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Jalali R, Bieniecka A, Jankowski M, Michel PS, Popielarczyk M, Majewski MK, Zwiernik J, Harazny JM. The Absence of Typical Stroke Symptoms and Risk Factors Represents the Greatest Risk of an Incorrect Diagnosis in Stroke Patients. J Pers Med 2024; 14:964. [PMID: 39338218 PMCID: PMC11433094 DOI: 10.3390/jpm14090964] [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: 07/10/2024] [Revised: 09/02/2024] [Accepted: 09/05/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Stroke is one of the most misdiagnosed conditions that causes serious medical disabilities. Its early and accurate diagnosis by the emergency team is crucial for the patient's survival. This study aimed to determine the percentage of brain strokes incorrectly diagnosed by paramedic teams and to analyze the factors influencing incorrect diagnoses. METHODS The data of 103 patients, mean age of 68.4 ± 14.96 years, admitted in 2019 to hospital emergency departments of the two hospitals in Olsztyn, Poland, were analyzed retrospectively. All patient data were obtained from their information cards. The parameters of the patients misdiagnosed and accurately diagnosed by paramedics were analyzed with Odds Ratio (OR) calculations using IBM SPSS version 23 software. RESULTS Stroke and transient ischemic attack were recognized in 77 cases (74.8%). In 26 patients (25.2%), the diagnosis made in the ambulance differed from that made in the hospital ward. The analysis of the Odds Ratio (OR) has shown that typical stroke risk factors, if present in a patient, facilitate the correct diagnosis. The greatest source of misdiagnosis of stroke by the paramedic team was the lack of hemiplegia (OR = 6.0). CONCLUSIONS The absence of typical stroke risk factors and neurological stroke symptoms, such as smoking, hemiplegia, aphasia, hypercholesterolemia, arrhythmia, diabetes or a drooping corner of the mouth, constitutes a high risk of misdiagnosing stroke by the paramedic team.
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Affiliation(s)
- Rakesh Jalali
- Department of Emergency Medicine, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Aleksandra Bieniecka
- Students’ Research Group, Department of Human Physiology and Pathophysiology, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (A.B.); (M.J.); (P.S.M.)
| | - Marek Jankowski
- Students’ Research Group, Department of Human Physiology and Pathophysiology, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (A.B.); (M.J.); (P.S.M.)
| | - Patryk Stanisław Michel
- Students’ Research Group, Department of Human Physiology and Pathophysiology, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (A.B.); (M.J.); (P.S.M.)
| | - Marta Popielarczyk
- School of Public Health, University of Warmia and Mazury, 10-719 Olsztyn, Poland;
| | - Mariusz Krzysztof Majewski
- Department of Human Physiology and Pathophysiology, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (M.K.M.); (J.M.H.)
| | - Jacek Zwiernik
- Department of Neurology and Neurosurgery, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland;
| | - Joanna Maria Harazny
- Department of Human Physiology and Pathophysiology, School of Medicine, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (M.K.M.); (J.M.H.)
- Clinical Research Center, Department of Nephrology and Hypertension, University Erlangen-Nuremberg, 91054 Erlangen, Germany
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Inoa V, Goyal N. Role of Stroke Scales and Scores in Cerebrovascular Disease. Neurol Clin 2024; 42:753-765. [PMID: 38937040 DOI: 10.1016/j.ncl.2024.03.008] [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] [Indexed: 06/29/2024]
Abstract
This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.
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Affiliation(s)
- Violiza Inoa
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nitin Goyal
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Candefjord S, Andersson Hagiwara M, Sjöqvist BA, Karlsson JE, Nordanstig A, Rosengren L, Söderholm HM. Video support for prehospital stroke consultation: implications for system design and clinical implementation from prehospital simulations. BMC Med Inform Decis Mak 2024; 24:146. [PMID: 38811986 PMCID: PMC11138054 DOI: 10.1186/s12911-024-02539-7] [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: 10/15/2022] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Video consultations between hospital-based neurologists and Emergency Medical Services (EMS) have potential to increase precision of decisions regarding stroke patient assessment, management and transport. In this study we explored the use of real-time video streaming for neurologist-EMS consultation from the ambulance, using highly realistic full-scale prehospital simulations including role-play between on-scene EMS teams, simulated patients (actors), and neurologists specialized in stroke and reperfusion located at the remote regional stroke center. METHODS Video streams from three angles were used for collaborative assessment of stroke using the National Institutes of Health Stroke Scale (NIHSS) to assess symptoms affecting patient's legs, arms, language, and facial expressions. The aim of the assessment was to determine appropriate management and transport destination based on the combination of geographical location and severity of stroke symptoms. Two realistic patient scenarios were created, with severe and moderate stroke symptoms, respectively. Each scenario was simulated using a neurologist acting as stroke patient and an ambulance team performing patient assessment. Four ambulance teams with two nurses each all performed both scenarios, for a total of eight cases. All scenarios were video recorded using handheld and fixed cameras. The audio from the video consultations was transcribed. Each team participated in a semi-structured interview, and neurologists and actors were also interviewed. Interviews were audio recorded and transcribed. RESULTS Analysis of video-recordings and post-interviews (n = 7) show a more thorough prehospital patient assessment, but longer total on-scene time, compared to a baseline scenario not using video consultation. Both ambulance nurses and neurologists deem that video consultation has potential to provide improved precision of assessment of stroke patients. Interviews verify the system design effectiveness and suggest minor modifications. CONCLUSIONS The results indicate potential patient benefit based on a more effective assessment of the patient's condition, which could lead to increased precision in decisions and more patients receiving optimal care. The findings outline requirements for pilot implementation and future clinical tests.
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Affiliation(s)
- Stefan Candefjord
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, 412 96, Sweden.
| | - Magnus Andersson Hagiwara
- Center for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, 501 90, Sweden
| | - Bengt Arne Sjöqvist
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, 412 96, Sweden
| | - Jan-Erik Karlsson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Nordanstig
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Simulation Center West, Sahlgrenska University Hospital and University of Gothenburg, , Gothenburg, Sweden
| | - Lars Rosengren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Guterud M, Hardeland C, Bugge HF, Sandset EC, Svendsen EJ, Hov MR. Experiences from a cluster-randomized trial (ParaNASPP) exploring triage and diagnostic accuracy in paramedic-suspected stroke: a qualitative interview study. Eur J Neurol 2024; 31:e16252. [PMID: 38404142 PMCID: PMC11235795 DOI: 10.1111/ene.16252] [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: 11/24/2023] [Revised: 01/17/2024] [Accepted: 02/02/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE Timely prehospital stroke recognition was explored in the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) by implementation of stroke education for paramedics and use of the National Institutes of Health Stroke Scale (NIHSS) through a mobile application. The study tested triage and facilitated communication between paramedics and stroke physicians. To complement the quantitative results of the clinical trial, a qualitative approach was used to identify factors that influence triage decisions and diagnostic accuracy in prehospital stroke recognition experienced by paramedics and stroke physicians. METHOD Semi-structured qualitative individual interviews were performed following an interview guide. Informants were recruited from the enrolled paramedics and stroke physicians who participated in the ParaNASPP trial from Oslo University Hospital. Interviews were audio recorded, transcribed verbatim and approached inductively using the principles of thematic analysis. RESULTS Fourteen interviews were conducted, with seven paramedics and seven stroke physicians. Across both groups two overarching themes were identified related to triage decisions and diagnostic accuracy in prehospital stroke recognition: prehospital NIHSS reliably improves clinical assessment and communication quality; overtriage is widely accepted whilst undertriage is not. CONCLUSION Paramedics and stroke physicians described how prehospital NIHSS improved communication quality and reliably improved prehospital clinical assessment. The qualitative results support a rationale of an application algorithm to decide which NIHSS items should prompt immediate prenotification rather than a complete NIHSS as default.
