Community-based education improves stroke knowledge

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Public and outpatients’ awareness of calling emergency medical services immediately by acute stroke in an upper middle-income country: a cross-sectional questionnaire study in greater Gaborone, Botswana

Objectives

In this cross-sectional study from Botswana, we investigated awareness of calling emergency medical services (EMS) and seeking immediate medical assistance by acute stroke among stroke risk outpatients and public.

Method

Closed-ended questionnaires on awareness of calling EMS and seeking immediate medical assistance by acute stroke, were administered by research assistants to a representative selection of outpatients and public.

Results

The response rate was 96.0% (93.0% for public (2013) and 96.6% for outpatients (795)). Public respondents had mean age of 36.1 ± 14.5 years (age range 18–90 years) and 54.5% were females, while outpatients had mean age of 37.4 ± 12.7 years (age range 18–80 years) and 58.1% were females.

Awareness of calling EMS (78.3%), and of seeking immediate medical assistance (93.1%) by stroke attack was adequate. For calling EMS by acute stroke, outpatients had higher awareness than the public (p < 0.05) among those with unhealthy diet (90.9% vs 71.1%), family history of both stroke and heart diseases (90.7% vs 61.2%), no history of psychiatric diseases (93.2% vs 76.0%) and sedentary lifestyle (87.5% vs 74.8%).

Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight.

Male gender, ≥50 years age, primary education, family history of both stroke and heart diseases, current smoking, no history of HIV/AIDS, and light physical activity were predictors of low awareness of need for calling EMS.

Conclusion

Results call for educational campaigns on awareness of calling EMS and seeking immediate medical assistance among those with high risk factor levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02859-z.

• This is the first study comparing awareness of calling EMS among outpatients and public in sub-Saharan Africa

• Awareness of calling EMS or seeking immediate medical services by acute stroke was adequate among both outpatients and public

• Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight

• Results call for educational campaigns on awareness of calling EMS/ seeking immediate medical assistance by stroke.

What Do Spanish Speakers Think of the Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas (AHORA) Stroke Tool?

AHORA (Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas) is a Spanish language tool to identify stroke symptoms. A survey of 300 primarily Spanish-speaking, non-medical professionals was conducted to assess the acceptance of the tool, specifically about ease of understanding and ability to implement it. The overwhelming majority of respondents reacted very positively to the tool, finding it quite easy to learn, teach, and understand. Respondent feedback, pitfalls, and questions for further research are presented.

Effectiveness of Public Education Campaigns for Stroke Symptom Recognition and Response in Non-Elderly Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The incidence of stroke is on the rise among younger adults. Stroke educational campaigns are often used to raise public knowledge of stroke warning signs and response actions, but their effectiveness in non-elderly adults is unclear. This study investigated the effectiveness of stroke campaigns in improving stroke symptom recognition and intention to call emergency medical services in adults aged < 65 years, and described the characteristics of public stroke education in this demographic group.

MATERIALS AND METHODS

Seven databases (Cochrane Library, CINAHL, Embase, Medline, PsycINFO, Scopus, and ProQuest Dissertations and Theses) were searched from inception to 24 January 2021. A meta-analysis was conducted to synthesize the effects of stroke education campaigns on stroke symptom recognition and intention to call emergency medical services in adults < 65 years. A narrative synthesis approach was used to explore the types of educational content and campaign best suited to this demographic group.

RESULTS

Thirteen studies from 2001 to 2019 were included in this review. Out of the thirteen studies, five were included in the meta-analysis to synthesize the effects of stroke education campaigns on symptom recognition and four were included for synthesizing the effects on intention to call emergency medical services. The estimated pooled risk ratio for post-campaign compared with pre-campaign in stroke symptom recognition and intention to call emergency medical services was 1.20 (95% CI: 1.07-1.36, p = 0.002) and 1.19 (95% CI: 1.11-1.28, p < 0.00001), respectively. Usage of acronyms in broadcast and digital media campaigns appears promising in enhancing recognition of and responsiveness to stroke symptoms.

CONCLUSIONS

Public stroke education campaigns were found to have a significant impact on stroke symptom recognition and intention to call emergency medical services. The evidence generated from this review could be applied to inform future campaigns targeted at younger adults.

AHORA: a Spanish language tool to identify acute stroke symptoms

OBJECTIVE

To develop a Spanish language tool for acute stroke identification.

METHODS

A Spanish language translation of the Balance-Eyes-Face-Arm-Speech-Time tool was developed within our emergency medical services agency.

RESULTS

The authors present a new prehospital stroke tool, Andar, Hablar, Ojos, Rostro and Ambos Brazos o Piernas (AHORA) (which means now in Spanish) to help combat the language barrier and reinforce the necessity to call 9-1-1 as soon as any stroke symptoms are noted.

CONCLUSION

AHORA is a Spanish language tool that aims to help Spanish-speaking individuals to identify an acute stroke and obtain prompt help.

The Impact of Stroke Public Awareness Campaigns Differs Between Sociodemographic Groups

BACKGROUND

Prehospital delays are a major obstacle to timely reperfusion therapy in acute ischemic stroke. Stroke sign recognition, however, remains poor in the community. We present an analysis of repeated surveys to assess the impact of Face, Arm, Speech, Time (FAST) public awareness campaigns on stroke knowledge.

METHODS

Four cross-sectional surveys were conducted between July 2016 and January 2019 in the province of Quebec, Canada (n = 2,451). Knowledge of FAST stroke signs (face drooping, arm weakness and speech difficulties) was assessed with open-ended questions. A bilingual English/French FAST public awareness campaign preceded survey waves 1-3 and two campaigns preceded wave 4. We used multivariable ordinal regression models weighted for age and sex to assess FAST stroke sign knowledge.

