens (79.0% vs. 54.7%, p < 0.0001) and were more often recognized by EMS as strokes (77.7% vs. 57.9%, p = 0.0005). Dispatcher recognition was independently associated with EMS stroke recognition (aOR = 3.8 [1.9 to 7.7]), but not with transportation times, door-to-CT times, or t-PA delivery. CONCLUSIONS Emergency dispatcher stroke recognition is associated with higher rates of on-scene stroke scale performance and EMS ischemic stroke recognition but not with reduced transport times, door-to-CT times, or t-PA treatment.
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Redlener M, Olivieri P, Loo GT, Munjal K, Hilton MT, Potkin KT, Levy M, Rabrich J, Gunderson MR, Braithwaite SA. National Assessment of Quality Programs in Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:370-378. [PMID: 29297735 DOI: 10.1080/10903127.2017.1380094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS. METHODS A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©. RESULTS A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%). CONCLUSIONS EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.
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Abstract
Introduction Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Problem Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature. METHODS A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment. RESULTS The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review. CONCLUSION Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.
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Eriksson M, Glader EL, Norrving B, Stegmayr B, Asplund K. Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden. Brain Behav 2017; 7:e00654. [PMID: 28413705 PMCID: PMC5390837 DOI: 10.1002/brb3.654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/16/2016] [Accepted: 01/10/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy. METHODS This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012. RESULTS The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n = 9), 0.5% to 38.7% in specialized nonuniversity hospitals (n = 22), and 4.2% to 40.3% in community hospitals (n = 41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r = .75). CONCLUSION Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.
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Affiliation(s)
- Marie Eriksson
- Department of Statistics USBE, Umeå University Umeå Sweden.,Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Bo Norrving
- Section of Neurology Department of Clinical Sciences Lund University Lund Sweden
| | - Birgitta Stegmayr
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Kjell Asplund
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
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French BR, Boddepalli RS, Govindarajan R. Acute Ischemic Stroke: Current Status and Future Directions. MISSOURI MEDICINE 2016; 113:480-486. [PMID: 30228538 PMCID: PMC6139763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The evolving knowledge on stroke in conjunction with advances in the field of imaging, treatment approaches using recombinant tissue plasminogen activator (rtPA) or thrombectomy devices in recanalization, and efficient emergency stroke workflow processes have opened new frontiers in managing patients with an acute ischemic stroke. These frontiers have been reformed and overcome in overcoming the decades-long watch and wait approach towards patients with ischemic stroke. In this article, we focus on the current strategies for managing ischemic stroke and conclude by providing a brief overview of anticipating developments that can transform future stroke treatments.
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Affiliation(s)
- Brandi R French
- Brandi R. French, MD, Assistant Professor of Clinical Vascular Neurology, Medical Director of Inpatient Neurosciences Unit in the Department of Neurology, University of Missouri - Columbia, Missouri
| | - Raja S Boddepalli
- Raja S. Boddepalli, MD, Research Assistant in the Department of Neurology, University of Missouri - Columbia, Missouri
| | - Raghav Govindarajan
- Raghav Govindarajan MD, FISQua, FACSc, FCCP, MSMA member since 2013 and 2017 Boone County Medical society President, Assistant Professor in the Department of Neurology, University of Missouri - Columbia, Missouri
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Frischknecht Christensen E, Berlac PA, Nielsen H, Christiansen CF. The Danish quality database for prehospital emergency medical services. Clin Epidemiol 2016; 8:667-671. [PMID: 27843347 PMCID: PMC5098515 DOI: 10.2147/clep.s100919] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM OF DATABASE The aim of the Danish quality database for prehospital emergency medical services (QEMS) is to assess, monitor, and improve the quality of prehospital emergency medical service care in the entire prehospital patient pathway. The aim of this review is to describe the design and the implementation of QEMS. STUDY POPULATION The study population consists of all "112 patient contacts" defined as emergency patients, where the entrance to health care is a 112 call forwarded to one of the five regional emergency medical coordination centers in Denmark since January 1, 2014. Estimated annual number of included "112 patients" is 300,000-350,000. MAIN VARIABLES We defined nine quality indicators and the following variables: time stamps for emergency calls received at one of the five regional emergency medical coordination centers, dispatch of prehospital unit(s), arrival of first prehospital unit, arrival of first supplemental prehospital unit, and mission completion. Finally, professional level and type of the prehospital resource dispatched to an incident and end-of-mission status (mission completed by phone, on scene, or admission to hospital) are registered. DESCRIPTIVE DATA Descriptive data included age, region, and Danish Index for Emergency Care including urgency level. CONCLUSION QEMS is a new database under establishment and is expected to provide the basis for quality improvement in the prehospital setting and in the entire patient care pathway, for example, by providing prehospital data for research and other quality databases.