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Affiliation(s)
- Mona Guterud
- Department of ResearchNorwegian Air Ambulance FoundationOsloNorway
- Division of Prehospital ServicesOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Camilla Hardeland
- Division of Prehospital ServicesOslo University HospitalOsloNorway
- Department of Nursing, Health and Laboratory ScienceØstfold University CollegeHaldenNorway
| | - Helge Fagerheim Bugge
- Department of ResearchNorwegian Air Ambulance FoundationOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of NeurologyOslo University HospitalOsloNorway
| | - Else Charlotte Sandset
- Department of ResearchNorwegian Air Ambulance FoundationOsloNorway
- Department of NeurologyOslo University HospitalOsloNorway
| | - Edel Jannecke Svendsen
- Institute of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
- Department of ResearchSunnaas Rehabilitation HospitalOsloNorway
| | - Maren Ranhoff Hov
- Department of ResearchNorwegian Air Ambulance FoundationOsloNorway
- Department of Nursing, Health and Laboratory ScienceØstfold University CollegeHaldenNorway
- Institute of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
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5
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Hunt B, Zhao H, Cassidy A, Peart S, Olaussen A. Diagnostic Accuracy of Posterior Circulation Stroke by Paramedics: A Systematic Review. PREHOSP EMERG CARE 2023; 28:823-831. [PMID: 37846931 DOI: 10.1080/10903127.2023.2270041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/15/2023] [Accepted: 10/06/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE This systematic review aims to identify the diagnostic accuracy of posterior circulation stroke (PCS) by paramedics and the causes and duration of delay in its recognition. METHODS A systematic search using CINAHL Plus, MEDLINE, Scopus, and PubMed was performed. All databases were searched up to May 25, 2022. Studies were included where patients were adults, assessed by paramedics, and PCS was the primary diagnosis. Bias was assessed using the Newcastle-Ottawa Scale and the Effective Practice and Organization of Care tool. Results have been described by proportions, and both sensitivity calculations and subgroup analysis were performed utilizing MedCalc. RESULTS A total of 797 titles/abstracts and a subsequent 87 full texts were screened, of which 15 were included. There were 5395 patients who were assessed by paramedics and had a confirmed diagnosis of PCS. Among five studies containing both true positive and false negative data, there were 98 (45.8%) true positives. PCS patients lost an average of 27 min (p < 0.001) compared to anterior stroke patients in the prehospital setting. One study revealed that educational intervention, including implementing the finger-to-nose test, increased the sensitivity for diagnosis from 45.8 to 74.1% (p = 0.039) and decreased the time from door to computed tomography from 62 to 41 min (p = 0.037). CONCLUSION There is a substantial lack of evidence regarding the diagnosis of PCS by paramedics. Despite the low quality of evidence available, overall, the sensitivity for paramedic PCS diagnosis appears to be poor. Further investigation is required into paramedics' diagnosis of PCS and the use of educational interventions.Prospective Register of Systematic Reviews Registration Number: CRD42022324675.
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Affiliation(s)
- Brooke Hunt
- Department of Paramedicine, Monash University, Melbourne, Australia
| | - Henry Zhao
- Department of Medicine, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
- Victorian Stroke Telemedicine, Ambulance Victoria, Melbourne, Australia
| | | | - Sam Peart
- Department of Paramedicine, Monash University, Melbourne, Australia
| | - Alexander Olaussen
- Department of Paramedicine, Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Cimino J, Braun C. Clinical Research in Prehospital Care: Current and Future Challenges. Clin Pract 2023; 13:1266-1285. [PMID: 37887090 PMCID: PMC10605888 DOI: 10.3390/clinpract13050114] [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: 08/21/2023] [Revised: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023] Open
Abstract
Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.
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Affiliation(s)
- Jonathan Cimino
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
| | - Claude Braun
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
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7
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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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8
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Jalo H, Seth M, Pikkarainen M, Häggström I, Jood K, Bakidou A, Sjöqvist BA, Candefjord S. Early identification and characterisation of stroke to support prehospital decision-making using artificial intelligence: a scoping review protocol. BMJ Open 2023; 13:e069660. [PMID: 37217266 PMCID: PMC10230929 DOI: 10.1136/bmjopen-2022-069660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Stroke is a time-critical condition and one of the leading causes of mortality and disability worldwide. To decrease mortality and improve patient outcome by improving access to optimal treatment, there is an emerging need to improve the accuracy of the methods used to identify and characterise stroke in prehospital settings and emergency departments (EDs). This might be accomplished by developing computerised decision support systems (CDSSs) that are based on artificial intelligence (AI) and potential new data sources such as vital signs, biomarkers and image and video analysis. This scoping review aims to summarise literature on existing methods for early characterisation of stroke by using AI. METHODS AND ANALYSIS The review will be performed with respect to the Arksey and O'Malley's model. Peer-reviewed articles about AI-based CDSSs for the characterisation of stroke or new potential data sources for stroke CDSSs, published between January 1995 and April 2023 and written in English, will be included. Studies reporting methods that depend on mobile CT scanning or with no focus on prehospital or ED care will be excluded. Screening will be done in two steps: title and abstract screening followed by full-text screening. Two reviewers will perform the screening process independently, and a third reviewer will be involved in case of disagreement. Final decision will be made based on majority vote. Results will be reported using a descriptive summary and thematic analysis. ETHICS AND DISSEMINATION The methodology used in the protocol is based on information publicly available and does not need ethical approval. The results from the review will be submitted for publication in a peer-reviewed journal. The findings will be shared at relevant national and international conferences and meetings in the field of digital health and neurology.