RESULTS

We observed an overall significant improvement of 26% in FAST stroke sign knowledge between survey waves 1 and 4 (odds ratio [OR] = 1.26; 95% CI: 1.02, 1.55; p = 0.035). After the last campaign, however, 30.5% (95% CI: 27.5, 33.6) of people were still unable to name a single FAST sign. Factors associated with worse performance were male sex (OR = 0.68; 95% CI: 0.53, 0.86; p = 0.002) and retirement (OR = 0.54; 95% CI: 0.35, 0.83; p = 0.005). People with lower household income and education had a tendency towards worse stroke sign knowledge and were significantly less aware of the FAST campaigns.

CONCLUSIONS

Knowledge of FAST stroke signs in the general population improved after multiple public awareness campaigns, although it remained low overall. Future FAST campaigns should especially target men, retired people and individuals with a lower socioeconomic status.

A Community-Engaged Stroke Preparedness Intervention in Chicago

Background

We evaluated a community‐engaged stroke preparedness intervention that aimed to increase early hospital arrival and emergency medical services (EMS) utilization among patients with stroke in the South Side of Chicago, Illinois.

Methods and Results

We compared change in early hospital arrival (<3 hours from symptom onset) and EMS utilization before and after our intervention among patients with confirmed ischemic stroke at an intervention hospital on the South Side of Chicago with concurrent data from 6 hospitals in nonintervention communities on the North Side of Chicago and 17 hospitals in St Louis, Missouri. We assessed EMS utilization for suspected stroke secondarily, using geospatial information systems analysis of Chicago ambulance transports before and after our intervention. Among 21 497 patients with confirmed ischemic stroke across all sites, early arrival rates at the intervention hospital increased by 0.5% per month (95% CI, −0.2% to 1.2%) after intervention compared with the preintervention period but were not different from North Side Chicago hospitals (difference of −0.3% per month [95% CI, −0.12% to 0.06%]) or St Louis hospitals (difference of 0.7% per month [95% CI, −0.1% to 1.4%]). EMS utilization at the intervention hospital decreased by 0.8% per month (95% CI, −1.7% to 0.2%) but was not different from North Side Chicago hospitals (difference of 0.004% per month [95% CI, −1.1% to 1.1%]) or St Louis hospitals (difference of −0.7% per month [95% CI, −1.7% to 0.3%]). EMS utilization for suspected stroke increased in the areas surrounding the intervention hospital (odds ratio [OR], 1.4; 95% CI, 1.2–1.6) and in the South Side (OR, 1.2; 95% CI, 1.1–1.3), but not in the North Side (OR, 1.0; 95% CI, 0.9–1.1).

Conclusions

Following a community stroke preparedness intervention, early hospital arrival and EMS utilization for confirmed ischemic stroke did not increase. However, ambulance transports for suspected stroke increased in the intervention community compared with other regions.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02301299.

"Worth the Walk": Culturally Tailored Stroke Risk Factor Reduction Intervention in Community Senior Centers

Background Racial/ethnic minority older adults have worse stroke burden than non-Hispanic white and younger counterparts. Our academic-community partner team tested a culturally tailored 1-month (8-session) intervention to increase walking and stroke knowledge among Latino, Korean, Chinese, and black seniors. Methods and Results We conducted a randomized wait-list controlled trial of 233 adults aged 60 years and older, with a history of hypertension, recruited from senior centers. Outcomes were measured at baseline (T0), immediately after the 1-month intervention (T1), and 2 months later (T2). The primary outcome was pedometer-measured change in steps. Secondary outcomes included stroke knowledge (eg, intention to call 911 for stroke symptoms) and other self-reported and clinical measures of health. Mean age of participants was 74 years; 90% completed T2. Intervention participants had better daily walking change scores than control participants at T1 (489 versus -398 steps; mean difference in change=887; 97.5% CI, 137-1636), but not T2 after adjusting for multiple comparisons (233 versus -714; mean difference in change=947; 97.5% CI, -108 to 2002). The intervention increased the percent of stroke symptoms for which participants would call 911 (from 49% to 68%); the control group did not change (mean difference in change T0-T1=22%; 99.9% CI, 9-34%). This effect persisted at T2. The intervention did not affect measures of health (eg, blood pressure). Conclusions This community-partnered intervention did not succeed in increasing and sustaining meaningful improvements in walking levels among minority seniors, but it caused large, sustained improvements in stroke preparedness. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02181062.

A Unique Approach to Quality Improvement Within the Stroke System of Care Utilizing Developmental Evaluation

Stroke is a significant cause of death that requires multiple systems of care to work together to prevent incidence and improve patient outcomes. The Wisconsin Coverdell Stroke Program partnered with a Model Hospital to understand and improve the stroke system of care in one community. Developmental evaluation (DE) is an approach in which evaluators collaborate closely with project stakeholders to examine complex processes and systems within changeable contexts to develop interventions to improve outcomes. DE was used to assess this community's stroke systems across the care continuum through process mapping with Model Hospital staff and through key stakeholder interviews with Model Hospital and emergency medical services staff, patients, and caregivers. Process mapping identified how patients and health care data flow through the system of care and highlighted areas where streamlining could improve the movement of patients and data across the care continuum. Interviews with stakeholders unveiled challenges and successes about how patient data are accessed and shared across the care continuum, and ideas for improving systems to be more efficient and supportive of stroke prevention and patient outcomes. Overall, DE was valuable in gaining an in-depth understanding of this complex environment to develop strategies to enhance stroke systems of care.

