Factors Associated with Delay of Emergency Medical Services Activation in Patients with Acute Stroke

Enhancing stroke response in school children: Efficacy of the HOBIT program - a cluster randomized trial

Objective: Stroke treatment is often hampered by delayed Emergency Medical Services activation. Public campaigns to improve the response to stroke symptoms are either costly or not working. We evaluate the effectiveness of a school-based HOBIT program in improving Emergency Medical Services activation. Methods: This cluster randomized trial was conducted from May to June 2023 at 13 schools in the South Moravian region of Czechia. Schools were randomized to the HOBIT intervention or control group with a 3:1 ratio. Both groups had knowledge assessments at baseline and follow-up. The primary outcome was the percentage change from the pretest to the follow-up test in the intervention group compared to the control group in 4 domains: 1) knowledge, 2) self-efficacy, 3) outcome expectations, 4) behavioral intentions. Results: The baseline knowledge was greater than 50 % in most metrics except for knowledge of the FAST test, which was only 16 %. The intervention effect was 16 % (95 % CI 12-21) for knowledge, 10 % (95 % CI 4-15) for self-efficacy,10 % (95 % CI 5-15) for outcome expectations, 8 % (95 % CI 2-11) for behavioral intentions. Conclusions: In school children, even those with high baseline, "HOBIT" intervention can improve determinants and behavioral intentions of Emergency Medical Services activation for suspected stroke.

The use of intervention mapping to guide the development of a school-based intervention to improve emergency medical services activation for stroke

BACKGROUND

If carried out correctly and without delay, activation of emergency services by stroke bystanders could improve mortality and disability from stroke. This paper describes the development of a school-based intervention using the Intervention Mapping approach. It aims to improve the appropriate activation of emergency medical services for suspected stroke by 12-15-year-old children.

METHODS

The development of the intervention was guided by Intervention Mapping approach. The logic model of the problem was created through analysis of the existing literature and semi-structured interviews with stakeholders. Based on these findings, performance objectives and their determinants were determined and matched to create a model for changing emergency medical services activation behavior. Behavior change methods and their practical applications were then determined. Based on them, intervention messages and materials were designed, the intervention was drafted, pretested, and finalized.

RESULTS

It was found that the main performance objectives for the activation of emergency medical services were (1) recognizing symptoms, (2) communicating with the victim, and (3) calling an ambulance immediately. Their main determinants were knowledge, social influence, risk perception, self-efficacy, outcome expectations, and skills. Determinants were then matched with performance objectives to create the matrices of requested behavior changes. The following change methods were chosen: modeling, elaboration, belief selection, providing cues, scenario-based risk information, and cultural similarity. Methods were translated into practical applications in the form of a short educational film. The production company created, pretested, and finalized the film. As a result, a 5-minute entertainment-education video was created modeling an acute stroke with a child as the main bystander.

CONCLUSION

The Intervention Mapping approach guided the development of a school-based program to improve Emergency medical services activation in stroke by 12-15 year old children. Our process and approach can serve as a model for researchers and health promotion professionals aiming to improve help-seeking behavior for stroke to improve stroke help-seeking behavior as well as other acute diseases.

Analysis of the Factors Intervening in the Prehospital Time in a Stroke Code

INTRODUCTION

Strokes continue to be considered public health problems due to the great social and health impact they entail. They are the second cause of death in the world, with a high incidence and prevalence. They are time-dependent diseases, and more than 80% of cases could be avoidable with greater management of risk factors.

OBJECTIVE

to analyze the factors that influence prehospital time in a stroke code. Assess the population's knowledge of stroke symptoms and teach them how to act when a case is suspected. Document the continued training of health professionals for the early identification of patients with a suspected stroke. Demonstrate the importance of calling EMS as the first contact to reduce delays in prehospital time in a stroke.

METHODOLOGY

A bibliographic review was carried out focusing on articles published between December 2014 and August 2023. The following databases were consulted: Pubmed (Medline), Dialnet, Google Scholar, Web of Science (WOS), Scielo, Scopus, and ScienceDirect.

RESULTS

After applying the article selection criteria and evaluating the quality of the methodology, a total of 18 articles were obtained. The results affirm that the importance of achieving a reduction in prehospital time is based mainly on knowledge of the symptoms and the use of new technologies.

CONCLUSIONS

The evidence supports that the prehospital time of action in the stroke code is affected by numerous factors. These factors are determining factors in the time of action to achieve good effectiveness in the treatment of the pathology.