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Affiliation(s)
- Hoor Jalo
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Mattias Seth
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Minna Pikkarainen
- Department of Occupational Therapy, Prosthetics and Orthotics, Oslo Metropolitan University, Oslo, Norway
| | - Ida Häggström
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Katarina Jood
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Bakidou
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- PreHospen - Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Bengt Arne Sjöqvist
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Stefan Candefjord
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
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Koskela L, Raatiniemi L, Ehrola A, Kaakinen T, Lahtinen S, Liisanantti J. Accuracy of dispatch and prehospital triage performance in poisonings - A retrospective study from northern Finland. Acta Anaesthesiol Scand 2023; 67:112-119. [PMID: 36183301 PMCID: PMC10092780 DOI: 10.1111/aas.14152] [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: 02/10/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Increasing numbers of dispatches place a burden on EMS; this study sought to assess the prehospital evaluation of poisoned patients transported to hospital. The primary aim of this study was to measure dispatch centre and EMS provider performance as well as factors contributing to the recognition of poisoning among prehospital patients. The secondary aim was to compare triage performance between dispatch centres and EMS providers. METHODS A retrospective single-centre study in Northern Finland was conducted. Patients suspected as poisonings by dispatch centres as well as other EMS-transported patients who received a diagnosis of poisoning in hospital between June 1, 2015 and June 1, 2017, were included. RESULTS There were a total of 1668 poisoning-related EMS missions. Dispatch centres suspected poisonings with sensitivity of 79.9% (95% CI 76.7-82.9) and specificity of 98.9% (95% CI 98.9-99.0) when all EMS missions were taken into account. In a logistic regression model, decreased state of consciousness as dispatch code (OR 7.18, 95% CI 1.90-27.05) and intravenous fluid resuscitation (OR 6.58, 95% CI 1.34-32.37) were associated with EMS transport providers not recognizing poisoning. Overtriage rate appeared significantly higher (33.6%, 95% CI 28.6-39.2) for dispatch when compared with transport (17.8%, 95% CI 13.9-22.6). CONCLUSION Dispatch centres seem to suspect poisonings fairly accurately. Poisonings unrecognized by EMS providers may be linked with intravenous fluid resuscitation and decreased patient consciousness. Overtriage appears to resolve somewhat from dispatch to transport. There were no fatal poisonings in this study population.
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Affiliation(s)
- Lauri Koskela
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland
| | - Lasse Raatiniemi
- Centre for prehospital emergency care, Oulu University Hospital, Oulu, Finland
| | - Ari Ehrola
- Emergency Medical Services, Northern Ostrobothnian Hospital District, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu, Finland.,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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10
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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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11
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Glober NK, Fulks T, Supples M, Panagos P, Kim D. Factors Predicting Misidentification of Acute Ischemic Stroke and Large Vessel Occlusion by Paramedics. Crit Pathw Cardiol 2022; 21:172-175. [PMID: 36413394 PMCID: PMC9678438 DOI: 10.1097/hpc.0000000000000307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The emergence of thrombectomy for large vessel occlusions has increased the importance of accurate prehospital identification and triage of acute ischemic stroke (AIS). Despite available clinical scores, prehospital identification is suboptimal. Our objective was to improve the sensitivity of prehospital AIS identification by combining dispatch information with paramedic impression. We performed a retrospective cohort review of emergency medical services and hospital records of all patients for whom a stroke alert was activated in 1 urban, academic emergency department from January 1, 2018, to December 31, 2019. Using admission diagnosis of acute stroke as outcome, we calculated the sensitivity and specificity of dispatch and paramedic impression in identifying AIS and large vessel occlusion. We identified factors that, when included together, would improve the sensitivity of prehospital AIS identification. Two-hundred twenty-six stroke alerts were activated by emergency department physicians after transport by Indianapolis emergency medical services. Forty-four percent (99/226) were female, median age was 58 years (interquartile range, 50-67 years), and median National Institutes of Health Stroke Scale was 6 (interquartile range, 2-12). Paramedics demonstrated superior sensitivity (59% vs. 48%) but inferior specificity (56% vs. 73%) for detection of stroke as compared with dispatch. A strategy incorporating dispatch code of stroke, or paramedic impression of altered mental status or weakness in addition to stroke, would be 84% sensitive and 27% specific for identification of stroke. To optimize rapid and sensitive stroke detection, prehospital systems should consider inclusion of patients with dispatch code of stroke and provider impression of altered mental status or generalized weakness.
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Affiliation(s)
- Nancy K. Glober
- From the Department of Emergency Medicine, Indiana University, Indianapolis, IN
| | - Tyler Fulks
- Department of Emergency Medicine, Southern Illinois University, Springfield, IL
| | - Michael Supples
- From the Department of Emergency Medicine, Indiana University, Indianapolis, IN
| | - Peter Panagos
- Department of Emergency Medicine, Washington University at St. Louis, St. Louis, MO
| | - David Kim
- Department of Emergency Medicine, Stanford University, Palo Alto, CA
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12
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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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13
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Walter S, Phillips D, Wells B, Moon R, Bertsch T, Grunwald IQ, Fassbender K. Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms. Front Neurol 2022; 13:833933. [PMID: 35463123 PMCID: PMC9021751 DOI: 10.3389/fneur.2022.833933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.
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Affiliation(s)
- Silke Walter
- Neurology, Saarland University, Homburg, Germany
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
- *Correspondence: Silke Walter
| | - Daniel Phillips
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Brittany Wells
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Robert Moon
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Iris Q. Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, United Kingdom
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14
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Sepponen R, Saviluoto A, Jäntti H, Harve-Rytsälä H, Lääperi M, Nurmi J. Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting. J Stroke Cerebrovasc Dis 2022; 31:106319. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022] Open
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15
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Bugge HF, Guterud M, Bache KCG, Braarud AC, Eriksen E, Fremstad KO, Ihle-Hansen H, Ingebretsen SH, Kramer-Johansen J, Larsen K, Røislien J, Thorsen K, Toft M, Sandset EC, Hov MR. Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) study protocol: a stepped wedge randomised trial of stroke screening using the National Institutes of Health Stroke Scale in the ambulance. Trials 2022; 23:113. [PMID: 35120559 PMCID: PMC8814805 DOI: 10.1186/s13063-022-06006-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background Less than 50% of stroke patients in Norway reach hospital within 4 h of symptom onset. Early prehospital identification of stroke and triage to the right level of care may result in more patients receiving acute treatment. Quality of communication between paramedics and the stroke centre directly affects prehospital on-scene time, emphasising this as a key factor to reduce prehospital delay. Prehospital stroke scales are developed for quick and easy identification of stroke, but have poor sensitivity and specificity compared to an in-hospital assessment with the National Institutes of Health Stroke Scale (NIHSS). The aim of the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) is to assess whether a structured learning program, prehospital NIHSS and a mobile application facilitating communication with the stroke physician may improve triage of acute stroke patients. Methods A stepped wedge cluster randomised controlled intervention design will be used in this trial in Oslo, Norway. Paramedics at five ambulance stations will enrol adult patients with suspected stroke within 24 h of symptom onset. All paramedics will begin in a control phase with standard procedures. Through an e-learning program and practical training, a random and sequential switch to the intervention phase takes place. A mobile application for NIHSS scoring, including vital patient information for treatment decisions, transferring data from paramedics to the on-call stroke physician at the Stroke Unit at Oslo University Hospital, will be provided for the intervention. The primary outcome measure is positive predictive value (PPV) for prehospital identification of patients with acute stroke defined as the proportion of patients accepted for stroke evaluation and discharged with a final stroke diagnosis. One thousand three hundred patients provide a 50% surplus to the 808 patients needed for 80% power to detect a 10% increase in PPV. Discussion Structured and digital communication using a common scale like NIHSS may result in increased probability for better identification of stroke patients and less stroke mimics delivered to a stroke team for acute diagnostics and treatment in our population. Trial registration ClinicalTrials.govNCT04137874. Registered on October 24, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06006-4.