Awareness of stroke among patients attending primary healthcare services in Abha, Southwestern Saudi Arabia

Objectives:

To examine the awareness about major symptoms, risk factors, and response to stroke among the population in Abha, Southwestern Kingdom of Saudi Arabia. Improving stroke-related knowledge may advance stroke prevention and reduce pretreatment delay and disabilities.

Methods:

We conducted a cross-sectional study among a representative sample of primary healthcare adult patients between January-May 2016 and used a validated Arabic questionnaire to evaluate the participants’ awareness about stroke.

Results:

The study involved 1472 adults. Only 63.6% and 43.7% of participants correctly recognized thrombosis and hemorrhage as types of stroke. Commonly identified risk factors were hypertension (55.8%), dyslipidemia (45.8%), and smoking (41.9%). Sudden severe headache (54.1%), dizziness (51.0%), and difficulty in speaking (44.3%) were the most frequently recognized symptoms. The most frequently reported correct responses to stroke were contacting a doctor (73.0%), going to the hospital (67.2%), and calling an ambulance (52.4%). Improper responses to stroke (ignoring the condition or self-prescription) were noted in 18.8% of participants. Logistic regression revealed that physicians, nurses, friends and relatives as a source of knowledge were significantly associated with a lower insufficient knowledge of stroke symptoms and risk factors. On the other hand, women, persons above 40 years old, and married persons were significantly more prone to have insufficient knowledge about a proper response to stroke.

Conclusion:

Our study revealed a notable deficit of knowledge about warning symptoms, risk factors, and proper response to stroke. Health education strategies to improve stroke awareness are required and could potentially prevent and improve the outcome of stroke.

Predicting the functional independence during the recovery phase for poststroke patients

BACKGROUND

Successful recovery of stroke survivors can be challenging. However, when targeted functional capacities are predicted early in the recovery phase, necessary nursing intervention can be initiated aiming at supporting the client moving forward in the rehabilitation journey.

AIMS

This study aimed to evaluate stroke self-efficacy of poststroke patients and identify the differences in stroke self-efficacy level among some relevant variables.

DESIGN

A descriptive cross-sectional design was employed to achieve the aforementioned objectives.

METHODS

A purposive sample of 207 poststroke patients who were recovering from stroke in three major teaching hospitals at Baghdad city were recruited to participate in the study. Data collection process started 3 November 2016 -15 May 2017. Inclusion criteria embraced stroke patients who were adult, have Glasgow Coma Scale score 14-15, capable of giving written or verbal consent. The modified version of the stroke self-efficacy questionnaire was used for data collection.

RESULTS

A significant statistical difference at the p-value ≤ 0.05 level, in stroke self-efficacy, was verified among subjects' age, residency, stroke incidence and patient's knowledge about his/her stroke medical diagnosis.

Need to Prioritize Education of the Public Regarding Stroke Symptoms and Faster Activation of the 9-1-1 System: Findings from the Florida-Puerto Rico CReSD Stroke Registry

Objective: Demographic differences (race/ethnicity/sex) in 9-1-1 emergency medical services (EMS) access and utilization have been reported for various time-dependent critical illnesses along with associated outcome disparities. However, data are lacking with respect to measuring the various components of time taken to reach definitive care facilities following the onset of acute stroke symptoms (i.e., stroke onset to 9-1-1 call, EMS response, time on-scene, transport interval) and particularly with respect to any differences across ethnicities and sex. Therefore, the specific aim of this study was to measure the various time intervals elapsing following the first symptom onset (FSO) from an acute stroke until stroke hospital arrival (SHA) and to delineate any race/ethnic/sex-related differences among any of those measurements. Methods: The Florida-Puerto Rico Stroke Registry (FLPRSR) is an on-going, voluntary stroke registry of hospitals participating in the Get with the Guidelines-Stroke initiative. The study population included patients treated at Florida hospitals participating in the FLPRSR between 2010 and 2014 who had called 9-1-1 and were managed and transported by EMS. In total, 10,481 patients (16% black, 8% Hispanic, 74% white) had complete data-sets that included birthdate/year, sex, ethnic background, date/hour/minute of FSO and date/hour/minute of EMS response, scene arrival, and SHA. Results: Median time from FSO to SHA was 339 minutes (interquartile range [IQR] of 284-442), 301 of which constituted the time elapsed from FSO to the 9-1-1 call (IQR =249-392) versus only 10 from 9-1-1 call to EMS arrival (IQR =7-14), 14 on-scene (IQR =11-18) and 12 for transport to SHA (IQR =8-19). The FSO to 9-1-1 call interval, being by far the longest interval, was longest among whites and blacks (302 minutes for both) versus 291 for Hispanics (p = 0.01). However, this 11-minute difference was not deemed clinically-significant. There were neither significant sex-related differences nor any racial/ethnic/sex differences in the relatively short EMS-related intervals. Conclusions: Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.

Public health campaigns and their effect on stroke knowledge in a high-risk urban population: A five-year study

Background The level of knowledge of stroke risk factors and stroke symptoms within a population may determine their ability to recognize and ultimately react to a stroke. Independent agencies have addressed this through extensive awareness campaigns. The aim of this study was to determine the change in baseline knowledge of stroke risk factors, symptoms, and source of stroke knowledge in a high-risk Toronto population between 2010 and 2015. Methods Questionnaires were distributed to adults presenting to cardiovascular clinics at the University of Toronto in Toronto, Canada. In 2010 and 2015, a total of 207 and 818 individuals, respectively, participated in the study. Participants were identified as stroke literate if they identified (1) at least one stroke risk factor and (2) at least one stroke symptom. Results A total of 198 (95.6%) and 791 (96.7%) participants, respectively, completed the questionnaire in 2010 and 2015. The most frequently identified risk factors for stroke in 2010 and 2015 were, respectively, smoking (58.1%) and hypertension (49.0%). The most common stroke symptom identified was trouble speaking (56.6%) in 2010 and weakness, numbness or paralysis (67.1%) in 2015. Approximately equal percentages of respondents were able to identify ≥1 risk factor (80.3% vs. 83.1%, p = 0.34) and ≥1 symptom (90.9% vs. 88.7%, p = 0.38). Overall, the proportion of respondents who were able to correctly list ≥1 stroke risk factors and stroke symptoms was similar in both groups.(76.8% vs. 75.5%, p = 0.70). The most commonly reported stroke information resource was television (61.1% vs. 67.6%, p = 0.09). Conclusion Stroke literacy has remained stable in this selected high-risk population despite large investments in public campaigns over recent years. However, the baseline remains high over the study period. Evaluation of previous campaigns and development of targeted advertisements using more commonly used media sources offer opportunities to enhance education.