The Rapid Arterial oCclusion Evaluation (RACE) scale accuracy for diagnosis of acute ischemic stroke in emergency department - A multicenter study

OBJECTIVE

It seems that the available data on performance of the Rapid Arterial oCclusion Evaluation (RACE) as a prehospital stroke scale for differentiating all AIS cases, not only large vessel occlusion (LVO), from the stroke mimics is lacking. As a result, we intend to evaluate the accuracy of the RACE criteria in diagnosing of AIS in patients transferred to the emergency department (ED).

METHOD

The present study was a diagnostic accuracy cross-sectional study during 2021 in Iran. The study population consist of all suspected acute ischemic stroke (AIS) patients who transferred to the ED by emergency medical services (EMS). A 3-part checklist consisting of the basic and demographic information of the patients, items related to the RACE scale, and the final diagnosis of the patients based on interpretation of patients' brain MRI was used for data collection. All data were entered in Stata 14 software. We used the ROC analysis to evaluate the diagnostic power of the test.

RESULT

In this study, data from 805 patients with the mean age of 66.9 ± 13.9 years were studied of whom 57.5% were males. Of all the patients suspected of stroke who transferred to the ED, 562 (69.8%) had a definite final diagnosis of AIS. The sensitivity and specificity of the RACE scale for the recommended cut-off point (score ≥ 5) were 50.18% and 92.18%, respectively. According to the Youden J index, the best cut-off point for this tool for differentiating AIS cases was a score > 2, at which sensitivity and specificity were 74.73% and 87.65%, respectively.

CONCLUSION

It seems that, the RACE scale is an accurate diagnostic tool to detect and screen AIS patients in ED, Of course, not at the previously suggested cut-off point (score ≥ 5), but at the score > 2.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Pre-Hospital Delay in Patients With Acute Stroke During the Initial Phase of the Coronavirus Disease 2019 Outbreak

BACKGROUND

When a sudden outbreak of an infectious disease occurs, emergency medical services (EMS) response could be negatively affected. The poor prognosis of acute stroke may be largely attributed to delays in treatment. This study aimed to identify the impact of the sudden outbreak of coronavirus disease 2019 (COVID-19) on EMS response for patients with acute stroke.

METHODS

This comparative cross-sectional study was conducted in 25 safety centers in Seoul, Korea. We enrolled patients with acute stroke who were transferred to the emergency department by EMS. The study period was from February-April 2020 and the same period in 2019. Patients were divided into two groups, pre-COVID-19 period and early-COVID-19 period, and previously collected patient data were analyzed. We performed comparative analyses of EMS response and clinical outcomes between the groups.

RESULTS

Of 465 patients, 231 (49.7%) had an acute stroke during the study period. There was no significant difference between clinical characteristics of patients with acute stroke before and after the COVID-19 outbreak. EMS response times increased significantly during the early COVID-19 outbreak. The intensive care unit admission rate and mortality rate increased during the early COVID-19 outbreak.

CONCLUSION

In the initial phase after the sudden COVID-19 outbreak, EMS response times for acute stroke were delayed and the clinical outcomes of patients with acute stroke deteriorated.

Delays in Presentation Time Under the COVID-19 Epidemic in Patients With Transient Ischemic Attack and Mild Stroke: A Retrospective Study of Three Hospitals in a Japanese Prefecture

Background: Coronavirus Disease 2019 (COVID-19) has spread worldwide with collateral damage and therefore might affect the behavior of stroke patients with mild symptoms seeking medical attention.

Methods: Patients with ischemic stroke who were admitted to hospitals within 7 days of onset were retrospectively registered. The clinical characteristics, including onset-to-door time (ODT), of patients with a transient ischemic attack (TIA)/mild stroke (National Institutes of Health Stroke Scale [NIHSS] score of ≤ 3 on admission) or moderate/severe stroke were compared between those admitted from April 2019 to March 2020 (pre-COVID-19 period) and from April to September 2020 (COVID-19 period). Multivariable regression analysis was performed to identify factors associated with the ODT.

Results: Of 1,100 patients (732 men, median age, 73 years), 754 were admitted during the pre-COVID-19 period, and 346 were admitted during the COVID-19 period. The number and proportion of patients with TIA/minor stroke were 464 (61.5%) in the pre-COVID-19 period and 216 (62.4%) during the COVID-19 period. Among patients with TIA/mild stroke, the ODT was longer in patients admitted during the COVID-19 period compared with that of the pre-COVID-19 period (median 864 min vs. 508 min, p = 0.003). Multivariable analysis revealed the COVID-19 period of admission was associated with longer ODT (standardized partial regression coefficient 0.09, p = 0.003) after adjustment for age, sex, route of arrival, NIHSS score on admission, and the presence of hypertension, diabetes mellitus, and wake-up stroke. No significant change in the ODT was seen in patients with moderate/severe stroke.

Conclusions: The COVID-19 epidemic might increase the ODT of patients with TIA/mild stroke.