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Affiliation(s)
- Helge Fagerheim Bugge
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mona Guterud
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Kristi C G Bache
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basal Medical Science, University of Oslo, Oslo, Norway
| | | | - Erik Eriksen
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
| | - Kjell Otto Fremstad
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Hege Ihle-Hansen
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
| | | | - Jo Kramer-Johansen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - Karianne Larsen
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basal Medical Science, University of Oslo, Oslo, Norway
| | - Jo Røislien
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Oslo, Norway
| | | | - Mathias Toft
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Else Charlotte Sandset
- Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
| | - Maren Ranhoff Hov
- Norwegian Air Ambulance Foundation, Oslo, Norway. .,Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway. .,Oslo Metropolitan University, Oslo, Norway.
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16
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Matsoukas S, Giovanni B, Rubinstein L, Majidi S, Stein LK, Fifi JT. Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort. Cerebrovasc Dis Extra 2021; 11:137-144. [PMID: 34823243 PMCID: PMC8740215 DOI: 10.1159/000520078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system. Methods We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients' initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort. Results Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with p = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (p < 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (p < 0.001) for the DS versus BM cohort, respectively. Conclusions Modeled EMS prehospital triage of ELVO patients' results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, The Mount Sinai Hospital, New York, New York, USA,
| | - Brian Giovanni
- Department of Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Liorah Rubinstein
- Department of Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Shahram Majidi
- Department of Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Laura K Stein
- Department of Neurology, The Mount Sinai Hospital, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, The Mount Sinai Hospital, New York, New York, USA.,Department of Neurology, The Mount Sinai Hospital, New York, New York, USA
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17
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Iversen AB, Johnsen SP, Blauenfeldt RA, Gude MF, Dalby RB, Christensen B, Andersen G, Christensen MB. Help-seeking behaviour and subsequent patient and system delays in stroke. Acta Neurol Scand 2021; 144:524-534. [PMID: 34124770 DOI: 10.1111/ane.13484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Prehospital delay is the main reason why only a limited number of stroke patients receive reperfusion therapy. We aimed to investigate help-seeking behaviour in patients and bystanders after onset of stroke and subsequent patient and system delay. MATERIALS & METHODS We conducted a cross-sectional study of 332 patients with stroke. We performed structured interviews and used data from the medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay. RESULTS The median patient delay was 280 min, and the median system delay was 97 min. For a patient delay of <3 h, an additional non-significant system delay of median 30 min was seen for a first contact to a general practitioner (GP), and an additional significant delay of median 490 min was seen for the small group of patients with a first contact to 'other' healthcare professionals compared to the Emergency Medical Services (EMS). For a patient delay of more than 3 h, an additional system delay of median 78 min was found when the first contact was directed to the out-of-hours primary care (OOH-PC). A total of 17% of patients were admitted to another hospital or department before arrival at the stroke centre; this resulted in a substantially prolonged system delay of a median of 431 min. CONCLUSIONS Patient delay remains the main reason for delayed arrival at the stroke centre. Appropriate help-seeking behaviour and efficient pre-hospital triage are essential for reducing the prehospital delay and increasing the proportion of patients receiving reperfusion therapy.
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Affiliation(s)
- Ane Bull Iversen
- Department of Clinical Medicine – Neurology Aarhus University Aarhus N Denmark
- Research Unit for General Practice Aarhus C Denmark
- Department of Public Health Aarhus University Aarhus C Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research Department of Clinical Medicine Aalborg University and Aalborg University Hospital Aalborg Denmark
| | | | - Martin Faurholdt Gude
- Department of Clinical Medicine Pre‐hospital Emergency Medical Services Aarhus University Aarhus N Denmark
| | - Rikke Beese Dalby
- Department of Clinical Medicine – Radiology Aarhus University Hospital Aarhus N Denmark
| | - Bo Christensen
- Research Unit for General Practice Aarhus C Denmark
- Department of Public Health Aarhus University Aarhus C Denmark
| | - Grethe Andersen
- Department of Clinical Medicine – Neurology Aarhus University Aarhus N Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice Aarhus C Denmark
- Department of Public Health Aarhus University Aarhus C Denmark
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18
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Hoyer C, Szabo K. Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting. Front Neurol 2021; 12:682827. [PMID: 34335448 PMCID: PMC8317999 DOI: 10.3389/fneur.2021.682827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
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19
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Jones SP, Bray JE, Gibson JM, McClelland G, Miller C, Price CI, Watkins CL. Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review. Emerg Med J 2021; 38:387-393. [PMID: 33608393 PMCID: PMC8077214 DOI: 10.1136/emermed-2020-209607] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/30/2020] [Accepted: 12/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives). METHOD We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool. RESULTS Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%-28%), nausea/vomiting (n=94; 8%-38%), dizziness (n=86; 23%-27%), changes in mental status (n=51; 8%-25%) and visual disturbance/impairment (n=43; 13%-28%). CONCLUSION Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.
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Affiliation(s)
- Stephanie P Jones
- Faculty of Health and Care, University of Central Lancashire, Preston, UK
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Graham McClelland
- Research and Development, North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Colette Miller
- Faculty of Health and Care, University of Central Lancashire, Preston, UK
| | - Chris I Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Caroline L Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston, UK
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20
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Yaeger KA, Rossitto CP, Marayati NF, Lara-Reyna J, Ladner T, Hardigan T, Shoirah H, Mocco J, Fifi JT. Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow. J Neurointerv Surg 2021; 14:237-241. [PMID: 33832969 DOI: 10.1136/neurintsurg-2021-017297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times. METHODS We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes. RESULTS Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04). CONCLUSIONS Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.
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Affiliation(s)
- Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoum Fares Marayati
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Travis Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hazem Shoirah
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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21
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Rogers H, Chalil Madathil K, Joseph A, McNeese N, Holmstedt C, Holden R, McElligott JT. Task, usability, and error analyses of ambulance-based telemedicine for stroke care. ACTA ACUST UNITED AC 2021. [DOI: 10.1080/24725579.2021.1883775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Hunter Rogers
- College of Engineering, Computing and Applied Sciences, Departments of Civil and Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Kapil Chalil Madathil
- College of Engineering, Computing and Applied Sciences, Departments of Civil and Industrial Engineering, Clemson University, Clemson, SC, USA
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anjali Joseph
- College of Engineering, Computing and Applied Sciences, Departments of Civil and Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Nathan McNeese
- College of Engineering, Computing and Applied Sciences, Departments of Civil and Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Christine Holmstedt
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Richard Holden
- School of Medicine, Indiana University, Bloomington, IN, USA
| | - James T. McElligott
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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22
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Prehospital stroke management in the thrombectomy era. Lancet Neurol 2020; 19:601-610. [DOI: 10.1016/s1474-4422(20)30102-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
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23
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Smith DE, Siket MS. High-Risk Chief Complaints III: Neurologic Emergencies. Emerg Med Clin North Am 2020; 38:523-537. [PMID: 32336338 DOI: 10.1016/j.emc.2020.02.006] [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: 11/16/2022]
Abstract
A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.
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Affiliation(s)
- Danielle E Smith
- Robert Larner College of Medicine of the University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405, USA
| | - Matthew S Siket
- Surgery, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC 2, Burlington, VT 05401, USA.