Knowledge of thrombolytic therapy for acute ischemic stroke among community residents in western urban China

BACKGROUND AND PURPOSE

Thrombolytic therapy rate for acute ischemic stroke remains low, and improving public awareness of thrombolytic therapy may be helpful to reduce delay and increase chances of thrombolytic therapy. Our purpose was to survey the level of knowledge about thrombolytic therapy for acute ischemic stroke among community residents in Yuzhong district, Chongqing, China.

METHODS

In 2011, a population-based face-to-face interview survey was conducted in Yuzhong district, Chongqing. A total of 1500 potential participants aged ≥18 years old were selected using a multi-stage sampling method.

RESULTS

A total of 1101 participants completed the survey. Only 23.3% (95% CI = 20.8 to 25.8) were aware of thrombolytic therapy for acute ischemic stroke, of whom 59.9% (95% CI = 53.9 to 65.9) knew the time window. Awareness of thrombolytic therapy was higher among young people, those with higher levels of education and household income, those with health insurance, and those who knew all 5 stroke warning signs, while awareness of the time window was higher among those aged 75 years or older. Multivariate logistic regression analysis showed that awareness of thrombolytic therapy was independently associated with age, education level, health insurance and knowledge of stroke warning signs (P<0.05).

CONCLUSIONS

In this population-based survey the community residents have poor awareness of thrombolytic therapy for acute ischemic stroke.

Prehospital stroke care: limitations of current interventions and focus on new developments

BACKGROUND

The global burden of stroke is immense, both in medical and economic terms. With the aging population and the ongoing industrialization of the third world, stroke prevalence is expected to increase and will have a major effect on national health expenditures. Currently, the medical treatment for acute ischemic stroke is limited to intravenous recombinant tissue plasminogen activator (IV r-tPA), but its time dependency leads to low utilization rates in routine clinical practice. Prehospital delay contributes significantly to delayed or missed treatment opportunities in acute stroke. State-of-the-art acute stroke care, starting in the prehospital phase, could thereby reduce the disease burden and its enormous financial costs.

SUMMARY

The first part of this review focuses on current education measures for the general public, the emergency medical services (EMS) dispatchers and paramedics. Although much has been expected of these measures to improve stroke care, no major effects on prehospital delay or missed treatment opportunities have been demonstrated over the years. Most interventional studies showed little or no effect on the onset-to-door time, IV r-tPA utilization rates or outcome, except for prenotification of the receiving hospital by the EMS. No data are currently available on the cost-effectiveness of these commonly used measures. In the second part, we discuss new developments for the improvement of prehospital stroke diagnosis and treatment which could open new perspectives in the nearby future. These include the implementation of prehospital telestroke and the deployment of mobile stroke units. These approaches may improve patient care and could serve as a platform for prehospital clinical trials. Other opportunities include the implementation of noninvasive diagnostics (like transcranial ultrasound and blood-borne biomarkers) and the reevaluation of neuroprotective strategies in the prehospital phase. Key Messages: Timely initiation of treatment can effectively reduce the medical and economic burden of stroke and should begin with optimal prehospital stroke care. For this, prehospital telemedicine is a particularly attractive approach because it is a scalable solution that has the potential to rapidly optimize acute stroke care at limited cost.

Community-based stroke system of care for Chinese rural areas

BACKGROUND AND PURPOSE

Stroke system of care plays key roles both in providing effective therapies and in improving the overall outcome of patients with stroke. Our purpose was to develop and evaluate the system in Chinese rural areas.

METHODS

A stroke system of care was developed from November 2009 to November 2010 in 3 townships in Ganyu County. An additional 3 matched townships were invited as controls. We first investigated stroke management in these townships and then implemented stroke system of care and an education campaign in the 3 intervention townships. The effectiveness of the system was then evaluated.

RESULTS

There were 1036 patients with new stroke among 344 345 subjects in the 6 rural communities. The incidence of stroke in the rural areas was 301/100 000, and the mortality rate was 55/100 000. The proportions significantly increased in the intervention communities after the implementation of the stroke system of care and education campaign when compared with the control communities, including patients presenting at rural hospitals within 3 hours of symptom onset (13.6% versus 8.7%; P=0.017), diagnosed by computed tomographic scanning within 24 hours of admission (65.3% versus 58.5%; P=0.034), and received thrombolytic treatment (3.9% versus 1.7%; P=0.038). During the 1-year follow-up, 32 (6.5%) patients with stroke in the intervention communities and 48 (10.1%) in the control communities died. The disability rate of stroke was significantly reduced in the intervention communities at postintervention (38.4% versus 48.1%; P=0.001).

CONCLUSIONS

A stroke system of care would be reliable and practical in Chinese rural areas.

CLINICAL TRIAL REGISTRATION URL

http://www.chictr.org. Unique identifier: ChiCTR-RCH-13003408.