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Affiliation(s)
- Erika Frischknecht Christensen
- Clinical Institute, Aalborg University; Department of Anesthesiology and Intensive Care, Aalborg University Hospital, Aalborg; Prehospital Emergency Medical Services, North Denmark Region
| | | | - Henrik Nielsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Christensen EF, Larsen TM, Jensen FB, Bendtsen MD, Hansen PA, Johnsen SP, Christiansen CF. Diagnosis and mortality in prehospital emergency patients transported to hospital: a population-based and registry-based cohort study. BMJ Open 2016; 6:e011558. [PMID: 27377636 PMCID: PMC4947831 DOI: 10.1136/bmjopen-2016-011558] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Knowledge about patients after calling for an ambulance is limited to subgroups, such as patients with cardiac arrest, myocardial infarction, trauma and stroke, while population-based studies including all diagnoses are few. We examined the diagnostic pattern and mortality among all patients brought to hospital by ambulance after emergency calls. DESIGN Registry-based cohort study. SETTING AND PARTICIPANTS We included patients brought to hospital in an ambulance dispatched after emergency calls during 2007-2014 in the North Denmark Region (580 000 inhabitants). We reported hospital diagnosis according to the chapters of the International Classification of Diseases, 10th Edition (ICD-10), and studied death on days 1 and 30 after the call. Cohort characteristics and diagnoses were described, and the Kaplan-Meier method was used to estimate mortality and 95% CIs. RESULTS In total, 148 757 patients were included, mean age 52.9 (SD 24.3) years. The most frequent ICD-10 diagnosis chapters were: 'injury and poisoning' (30.0%), and the 2 non-specific diagnosis chapters: 'symptoms and abnormal findings, not elsewhere classified' (17.5%) and 'factors influencing health status and contact with health services' (14.1%), followed by 'diseases of the circulatory system' (10.6%) and 'diseases of the respiratory system' (6.7%). The overall 1-day mortality was 1.8% (CI 1.7% to 1.8%) and 30-day mortality 4.7% (CI 4.6% to 4.8%). 'Diseases of the circulatory system' had the highest 1-day mortality of 7.7% (CI 7.3% to 8.1%) accounting for 1209 deaths. After 30 days, the highest number of deaths were among circulatory diseases (2313), respiratory diseases (1148), 'symptoms and abnormal findings, not elsewhere classified' (1119) and 'injury and poisoning' (741), and 30 days mortality in percentage was 14.7%, 11.6%, 4.3% and 1.7%, respectively. CONCLUSIONS Patients' diagnoses from hospital stay after calling 1-1-2 in this population-based study were distributed across all ICD-10 chapters. Mortality varied widely between diagnostic groups. Non-specific diagnoses accounted for one-third of the patients and contributed to mortality in terms of total number of deaths.
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Affiliation(s)
- Erika Frischknecht Christensen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Thomas Mulvad Larsen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark
- Unit of Business Intelligence, North Denmark Region, Aalborg, Denmark
| | | | - Mette Dahl Bendtsen
- Department of Clinical Medicine, Pre-hospital and Emergency Research, Aalborg University, Aalborg, Denmark
- Unit of Clinical Biostatistics and Bioinformatics, Aalborg University Hospital, Aalborg, Denmark
| | - Poul Anders Hansen
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Shams T, Zaidat O, Yavagal D, Xavier A, Jovin T, Janardhan V. Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2016; 5:1-28. [PMID: 27610118 PMCID: PMC4934489 DOI: 10.1159/000443617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.