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24
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Kemp K, Mertanen R, Lääperi M, Niemi-Murola L, Lehtonen L, Castren M. Nonspecific complaints in the emergency department - a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:6. [PMID: 31992333 PMCID: PMC6986144 DOI: 10.1186/s13049-020-0699-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This prognostic systematic review draws a synthesis of reported outcomes for patients presenting with NSC and compares them with outcomes for patients presenting with a specific complaint. METHODS We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the past 20 years. Studies were included which treated adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2599 studies were screened for eligibility and quality was assessed using the SIGN assessment for bias tool. We excluded any low-quality studies, resulting in nine studies for quantitative analysis. We analysed the included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and re-visitation rate and compared outcomes to patients presenting with specific complaints (SC), where data were available. We grouped discharge diagnoses by ICD-10 category. RESULTS We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 2.50 (95% CI 1.40-4.47)]. They were triaged as urgent less often than SC patients [OR 2.12 (95% CI 1.08-4.16)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 3.86 (95% CI 1.76-8.47)]. These patients seemed to require more resources than patients with SC. The number for intensive care admissions did not seem to be increased. Data were insufficient to make conclusions regarding re-visitation rates. Discharge diagnoses were spread throughout the ICD-10 main chapters, infections being the most prevalent. CONCLUSIONS Patients with NSC have a high risk of mortality and their care in the Emergency Department requires more time and resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.
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Affiliation(s)
- Kirsi Kemp
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland.
| | - Reija Mertanen
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Mitja Lääperi
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Leila Niemi-Murola
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
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25
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Loftspring MC, Lee JM. Rapid Diagnosis, Triage, and Treatment of a 59-Year-Old Man with Sudden-Onset Right-Sided Weakness and Difficulty Speaking. J Appl Lab Med 2020; 5:225-228. [PMID: 31811075 DOI: 10.1373/jalm.2019.029553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/21/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Matthew C Loftspring
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
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26
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Kummer BR, Lerario MP, Hunter MD, Wu X, Efraim ES, Salehi Omran S, Chen ML, Diaz IL, Sacchetti D, Lekic T, Kulick ER, Pishanidar S, Mir SA, Zhang Y, Asaeda G, Navi BB, Marshall RS, Fink ME. Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry. J Am Heart Assoc 2019; 8:e013529. [PMID: 31795824 PMCID: PMC6951069 DOI: 10.1161/jaha.119.013529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Mobile stroke units (MSUs) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi-institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm). Our exposure was MSU care, and our primary outcome was dispatch-to-thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch-to-thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P=0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0-mile radius (4.8 versus 2.7, P=0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch-to-thrombolysis time of 29.7 minutes (95% CI, 6.9-52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.
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Affiliation(s)
- Benjamin R Kummer
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY
| | - Mackenzie P Lerario
- Department of Neurology NewYork-Presbyterian Queens Flushing NY.,Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | | | - Xian Wu
- Department of Healthcare Policy and Research Weill Cornell Medicine New York NY
| | | | - Setareh Salehi Omran
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Monica L Chen
- Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Ivan L Diaz
- Department of Healthcare Policy and Research Weill Cornell Medicine New York NY
| | - Daniel Sacchetti
- Department of Neurology Brown Alpert School of Medicine Providence RI
| | - Tim Lekic
- Desert Neurology & Sleep La Quinta CA
| | - Erin R Kulick
- School of Public Health Brown University Providence RI
| | - Sammy Pishanidar
- Department of Neurology NewYork-Presbyterian Queens Flushing NY.,Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Saad A Mir
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Yi Zhang
- New York University Winthrop Hospital Mineola NY
| | | | - Babak B Navi
- Department of Neurology Weill Cornell Medicine New York NY.,Clinical Translational Neuroscience Unit Feil Family Brain & Mind Research Institute Weill Cornell Medicine New York NY
| | - Randolph S Marshall
- Department of Neurology Columbia College of Physicians & Surgeons New York NY
| | - Matthew E Fink
- Department of Neurology Weill Cornell Medicine New York NY
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27
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Harriott AM, Karakaya F, Ayata C. Headache after ischemic stroke: A systematic review and meta-analysis. Neurology 2019; 94:e75-e86. [PMID: 31694924 PMCID: PMC7011689 DOI: 10.1212/wnl.0000000000008591] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/26/2019] [Indexed: 01/24/2023] Open
Abstract
Objective Headache associated with ischemic stroke is poorly understood. To gain further insight, we systematically reviewed studies examining the prevalence and characteristics of new-onset poststroke headache. Methods Medline and PubMed databases were queried. A total of 1,812 articles were identified. Of these, 50 were included in this systematic review. Twenty were included in a meta-analysis and meta-regression. Results Headache occurred in 6%–44% of the ischemic stroke population. Most headaches had tension-type features, were moderate to severe, and became chronic in nature. Meta-analysis using an inverse-variance heterogeneity model revealed a pooled prevalence of 0.14 (95% confidence interval [CI] 0.07–0.23) with heterogeneity among studies. Metaregression revealed a significant association between prevalence and study location, the source population's national human development index (HDI), and study quality. We found higher prevalence in European (0.22, 95% CI 0.14–0.30) and North American (0.15, 95% CI 0.05–0.26) studies compared with Middle Eastern and Asian studies (0.08, 95% CI 0.01–0.18). However, within each region, populations from countries with higher HDI (p = 0.03) and studies with higher quality (p = 0.001) had lower prevalence. Calculated crude odds ratios (ORs) showed that posterior circulation stroke (pooled OR 1.92, 95% CI 1.4–2.64; n = 7 studies) and female sex (pooled OR 1.25, 95% CI 1.07–1.46; n = 11 studies) had greater odds of headache associated with ischemic stroke. Conclusions Taken together, these data suggest that headache is common at the onset of or shortly following ischemic stroke and may contribute to poststroke morbidity. Better understanding of headache associated with ischemic stroke is needed to establish treatment guidelines and inform patient management.
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Affiliation(s)
- Andrea M Harriott
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.).
| | - Fahri Karakaya
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.)
| | - Cenk Ayata
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.)
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28
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Li JL, McMullan JT, Sucharew H, Broderick JP, Katz B, Schmit P, Adeoye O. Potential Impact of C-STAT for Prehospital Stroke Triage up to 24 Hours on a Regional Stroke System. PREHOSP EMERG CARE 2019; 24:500-504. [DOI: 10.1080/10903127.2019.1676343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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29
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Andersson Hagiwara M, Lundberg L, Sjöqvist BA, Maurin Söderholm H. The Effects of Integrated IT Support on the Prehospital Stroke Process: Results from a Realistic Experiment. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2019; 3:300-328. [PMID: 35415430 PMCID: PMC8982745 DOI: 10.1007/s41666-019-00053-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 12/03/2022]
Abstract
Stroke is a serious condition and the stroke chain of care is a complex. The present study aims to explore the impact of a computerised decision support system (CDSS) for the prehospital stroke process, with focus on work processes and performance. The study used an exploratory approach with a randomised controlled crossover design in a realistic contextualised simulation experiment. The study compared clinical performance among 11 emergency medical services (EMS) teams of 22 EMS clinicians using (1) a computerised decision support system (CDSS) and (2) their usual paper-based process support. Data collection consisted of video recordings, postquestionnaires and post-interviews, and data were analysed using a combination of qualitative and quantitative approaches. In this experiment, using a CDSS improved patient assessment, decision making and compliance to process recommendations. Minimal impact of the CDSS was found on EMS clinicians' self-efficacy, suggesting that even though the system was found to be cumbersome to use it did not have any negative effects on self-efficacy. Negative effects of the CDSS include increased on-scene time and a cognitive burden of using the system, affecting patient interaction and collaboration with team members. The CDSS's overall process advantage to the prehospital stroke process is assumed to lead to a prehospital care that is both safer and of higher quality. The key to user acceptance of a system such as this CDSS is the relative advantages of improved documentation process and the resulting patient journal. This could improve the overall prehospital stroke process.