Stroke-related knowledge, beliefs, and behaviours of chinese and European canadians: implications for physical therapists

PURPOSE

To improve cross-cultural health education on risk-reducing behaviour change by examining the stroke-related knowledge, beliefs, and behaviours of Chinese Canadians (CCs).

METHODS

Participants (103 first-generation CCs and 101 European Canadians [ECs] representing the dominant cultural group in Canada) completed a cross-sectional questionnaire about knowledge, health behaviours, and beliefs related to stroke.

RESULTS

Compared with ECs, CCs were less aware of risk factors, warning signs, and appropriate responses to stroke in others. Information sources about stroke included mass media, family, and friends. CCs were less likely to smoke and drink alcohol but were also less likely to be physically active or to participate in structured exercise, less likely to have a healthy diet, and more likely to report stress.

CONCLUSIONS

Theoretical dimensions of culture may explain variations in stroke-related knowledge, behaviours, and beliefs between CCs and ECs. Awareness of cultural differences can help physical therapists evaluate clients and appropriately tailor lifestyle-related health education.

Knowledge, attitude and practice of stroke in India versus other developed and developing countries

Rising stroke and higher mortality among Indian population needs focused attention for prevention and early management of stroke. In India, very few studies have been carried out to determine the causes of deficiencies in knowledge, attitude and practice (KAP) of stroke among Indians. Study on KAP is essential to improve the awareness about stroke, early diagnosis and institution of appropriate management. In this article, we have reviewed the existing literature on this issue and tried to compare it with those of developed countries and suggested the measures we need to adopt in India to improve awareness and knowledge base.

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Background

Rapid access to emergency stroke care can reduce death and disability by enabling immediate provision of interventions such as thrombolysis, physiological monitoring and stabilisation. One of the ways that access to services can be facilitated is through emergency medical service (EMS) dispatchers. The sensitivity of EMS dispatchers for identifying stroke is < 50%. Studies have shown that activation of the EMSs is the single most important factor in the rapid triage and treatment of acute stroke patients.

Objectives

To facilitate recognition of stroke by emergency medical dispatchers (EMDs).

Design

An eight-phase mixed-methods study. Phase 1: a retrospective cohort study exploring stroke diagnosis. Phase 2: semi-structured interviews exploring public and EMS interactions. Phases 3 and 4: a content analysis of 999 calls exploring the interaction between the public and EMDs. Phases 5–7: development and implementation of stroke-specific online training (based on phases 1–4). Phase 8: an interrupted time series exploring the impact of the online training.

Setting

One ambulance service and four hospitals.

Participants

Patients arriving at hospital by ambulance with stroke suspected somewhere on the stroke pathway (phases 1 and 8). Patients arriving at hospital by ambulance with a final diagnosis of stroke (phase 2). Calls to the EMSs relating to phase 1 patients (phases 3 and 4). EMDs (phase 7).

Interventions

Stroke-specific online training package, designed to improve recognition of stroke for EMDs.

Main outcome measures

Phase 1: symptoms indicative of a final and dispatch diagnosis of stroke. Phase 2: factors involved in the decision to call the EMSs when stroke is suspected. Phases 3 and 4: keywords used by the public when describing stroke and non-stroke symptoms to EMDs. Phase 8: proportion of patients with a final diagnosis of stroke correctly dispatched as stroke by EMDs.

Results

Phase 1: for patients with a final diagnosis of stroke, facial weakness and speech problems were significantly associated with an EMD code of stroke. Phase 2: four factors were identified – perceived seriousness; seeking and receiving lay or professional advice; caller’s description of symptoms and emotional response to symptoms. Phases 3 and 4: mention of ‘stroke’ or one or more Face Arm Speech Test (FAST) items is much more common in stroke compared with non-stroke calls. Consciousness level was often difficult for callers to determine and/or communicate. Phase 8: there was a significant difference (p = 0.003) in proportions correctly dispatched as stroke – before the training was implemented 58 out of 92 (63%); during implementation of training 42 out of 48 (88%); and after training implemented 47 out of 59 (80%).

Conclusions

EMDs should be aware that callers are likely to describe loss of function (e.g. unable to grip) rather than symptoms (e.g. weakness) and that callers using the word ‘stroke’ or describing facial weakness, limb weakness or speech problems are likely to be calling about a stroke. Ambiguities and contradictions in dialogue about consciousness level arise during ambulance calls for suspected and confirmed stroke. The online training package improved recognition of stroke by EMDs. Recommendations for future research include testing the effectiveness of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) training package on the recognition of stroke across other EMSs in England; and exploring the impact of the early identification of stroke by call handlers on patient and process outcomes.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Awareness of risk factors and warning signs of stroke in a Nigeria university

BACKGROUND

Rapid access to medical services which is an important predictor of treatment and rehabilitation outcome requires that there is an understanding of stroke risk factors and early warning signs. This study assessed awareness of stroke risk factors and warning signs among students and staff of Obafemi Awolowo University, Nigeria.

METHODS

This was a cross sectional survey involving 994 (500 students and 494 staff) respondents. Information on the awareness of stroke risk factors and warning signs was collected with the aid of a structured questionnaire. Descriptive and inferential statistics were used for data analysis.

RESULTS

Weakness (66.2%) was the most commonly identified warning sign of stroke with more staff (69.8%) identifying correctly than students (62.6%). Hypertension (83.4%) was the most commonly identified stroke risk factor, with more staff (91.7%) identifying correctly than students (83.2%). There were significant differences (p < 0.05) in the awareness of some risk factors (age, hypertension, stress and obesity), and warning signs (dizziness, numbness, weakness, headache and vision problems) between students and staff. Predictors for adequate awareness of both stroke risk factors and warning signs were younger age, smoking history and higher educational level.

