Statewide Survey of 911 Communication Centers on Acute Stroke andMyocardial Infarction

Looking back to inform the future: a review of published paramedicine research

OBJECTIVE

Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community.

METHODS

We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample.

RESULTS

The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice.

CONCLUSIONS

Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.

The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch centre: A multicentre observational study

BACKGROUND

The early chain of care is critical for stroke patients. The most important part is the so-called 'system delay' i.e. the delay time from call to the emergency medical services until a diagnosis is established (computer tomography).

AIM

The purpose of this study was to relate the initial priority level given by the dispatch centre to the early chain of care in acute stroke and to short-term and long-term mortality.

METHODS

All patients hospitalised with the first and the final diagnosis of acute stroke, 15 December 2010-15 April 2011, were recruited across nine hospitals, each hospital with a stroke care unit.

RESULTS

In all, 897 stroke patients were included. Priority at the dispatch centre: 54% received highest priority 1, 41% priority 2 and 5% priority 3. Median system delay from call to emergency medical services until diagnosis by computer tomography was 2 h and 52 min, 4 h and 49 min and 6 h and 33 min respectively in the three priority groups ( p<0.0001). There was a similarly strong association between priority level at the dispatch centre and system delay to arrival in a hospital ward, suspicion of stroke by the emergency medical services nurse as well as the physician on hospital admission and the proportion of patients given thrombolysis. Mortality during the subsequent 30 days was 22% among patients with priority 1 and 14% among patients with priority 2.

CONCLUSION

Patients given a lower priority level at the dispatch centre had the longest system delay. Although many of these patients died, the risk of death was highest among those given the highest priority.

The effect of Cincinnati Prehospital Stroke Scale on telephone triage of stroke patients: evidence-based practice in emergency medical services

BACKGROUND

The emergency medical service is designed to recognize and transfer critically ill patients. Evidence-based practice has rarely been emphasized in the emergency medical service field, especially in the dispatch center.

AIMS

To identify the effect of the Cincinnati Prehospital Stroke Scale (CPSS) on telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center and to compare CPSS with the National Guidelines for Telephone Triage Tool (NGTT).

METHODS

A quasi-empirical study was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS. Two hundred and forty-six patients were randomly allocated to the CPSS intervention group (n = 121) and the NGTT control group (n = 125). True triage, triage error and odds ratio were statistically reported.

RESULTS

The mean age of the patients was 70.9 ± 12.7 years. Of all the cases, 77.7 and 65.6% of patients in the intervention and the control groups, respectively, were accurately triaged. Under-triage cases were 10.7 and 13.6% of the patients in the intervention and the control groups. Odds ratio was 1.14 (95% confidence interval 0.62-2.07) for the CPSS compared with the NGTT.

CONCLUSION

CPSS is more efficient for use by telephone triage nurses in identifying stroke. The use of CPSS assists nurses by reducing the triage error and supports the evidence-based care. It needs to be developed to cover signs and symptoms of posterior-circulation stroke patients.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition

BACKGROUND AND PURPOSE

The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience.

METHODS

We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices.

RESULTS

Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures.

CONCLUSIONS

Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Launching online education for 911 telecommunicators and EMS personnel: experiences from the North Carolina Rapid Response to Stroke Project

OBJECTIVE

We describe the development and implementation of the North Carolina Rapid Response to Stroke (NCRRS) project--a community-based online education project developed for 911 telecommunicators and EMS personnel.

METHODS

Two online courses, one for 911 telecommunicators and one for EMS personnel, were designed to provide timely and accessible continuing education on stroke assessment and care. Eight county-based emergency management systems, representing 15 agencies, were recruited for participation in a 4-month trial of the online courses in 2003. A total of 150 telecommunicators and 208 EMS personnel completed the courses.

RESULTS

Results showed high levels of participant satisfaction with the program and improvements in posttest scores; agency leaders also provided positive feedback on the project. Motivators to complete the education identified by participants included peers, agency support, and materials provided by the NCRRS project. Courses were revised on the basis of feedback and successfully sustained online through August 2006, providing free stroke education for almost 1,000 additional 911 telecommunicators and EMS personnel in North Carolina.

CONCLUSIONS

We describe the process of development and implementation that ensured project success. The results of this study show the need for and value of online stroke education for emergency services personnel and describe the challenges of developing and implementing online continuing education for this population. Similar education programs should be developed. Programs should incorporate comprehensive recruitment programs and community-based networks that sustain interest and promote full participation in educational offerings.