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Affiliation(s)
- Magnus Andersson Hagiwara
- PreHospen - Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90 Borås, Sweden
| | - Lars Lundberg
- PreHospen - Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90 Borås, Sweden
| | - Bengt Arne Sjöqvist
- Department of Electrical Engineering, Biomedical Signals and Systems, Chalmers University of Technology, SE-412 96 Gothenburg, Sweden
| | - Hanna Maurin Söderholm
- PreHospen-Centre for Prehospital Research, Faculty of Librarianship, Information, Education and IT, University of Borås, SE-501 90 Borås, Sweden
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30
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Alsholm L, Axelsson C, Andersson Hagiwara M, Niva M, Claesson L, Herlitz J, Magnusson C, Rosengren L, Jood K. Interrupted transport by the emergency medical service in stroke/transitory ischemic attack: A consequence of changed treatment routines in prehospital emergency care. Brain Behav 2019; 9:e01266. [PMID: 30980519 PMCID: PMC6520471 DOI: 10.1002/brb3.1266] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The discovery that not all patients who call for the emergency medical service (EMS) require transport to hospital has changed the structure of prehospital emergency care. Today, the EMS clinician at the scene already distinguishes patients with a time-critical condition such as stroke/transitory ischemic attack (TIA) from patients without. This highlights the importance of the early identification of stroke/TIA. AIM To describe patients with a final diagnosis of stroke/TIA whose transport to hospital was interrupted either due to a lack of suspicion of the disease by the EMS crew or due to refusal by the patient or a relative/friend. METHODS Data were obtained from a register in Gothenburg, covering patients hospitalised due to a final diagnosis of stroke/TIA. The inclusion criterion was that patients were assessed by the EMS but were not directly transported to hospital by the EMS. RESULTS Among all the patients who were assessed by the EMS nurse and subsequently diagnosed with stroke or TIA in 2015, the transport of 34 of 1,310 patients (2.6%) was interrupted. Twenty-five of these patients, of whom 20 had a stroke and five had a TIA, are described in terms of initial symptoms and outcome. The majority had residual symptoms at discharge from hospital. Initial symptoms were vertigo/disturbed balance in 11 of 25 cases. Another three had symptoms perceived as a change in personality and three had a headache. CONCLUSION From this pilot study, we hypothesise that a fraction of patients with stroke/TIA who call for the EMS have their direct transport to hospital interrupted due to a lack of suspicion of the disease by the EMS nurse at the scene. These patients appear to have more vague symptoms including vertigo and disturbed balance. Instruments to identify these patients at the scene are warranted.
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Affiliation(s)
- Linda Alsholm
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Christer Axelsson
- Prehospen-Centre of Prehosp Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Magnus Andersson Hagiwara
- Prehospen-Centre of Prehosp Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - My Niva
- Department of Ambulance Care, Jönköping County Hospital, Jönköping, Sweden
| | - Lisa Claesson
- Department of Ambulance Care, Halland County Hospital, Varberg, Sweden
| | - Johan Herlitz
- Prehospen-Centre of Prehosp Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Carl Magnusson
- Department of Molecular and Clinical Medicine, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Rosengren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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31
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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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32
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Quirins M, Dussaule C, Denier C, Masnou P. Epilepsy after stroke: Definitions, problems and a practical approach for clinicians. Rev Neurol (Paris) 2018; 175:126-132. [PMID: 30415978 DOI: 10.1016/j.neurol.2018.02.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/28/2018] [Indexed: 11/17/2022]
Abstract
Stroke, whether ischemic or hemorrhagic, is the main etiology of epilepsy in the elderly. However, incidences and outcomes differ according to stroke subtype and delay of onset following the stroke. While the medical literature is extensive, it is not always consistent, and many questions still remain regarding risk factors and management of vascular epilepsy. Thus, the present report here is an overview of the clinical aspects of vascular epilepsy using a practical approach that integrates data from meta-analyses and the more recently published expert recommendations.
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Affiliation(s)
- M Quirins
- Service de neurologie adulte, CHU Bicêtre, 78, avenue du Général Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - C Dussaule
- Service de neurologie adulte, CHU Bicêtre, 78, avenue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - C Denier
- Service de neurologie adulte, CHU Bicêtre, 78, avenue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
| | - P Masnou
- Service de neurologie adulte, CHU Bicêtre, 78, avenue du Général Leclerc, 94270 Le Kremlin Bicêtre, France
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33
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Andersson Hagiwara M, Wireklint Sundström B, Brink P, Herlitz J, Hansson PO. A shorter system delay for haemorrhagic stroke than ischaemic stroke among patients who use emergency medical service. Acta Neurol Scand 2018; 137:523-530. [PMID: 29315463 DOI: 10.1111/ane.12895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We compare various aspects in the early chain of care among patients with haemorrhagic stroke and ischaemic stroke. MATERIALS & METHODS The Emergency Medical Services (EMS) and nine emergency hospitals, each with a stroke unit, were included. All patients hospitalised with a first and a final diagnosis of stroke between 15 December 2010 and 15 April 2011 were included. The primary endpoint was the system delay (from call to the EMS until diagnosis). Secondary endpoints were: (i) use of the EMS, (ii) delay from symptom onset until call to the EMS; (iii) priority at the dispatch centre; (iv) priority by the EMS; and (v) suspicion of stroke by the EMS nurse and physician on admission to hospital. RESULTS Of 1336 patients, 172 (13%) had a haemorrhagic stroke. The delay from call to the EMS until diagnosis was significantly shorter in haemorrhagic stroke. The patient's decision time was significantly shorter in haemorrhagic stroke. The priority level at the dispatch centre did not differ between the two groups, whereas the EMS nurse gave a significantly higher priority to patients with haemorrhage. There was no significant difference between groups with regard to the suspicion of stroke either by the EMS nurse or by the physician on admission to hospital. CONCLUSIONS Patients with a haemorrhagic stroke differed from other stroke patients with a more frequent and rapid activation of EMS.