CONCLUSIONS

Majority of the respondents recognized individual important stroke risk factors and warning signs, but few recognized multiple stroke risk factors and warning signs. Awareness programs on stroke should be organized, even in communities with educated people to increase public awareness on the prevention of stroke and on the reduction of morbidity in the survivors.

Patterns of Emergency Medical Services Use and Its Association With Timely Stroke Treatment

Background—

Prior studies found that only about half of stroke patients arrived at hospitals via emergency medical services (EMSs), yet since then, there have been efforts to increase public awareness that time is brain. Using contemporary Get With the Guidelines-Stroke data, we assessed nationwide EMS use by stroke patients.

Methods and Results—

We analyzed data from 204 591 patients with ischemic and hemorrhagic stroke admitted to 1563 Get With the Guidelines-Stroke participating hospitals with data on National Institute of Health Stroke Score and insurance status. Hospital arrival by EMSs was observed in 63.7% of patients. Older patients, those with Medicaid and Medicare insurance, and those with severe stroke were more likely to activate EMSs. In contrast, minority race and ethnicity and living in rural communities were associated with decreased odds of EMS use. EMS transport was independently associated with earlier arrival (onset-to-door time, ≤3 hours; adjusted odds ratio, 2.00; 95% confidence interval, 1.93–2.08), prompter evaluation (more patients with door-to-imaging time, ≤25 minutes; odds ratio, 1.89; 95% confidence interval, 1.78–2.00), more rapid treatment (more patients with door-to-needle time, ≤60 minutes; odds ratio, 1.44; 95% confidence interval, 1.28–1.63), and more eligible patients to be treated with tissue-type plasminogen activator if onset is ≤2 hours (67% versus 44%; odds ratio, 1.47; 95% confidence interval, 1.33–1.64).

Conclusions—

Although EMS use is independently associated with more rapid evaluation and treatment of stroke, more than one third of stroke patients fail to use EMSs. Interventions aimed at increasing EMS activation should target populations at risk, particularly younger patients and those of minority race and ethnicity.

Effects of comprehensive education protocol in decreasing pre-hospital stroke delay among Chinese urban community population

BACKGROUND AND PURPOSE

Studies have shown that awareness of early stroke symptoms and the use of ambulances are two important factors in decreasing pre-hospital stroke delay. The purpose of this study is to evaluate a comprehensive educational stroke protocol in improving stroke response times.

METHOD

Two urban communities in Beijing (population ≍50 000), matched in economic status and geography, were enrolled in this study. A comprehensive educational protocol, which included public lectures and distribution of instructive material for the community and its medical staff, was implemented from August 2008 to December 2010. Surveillance of new onset stroke in both communities was carried out during the same period. Pre-hospital delay time and percentage of patients using emergency medical services (EMS) were compared between the two communities.

RESULTS

After comprehensive educational protocol, we found that: (i) pre-hospital delay (time from stroke symptom onset to hospital arrival) decreased from 180 to 79 minutes, (ii) the proportion of patients arriving within three hours of stroke onset increased from 55·8% to 80·4%, (iii) pre-hospital delay of stroke patients with symptoms of paralysis, numbness, and speech impediments was decreased, and (iv) the proportion of stroke patients calling for EMS increased from 50·4% to 60·7%.

CONCLUSION

The comprehensive educational stroke protocol was significantly effective in decreasing pre-hospital stroke delay.

Needs analysis for educating community pharmacists to interface with prehospital stroke chain of survival

BACKGROUND

Awareness of the American Heart Association's Stroke Chain of Survival, and willingness to learn and share this information with the public, was assessed for community pharmacists practicing near a primary stroke center.

METHODS

Twenty-three community pharmacies local to a primary stroke center were identified and surveyed. The surveyor showed each pharmacist a flier with a mnemonic for assessing stroke symptoms, briefly explained steps in the Stroke Chain of Survival, and noted if the pharmacist was available, listened to the entire presentation, read the information on the flier, agreed to post the flier, and if the pharmacist made any comments. The surveyor also assessed whether the Stroke Chain of Survival was new information to each pharmacist.

RESULTS

All subjects read the information on the flier. Twenty-two (95.7%) listened to the entire presentation, and 23 (100%) were willing to post the flier. Two (11%) indicated that the parent company does not allow public posting of noncorporate information but agreed to post the flier internally. Twenty-one (91%) expressed appreciation for receiving the information. Seventeen (74%) indicated that the Stroke Chain of Survival was new information to them, 14 (61%) spontaneously remarked on the importance of the information, and 4 (17%) asked for additional information.

CONCLUSIONS

Community pharmacists surveyed were willing to interface with the prehospital phase of the Stroke Chain of Survival; nearly 75% of them required education to do so. Community pharmacies are potentially a venue for educating the public on the Stroke Chain of Survival. It may be necessary to approach community pharmacy corporate leadership to partner with such efforts.

Comparison of Stroke Warning Sign Campaigns in Australia, England, and Canada

Background

Public awareness of the signs of stroke is essential to ensure that those affected by stroke arrive at the hospital in time for lifesaving therapies. It is unclear how well stroke awareness campaigns improve awareness of stroke signs and whether people translate this into action.

Methods

We evaluated stroke awareness campaigns conducted in England, Australia, and Canada using pre- and post-campaign surveys. We assessed the proportion of people who could name the main signs of stroke, and compared the proportion naming these correctly between locations. We also assessed whether people would call emergency services in the event of a stroke. Proportion responding correctly was compared using chi-square analysis.