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Affiliation(s)
- Tanzila Shams
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
| | - Osama Zaidat
- Mercy Neuroscience and Stroke Center, Toledo, Ohio, USA
| | - Dileep Yavagal
- Jackson Memorial Hospital, University of Miami Health System, Miami, Fla., USA
| | - Andrew Xavier
- Detroit Medical Center, Wayne State University, Detroit, Mich., USA
| | - Tudor Jovin
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Vallabh Janardhan
- Texas Stroke Institute, HCA North Texas Division, Dallas-Fort Worth, Tex., USA
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Fire Engine Support and On-scene Time in Prehospital Stroke Care - A Prospective Observational Study. Prehosp Disaster Med 2016; 31:278-81. [PMID: 27018812 DOI: 10.1017/s1049023x16000303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction On-scene time (OST) previously has been shown to be a significant component of Emergency Medical Services' (EMS') operational delay in acute stroke. Since stroke patients are managed routinely by two-person ambulance crews, increasing the number of personnel available on the scene is a possible method to improve their performance. Hypothesis Using fire engine crews to support ambulances on the scene in acute stroke is hypothesized to be associated with a shorter OST. METHODS All patients transported to hospital as thrombolysis candidates during a one-year study period were registered by the ambulance crews using a case report form that included patient characteristics and operational EMS data. RESULTS Seventy-seven patients (41 [53%] male; mean age of 68.9 years [SD=15]; mean Glasgow Coma Score [GCS] of 15 points [IQR=14-15]) were eligible for the study. Forty-five cases were managed by ambulance and fire engine crews together and 32 by the ambulance crews alone. The median ambulance response time was seven minutes (IQR=5-10) and the fire engine response time was six minutes (IQR=5-8). The number of EMS personnel on the scene was six (IQR=5-7) and two (IQR=2-2), and the OST was 21 minutes (IQR=18-26) and 24 minutes (IQR=20-32; P =.073) for the groups, respectively. In a following regression analysis, using stroke as the dispatch code was the only variable associated with short (<22 minutes) OST with an odds ratio of 3.952 (95% CI, 1.279-12.207). CONCLUSION Dispatching fire engine crews to support ambulances in acute stroke care was not associated with a shorter on-scene stay when compared to standard management by two-person ambulance crews alone. Using stroke as the dispatch code was the only variable that was associated independently with a short OST. Puolakka T , Väyrynen T , Erkkilä E-P , Kuisma M . Fire engine support and on-scene time in prehospital stroke care - a prospective observational study. Prehosp Disaster Med. 2016;31(3):278-281.
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Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
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Oostema JA, Konen J, Chassee T, Nasiri M, Reeves MJ. Clinical predictors of accurate prehospital stroke recognition. Stroke 2015; 46:1513-7. [PMID: 25922507 DOI: 10.1161/strokeaha.115.008650] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/27/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital activation of in-hospital stroke response hastens treatment but depends on accurate emergency medical services (EMS) stroke recognition. We sought to measure EMS stroke recognition accuracy and identify clinical factors associated with correct stroke identification. METHODS Using EMS and hospital records, we assembled a cohort of EMS-transported suspect, confirmed, or missed ischemic stroke or transient ischemic attack cases. The sensitivity and positive predictive value (PPV) for EMS stroke recognition were calculated using the hospital discharge diagnosis as the gold standard. We used multivariable logistic regression analysis to determine the association between Cincinnati Prehospital Stroke Scale use and EMS stroke recognition. RESULTS During a 12-month period, 441 EMS-transported patients were enrolled; of which, 371 (84.1%) were EMS-suspected strokes and 70 (15.9%) were EMS-missed strokes. Overall, 264 cases (59.9%) were confirmed as either ischemic stroke (n=186) or transient ischemic attack (n=78). The sensitivity of EMS stroke recognition was 73.5% (95% confidence interval, 67.7-78.7), and PPV was 52.3% (95% confidence interval, 47.1-57.5). Sensitivity (84.7% versus 30.9%; P<0.0001) and PPV (56.2% versus 30.4%; P=0.0004) were higher among cases with Cincinnati Prehospital Stroke Scale documentation. In multivariate analysis, Cincinnati Prehospital Stroke Scale documentation was independently associated with EMS sensitivity (odds ratio, 12.0; 95% confidence interval, 5.7-25.5) and PPV (odds ratio, 2.5; 95% confidence interval, 1.3-4.7). CONCLUSIONS EMS providers recognized 3 quarters of the patients with ischemic stroke and transient ischemic attack; however, half of EMS-suspected strokes were false positives. Documentation of a Cincinnati Prehospital Stroke Scale was associated with higher EMS stroke recognition sensitivity and PPV.
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Affiliation(s)
- J Adam Oostema
- From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.).
| | - John Konen
- From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.)
| | - Todd Chassee
- From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.)
| | - Mojdeh Nasiri
- From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.)
| | - Mathew J Reeves
- From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.)
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