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Affiliation(s)
- M. Andersson Hagiwara
- PreHospen - Centre for Prehospital Research; Faculty of Caring Science, Work Life and Social Welfare; University of Borås; Borås Sweden
| | - B. Wireklint Sundström
- PreHospen - Centre for Prehospital Research; Faculty of Caring Science, Work Life and Social Welfare; University of Borås; Borås Sweden
| | - P. Brink
- Department of Health Sciences; Section for Nursing - Undergraduate Level; University West; Trollhättan Sweden
| | - J. Herlitz
- PreHospen - Centre for Prehospital Research; Faculty of Caring Science, Work Life and Social Welfare; University of Borås; Borås Sweden
| | - P.-O. Hansson
- Department of Molecular and Clinical Medicine; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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34
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Mullen MT, Pajerowski W, Messé SR, Mechem CC, Jia J, Abboud M, David G, Carr BG, Band R. Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies. Stroke 2018; 49:1021-1023. [PMID: 29491140 DOI: 10.1161/strokeaha.118.020691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/08/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the impact of a primary stroke center (PSC) destination policy in a major metropolitan city and used geographic modeling to evaluate expected changes for a comprehensive stroke center policy. METHODS We identified suspected stroke emergency medical services encounters from 1/1/2004 to 12/31/2013 in Philadelphia, PA. Transport times were compared before and after initiation of a PSC destination policy on 10/3/2011. Geographic modeling estimated the impact of bypassing the closest hospital for the closest PSC and for the closest comprehensive stroke center. RESULTS There were 2 326 943 emergency medical services runs during the study period, of which 15 099 had a provider diagnosis of stroke. Bypassing the closest hospital for a PSC was common before the official policy and increased steadily over time. Geographic modeling suggested that bypassing the closest hospital in favor of the closest PSC adds a median of 3.1 minutes to transport time. Bypassing to the closest comprehensive stroke center would add a median of 8.3 minutes. CONCLUSIONS Within a large metropolitan area, the time cost of routing patients preferentially to PSCs and comprehensive stroke centers is low.
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Affiliation(s)
- Michael T Mullen
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.).
| | - William Pajerowski
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Steven R Messé
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - C Crawford Mechem
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Judy Jia
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Michael Abboud
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Guy David
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Brendan G Carr
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
| | - Roger Band
- From the Department of Neurology (M.T.M., S.R.M., J.J.), Leonard Davis Institute of Health Economics (M.T.M., W.P., G.D.), Department of Healthcare Management, Wharton School (W.P., G.D.), Department of Emergency Medicine (C.C.M.), University of Pennsylvania, Philadelphia; Philadelphia Fire Department, PA (C.C.M.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (M.A.); and Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C., R.B.)
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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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Abstract
Introduction the early phase of stroke, minutes are critical. Since the majority of patients with stroke are transported by the Emergency Medical Service (EMS), the early handling and decision making by the EMS clinician is important. Problem The study aim was to evaluate the frequency of a documented suspicion of stroke by the EMS nurse, and to investigate differences in the clinical signs of stroke and clinical assessment in the prehospital setting among patients with regard to if there was a documented suspicion of stroke on EMS arrival or not, in patients with a final hospital diagnosis of stroke. METHODS The study had a retrospective observational design. Data were collected from reports on patients who were transported by the EMS and had a final diagnosis of stroke at a single hospital in western Sweden (630 beds) in 2015. The data sources were hospital and prehospital medical journals. RESULTS In total, 454 patients were included. Among them, the EMS clinician suspected stroke in 52%. The findings and documentation on patients with a suspected stroke differed from the remaining patients as follows: a) More frequently documented symptoms from the face, legs/arms, and speech; b) More frequently assessments of neurology, face, arms/legs, speech, and eyes; c) More frequently addressed the major complaint with regard to time and place of onset, duration, localization, and radiation; d) Less frequently documented symptoms of headache, vertigo, and nausea; and e) More frequently had an electrocardiogram (ECG) recorded and plasma glucose sampled. In addition to the 52% of patients who had a documented initial suspicion of stroke, seven percent of the patients had an initial suspicion of transitory ischemic attack (TIA) by the EMS clinician, and a neurologist was approached in another 10%. CONCLUSION Among 454 patients with a final diagnosis of stroke who were transported by the EMS, an initial suspicion of stroke was not documented in one-half of the cases. These patients differed from those in whom a suspicion of stroke was documented in terms of limited clinical signs of stroke, a less extensive clinical assessment, and fewer clinical investigations. Andersson E , Bohlin L , Herlitz J , Sundler AJ , Fekete Z , Andersson Hagiwara M . Prehospital identification of patients with a final hospital diagnosis of stroke. Prehosp Disaster Med. 2018;33(1):63-70.
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Jia J, Band R, Abboud ME, Pajerowski W, Guo M, David G, Mechem CC, Messé SR, Carr BG, Mullen MT. Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice. Front Neurol 2017; 8:466. [PMID: 28959230 PMCID: PMC5603652 DOI: 10.3389/fneur.2017.00466] [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] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/22/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. METHODS AND RESULTS Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom duration <6 h. In a multivariable model, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5-9, OR 2.62, 95% CI 1.41-4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29-9.09) and weakness (OR 2.28, 95% CI 1.35-3.85), and negatively associated with symptom duration >270 min (OR 0.41, 95% CI 0.25-0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration <6 h. CONCLUSION Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification.
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Affiliation(s)
- Judy Jia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Roger Band
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Michael E Abboud
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, MA, United States.,Brigham and Women's Hospital, Department of Emergency Medicine, Boston, MA, United States
| | - William Pajerowski
- Department of Healthcare Management, Wharton School, University of Pennsylvania, Philadelphia, PA, United States
| | - Michelle Guo
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Guy David
- Department of Healthcare Management, Wharton School, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - C Crawford Mechem
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Philadelphia Fire Department, Philadelphia, PA, United States
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Brendan G Carr
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
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Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
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Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Thrombolysis in Stroke within 30 Minutes: Results of the Acute Brain Care Intervention Study. PLoS One 2016; 11:e0166668. [PMID: 27861540 PMCID: PMC5115772 DOI: 10.1371/journal.pone.0166668] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 11/02/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND PURPOSE Time is brain: benefits of intravenous thrombolysis (IVT) in ischemic stroke last for 4.5 hours but rapidly decrease as time progresses following symptom onset. The goal of the Acute Brain Care (ABC) intervention study was to reduce the door-to-needle time (DNT) to ≤30 minutes by optimizing in-hospital stroke treatment. METHODS We performed a single-centre before (pre-intervention period: 2000-2005) versus after (post-intervention period: 2006-2012) comparison in a cohort of consecutive patients treated with IVT. The intervention consisted of the implementation of a multidisciplinary stroke protocol combining simple strategies to reduce the DNT. Primary endpoint was the DNT, presented as proportion ≤30 minutes and median time. Secondary clinical endpoints were symptomatic intracranial hemorrhage (SICH), and favourable outcome defined as a modified Rankin scale (mRs) score of 0-2 at 3 months. Endpoints were additionally adjusted for baseline imbalances between the groups. RESULTS In the pre-intervention period, none (0.0%) of the 100 patients (mean age 63.8 years, median National Institutes of Health Stroke Scale [NIHSS] score 14) treated with IVT had a DNT ≤30 minutes compared to 234 (62.7%) of the 373 patients (mean age 66.7 years, median NIHSS score 10) in the post-intervention period (p<0.001). The median DNT decreased from 75 (IQR 60-105) to 28 minutes (IQR 20-37, p<0.001). SICH rate remained stable (3.0% versus 4.4%, OR 1.50, 95% CI 0.43─5.25; adjusted OR 5.47, 95% CI 0.69-42.12). The proportion of patients with a favourable outcome increased (38.9% versus 52.3%, OR 1.72, 95% CI 1.09-2.73) but lost statistical significance after adjustment (adjusted OR 1.46, 95% CI 0.82-2.61). CONCLUSIONS Important and sustained reduction of the DNT to 30 minutes or less can be safely achieved by optimizing in-hospital stroke treatment. With its simple strategies, the ABC-protocol is a pragmatic framework for increasing the therapeutic yield in time-dependent stroke treatment.