Results

The amount spent on the campaigns was different in each country. The post-campaign survey was conducted among 400 people in Australia, 1921 in England, and 2703 in Canada. Sixty-eight per cent of people in Australia and 57% in Canada could name two or more signs of stroke ( P < 0·001). After the campaign, knowledge of each of the elements of the campaign (face, arm, speech, time) was significantly greater in England than in Australia ( P < 0·001 for each item). A high proportion of participants reported that they would call emergency services in the event of a stroke (97% in England, 90% in Australia, and 67% in Canada).

Conclusion

Knowledge of stroke signs and the action to be taken can be improved with awareness campaigns. The effectiveness of these campaigns may be enhanced by spend on media, media mix, and key messages. It is critical to ensure that campaigns provide the clear and bold message that prompt action is an essential ingredient to reduce death and disability following stroke.

Optimizing public health strategies for stroke education: need for a controlled trial

This brief review examines certain strategies for increasing community awareness and recognition of the warning signs and symptoms of stroke. Attention should be given to the intended audience, especially at-risk groups. To enhance stroke literacy, a complete message should include the following 4 aspects: (1) a stroke is a serious medical problem that involves the blood supply to the brain, (2) all 5 approved warning signs and symptoms, (3) the many risk factors involved in stroke, and (4) the need to promptly call 911 for emergency services and treatment. Such knowledge could lead to improvement in the rapid arrival to an emergency room and promote optimal and timely medical treatment. With several educational paradigms and strategies in existence, we propose that more rigorous study of their comparative performance and utility is needed. In a preliminary survey, our own program, called "KNOW FIVE - STAY ALIVE," provided greater posttest knowledge compared with the "FAST" program and a National Institutes of Health brochure called "Know Stroke. Know the signs, Act in time."

Stroke awareness: surveillance, educational campaigns, and public health practice

Stroke is a leading cause of death and disability in the United States. However, there is limited public knowledge about stroke signs and symptoms and the importance of seeking immediate medical care. Educational efforts such as stroke awareness campaigns are one way of informing the public about stroke symptoms and the need for early medical treatment following their onset. In this article, we present recent surveillance data concerning public awareness of stroke symptoms; summarize findings from 12 studies of the effectiveness of stroke awareness campaigns; and describe the efforts by three states to develop, implement, and evaluate heart disease and stroke programs, and the lessons to be learned from their experiences.

Delay in presentation after an acute stroke in a multiethnic population in South london: the South london stroke register

BACKGROUND

Delayed presentation to hospital after an acute stroke is a major explanation given for low thrombolysis rates. This study aimed to investigate the factors associated with delays in presentation after an acute stroke and changes after a mass media campaign.

METHODS AND RESULTS

Data were from a population-based study involving 1392 patients with first-ever strokes between 2002 and 2010 in a multiethnic South London population. Associations were determined between prehospital delay (≥3 hours) and variables of interest, including ethnicity, by using multivariate logistic regression analyses. Differences in prehospital delay and thrombolysis rates were determined for the period immediately before and after the FAST mass media campaign (2007/2008 versus 2009/2010). The median (Q(1) to Q(3)) time to presentation was 4.73 (1.55 to 12.70) hours, and 550 (39.5%) presented within 3 hours of symptom onset. In multivariate analysis, patients of black ethnicity had increased odds of delay (odds ratio: 1.63; 95% confidence interval, 1.11 to 2.38), whereas those with more severe strokes characterized by a higher National Institutes of Health Stroke Scale score (odds ratio: 0.35; 95% confidence interval, 0.20 to 0.61) had reduced odds of delay. There was no difference in the proportion of patients who arrived within 3 hours (P=0.30) in the period immediately before and after the FAST campaign (40.7% in 2007/2008 versus 44.9% in 2009/2010). Among patients with ischemic stroke, 119 (11.0%) received thrombolysis between 2002 and 2010, with no difference observed between the pre- and postcampaign periods (16.9% versus 16.4%).

CONCLUSION

Significant delays in seeking care after stroke still occur in this population despite efforts to increase public awareness. Future educational programs must identify and specifically address factors that influence behavior and should target those at higher risk of delay. (J Am Heart Assoc. 2012;1:e001685 doi: 10.1161/JAHA.112.001685.).

Regional differences in emergency medical services use for patients with acute stroke (findings from the National Hospital Ambulatory Medical Care Survey Emergency Department Data File)

BACKGROUND

Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED).

METHODS

Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects<18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED.

RESULTS

Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use.

CONCLUSIONS

Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Health education in patients with a recent stroke or transient ischaemic attack: a comprehensive review

Health education aims at the acquisition of skills and attitudes to modify behaviour that influences health, leads to a modification of risk factors and ultimately to a decrease in disability and case fatality from stroke. Health education is an underdeveloped but important aspect of stroke care. Health education could promote compliance and healthy behaviour, improve patients' understanding of their health status and treatment options and facilitate communication. We reviewed the effect of health education in stroke and transient ischaemic attack patients, aiming at feasibility, effectiveness at the level of knowledge, attitude and skills, health behaviour changes and stroke outcome. We also describe the current status of health education for patients with recent coronary artery disease and public health education in stroke. Basic knowledge of stroke and transient ischaemic attack patients of their disease and associated risk factors is not sufficient. This is also observed in patients with coronary artery disease and in the general population. A beneficial effect of health education in stroke and transient ischaemic attack patients on health behaviour, risk reduction or stroke outcome has not been proven. Trials in patients with coronary artery disease, however, have shown that health education could result in a change of lifestyle. No specific method is superior, although the individualised, repetitive and active methods appear more successful. More intervention studies of health education in stroke and transient ischaemic attack patients are needed. Future trials should be large, have a long follow-up, should use an intensive and repetitive approach and involve patients' relatives to induce and maintain a healthy lifestyle.