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Belt GH, Felberg RA, Rubin J, Halperin JJ. In-Transit Telemedicine Speeds Ischemic Stroke Treatment. Stroke 2016; 47:2413-5. [DOI: 10.1161/strokeaha.116.014270] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/08/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Time to treatment is critically important in ischemic stroke. We compared the efficacy and cost of teleneurology evaluation during patient transport with that of mobile stroke transport units.
Methods—
Using cellular-connected telemedicine devices, we assessed 89 presumptive stroke patients in ambulances in transit. Paramedics assisted remote teleneurologists in obtaining a simplified history and examination, then coordinating care with the receiving emergency department. We prospectively assessed door-to-needle and last-known-well-to-needle times for all intravenous alteplase–treated stroke patients brought to our emergency departments by emergency medical services’ transport, comparing those with and without in-transit telestroke.
Results—
From January 2015 through March 2016, 111 stroke patients received intravenous alteplase at study emergency departments. Mean door to needle was 13 minutes less with in-transit telestroke (28 versus 41;
P
=0.02). Although limitations in cellular communication degraded transmission quality, this did not prevent the completion of satisfactory patient evaluations.
Conclusions—
Improvement in time to treat seems comparable with in-transit telestroke and mobile stroke transport units. The low cost/unit makes this approach scalable, potentially providing rapid management of more patients.
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Affiliation(s)
- Gary H. Belt
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - Robert A. Felberg
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - Jane Rubin
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - John J. Halperin
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
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Sharma M, Helzner E, Sinert R, Levine SR, Brandler ES. Patient characteristics affecting stroke identification by emergency medical service providers in Brooklyn, New York. Intern Emerg Med 2016; 11:229-36. [PMID: 26553585 DOI: 10.1007/s11739-015-1347-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
Early identification of stroke should begin in the prehospital phase because the benefits of thrombolysis and clot extraction are time dependent. This study aims to identify patient characteristics that affect prehospital identification of stroke by Long Island college hospital (LICH) emergency medical services (EMS). All suspected strokes brought to LICH by LICH ambulances from January 1, 2010 to December 31, 2011 were included in the study. We compared prehospital care report-based diagnosis against the get with the guidelines (GWTG) database. Age-adjusted logistic regression models were used to study that the effect of individual patient characteristics have on EMS providers' diagnosis. Included in the study were 10,384 patients with mean age 43.9 years. Of whom, 75 had a GWTG cerebrovascular diagnosis: 53 were ischemic strokes, 7 transient ischemic attacks, 3 subarachnoid hemorrhage, and 12 intercerebral bleeds. LICH EMS correctly identified 44 of 75 GWTG strokes. Fifty-one patients were overcalled as stroke by the EMS. Overall EMS sensitivity was 58.7 % and specificity was 99.5 %. Dispatcher call type of altered mental status, stroke, unconsciousness, and increasing prehospital blood pressure quartile were found to be significantly predictive of a true stroke diagnosis. Patients with a past medical history and EMS providers' impression of seizures were more likely to be overcalled as a stroke in the field. More than a third of actual stroke patients were missed in the field in our study. Our results show that the patients' past medical history, dispatcher collected information and prehospital vital sign measurements are associated with a true diagnosis of stroke.
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Affiliation(s)
- Mohit Sharma
- Department of Community Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar, 143001, India.
| | - Elizabeth Helzner
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Medical Center, Brooklyn, NY, USA.
| | - Richard Sinert
- Department of Emergency Medicine, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Steven Richard Levine
- Department of Emergency Medicine, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, USA.
- Department of Neurology, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, USA.
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Lippman JM, Smith SNC, McMurry TL, Sutton ZG, Gunnell BS, Cote J, Perina DG, Cattell-Gordon DC, Rheuban KS, Solenski NJ, Worrall BB, Southerland AM. Mobile Telestroke During Ambulance Transport Is Feasible in a Rural EMS Setting: The iTREAT Study. Telemed J E Health 2015; 22:507-13. [PMID: 26600433 DOI: 10.1089/tmj.2015.0155] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of telemedicine in the diagnosis and treatment of acute stroke, or telestroke, is a well-accepted method of practice improving geographic disparities in timely access to neurological expertise. We propose that mobile telestroke assessment during ambulance transport is feasible using low-cost, widely available technology. MATERIALS AND METHODS We designed a platform including a tablet-based end point, high-speed modem with commercial wireless access, external antennae, and portable mounting apparatus. Mobile connectivity testing was performed along six primary ambulance routes in a rural network. Audiovisual (AV) quality was assessed simultaneously by both an in-vehicle and an in-hospital rater using a standardized 6-point rating scale (≥4 indicating feasibility). We sought to achieve 9 min of continuous AV connectivity presumed sufficient to perform mobile telestroke assessments. RESULTS Thirty test runs were completed: 93% achieved a minimum of 9 min of continuous video transmission with a mean mobile connectivity time of 18 min. Mean video and audio quality ratings were 4.51 (4.54 vehicle; 4.48 hospital) and 5.00 (5.13 in-vehicle; 4.87 hospital), respectively. Total initial cost of the system was $1,650 per ambulance. CONCLUSIONS In this small, single-centered study we maintained high-quality continuous video transmission along primary ambulance corridors using a low-cost mobile telemedicine platform. The system is designed to be portable and adaptable, with generalizability for rapid assessment of emergency conditions in which direct observational exam may improve prehospital diagnosis and treatment. Thus mobile telestroke assessment is feasible using low-cost components and commercial wireless connectivity. More research is needed to demonstrate clinical reliability and efficacy in a live-patient setting.
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Affiliation(s)
- Jason M Lippman
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Sherita N Chapman Smith
- 2 Department of Neurology, Virginia Commonwealth University Health System , Richmond, Virginia
| | - Timothy L McMurry
- 3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Zachary G Sutton
- 4 The Brody School of Medicine, East Carolina University , Greenville, North Carolina
| | - Brian S Gunnell
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Jack Cote
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Debra G Perina
- 6 Department of Emergency Medicine, University of Virginia Health System , Charlottesville, Virginia
| | - David C Cattell-Gordon
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Karen S Rheuban
- 5 Department of Center for Telehealth, University of Virginia Health System , Charlottesville, Virginia
| | - Nina J Solenski
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia
| | - Bradford B Worrall
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
| | - Andrew M Southerland
- 1 Department of Neurology, University of Virginia Health System , Charlottesville, Virginia.,3 Department of Public Health Sciences, University of Virginia Health System , Charlottesville, Virginia
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