Knowledge of Risk Factors, and Warning Signs of Stroke: A Systematic Review from a Gender Perspective

Stroke is one of the leading causes of death globally. Awareness of stroke risk factors and warning signs are important for stroke prevention and seeking care. The purpose of this systematic review was to review existing literature that assessed the knowledge of stroke risk factors and warning signs and allowed separate gender analysis. We conducted a systematic review of all published studies (to August 2008) examining knowledge of stroke risk factors and warning signs that included women and provided results separated by gender. Two reviewers selected studies for inclusion, assessed quality, and extracted data. The database search identified 2158 references for screening and 158 were selected for possible inclusion. Twenty-two studies were reviewed including 20 cross-sectional and two pretest–posttest design surveys. Overall, better stroke knowledge was observed in women compared with men in the majority of the studies although there is a general lack of knowledge in both genders. Four out of 18 studies reported better risk factor knowledge and eight out of 15 studies reported better knowledge in stroke warning signs in women compared with men. Women tended to know more evidence-based stroke risk factors than men. Stroke knowledge also appeared to be related to country of study origin, age, education, and medical history. Stroke knowledge among different populations and both in men and women is suboptimal. More research is necessary to further investigate gender differences in stroke knowledge with specific focus on how to use these differences to improve public health campaigns.

Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

BACKGROUND

Mass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear.

METHODS

Systematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development.

RESULTS

Ten studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised.

CONCLUSIONS

Campaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated.

Stroke education: discrepancies among factors influencing prehospital delay and stroke knowledge

BACKGROUND

Time is essential for the treatment of acute stroke. Much time is lost outside the hospital, either due to failure in identifying stroke symptoms or due to a delay in notification or transport. We review studies reporting factors associated with better stroke knowledge and shorter time delays. We summarise the evidences for the effect of stroke knowledge and education on people's reaction in the acute situation of stroke.

METHODS

We searched MEDLINE for studies reporting factors associated with prehospital time of stroke patients, or knowledge of stroke symptoms. Further, we searched for studies reporting educational interventions aimed at increasing stroke symptom knowledge in the population.

FINDINGS

We included a total of 182 studies. Surprisingly, those factors associated with better stroke knowledge such as education and sociodemographic variables were not related to shorter time delays. Few studies report shorter time delays or better stroke knowledge in persons having suffered a previous stroke. Factors associated with shorter time delays were more severe stroke and symptoms regarded as serious, but not better knowledge about the most frequent symptoms such as hemiparesis or disorders of speech. Only 25-56% of patients recognised their own symptoms as stroke. While stroke education increases the knowledge of warning signs, a few population studies measured the impact of education on time delays; in such studies, time delays decreased after education. This may partly be mediated by better organisation of EMS and hospitals.

INTERPRETATION

There is a discrepancy between theoretical stroke knowledge and the reaction in an acute situation. Help-seeking behaviour is more dependent on the perceived severity of symptoms than on symptom knowledge. Bystanders play an important role in the decision to call for help and should be included in stroke education. Education is effective and should be culturally adapted and presented in a social context. It is unclear which educational concept is best suited to enhance symptom recognition in the acute situation of stroke, especially in view of discrepancies between knowledge and action.

How can we reach them? Information seeking and preferences for a cancer family history campaign in underserved communities

Individuals with a family history of cancer are at elevated risk for the disease, and web-based tools are available to assist in assessing risk. Preferences for a potential campaign to promote awareness of the role of family history in cancer risk were sought, guided by McGuire's Input-Output Persuasion Model. A randomized telephone survey administered to five underserved communities assessed potential campaign messages, channels, sources, receivers, and destinations and use of the Internet (n = 101). Information sources sought about hereditary cancer and their predictors were assessed. Nearly half of the sample was African American and had annual income below $25,000. Most (59%) had Internet access at home. Few differences emerged as a function of race (African American vs. Other). The Internet was the most common (43%) first source sought for hereditary cancer information, followed by physicians (23%). In univariate multinomial logistic regression models, those with a high school education or more and those with greater family history (trend) were more likely than those without to choose the Internet as their first source of information over physicians. Our survey provided a wealth of information for understanding how to best launch our family history cancer risk communication campaign. Education level affected information seeking, and efforts are under way to lessen this potential barrier.

Statewide Survey of 911 Communication Centers on Acute Stroke andMyocardial Infarction

OBJECTIVE

We conducted a statewide survey of communication centers regarding practices, training, and outreach for stroke and myocardial infarction (MI) and explored differences for those that were Emergency Medical Dispatch (EMD) certified or not.

METHODS

A survey was mailed to all 115 centers that dispatched for emergency medical services (EMS) in North Carolina. Seventy-four percent (85/115) returned the survey.

RESULTS

For 31% of centers, all telecommunicators were EMD-certified, 28% of centers had some personnel certified, and 41% had no personnel certified. Forty-four percent of centers used dispatch guides or algorithms to aid telecommunicators. If telecommunicators suspected a stroke, 47% of the centers provided prearrival instructions and if they suspected an MI, 49% provided prearrival instructions. In the past 2 years, 27% of the telecommunicators received stroke-specific training and 29% received MI-specific training. Stroke or MI training for telecommunicators was more common among the EMD centers (51% stroke; 51% MI) than among the non-EMD centers (5% stroke; 9% MI). Only one center conducted a community outreach program about stroke or MI in the last 6 months.

CONCLUSIONS

Our results suggest that the development of statewide telecommunication training program to improve knowledge and care for suspected stroke or MI is needed in North Carolina. Dispatching for stroke and MI could be enhanced by requiring all communication centers to be EMD-certified and by creating consistent and standard dispatching practices across the state, using triage algorithms. Implementing these changes could improve rapid response and care for acute stroke and MI patients.