Call to hospital times for suspected stroke patients in the North East of England: a service evaluation

A qualitative exploration of ambulance clinician behaviour and decision making to identify factors influencing on-scene times for suspected stroke patients in North East England

Aims/objectives

Ambulance clinician assessment of suspected stroke patients aims to provide rapid access to specialist care, however regional and national data show increasing pre-hospital times. This study explored paramedic views about factors contributing to on-scene time (OST) for suspected stroke patients, with a view to identifying opportunities for future interventions, to reduce OST.

Methods

Views of paramedics from one regional service on factors influencing OST were explored using a qualitative approach. Semi-structured interviews with volunteers were recorded, transcribed and analysed using thematic analysis.

Results

Interviews were conducted with 13 paramedics between August and November 2021. Five interlinked themes were identified and described a range of factors influencing OST: 'Initial assessment and sources of information' describes how clinicians make assessments based on initial presentation, influenced by pre-arrival information from ambulance control and family members / bystanders at the scene, and how this influences OST.'Suitability for treatment and interventions' describes how paramedics consider actions such as the face, arms, speech test, cannulation, electrocardiograms and neurological assessments while recognising that pre-hospital interventions for suspected stroke are limited.'The environment' describes the influence of incident setting on OST, including the overall process needed to transport the patient to appropriate care.'Hospital interactions' describes how interactions with hospital staff influenced paramedic actions and OST.'Changing practice' describes the influence of experience and interaction with hospital staff leading to changes in paramedic practice over time.

Conclusion

This study provides insight into how UK paramedics spend time on scene with stroke patients. Multiple factors influencing OST were identified which signpost opportunities for interventions designed to reduce OST. Standardising on-scene assessments for stroke patients, refining communication processes between ambulance services and hospital stroke services and increasing availability of stroke continuing professional development for paramedics were all identified as potential targets for improving OST.

What factors contribute towards ambulance on-scene times for suspected stroke patients? An observational study

INTRODUCTION

Pre-hospital stroke care focusses on rapid access to specialist stroke units, but UK ambulance data shows increasing pre-hospital times. This study aimed to describe factors contributing towards ambulance on-scene times (OST) for suspected stroke patients and identify targets for a future intervention.

PATIENTS AND METHODS

Ambulance clinicians in North East Ambulance Service were asked to complete a survey after transporting any suspected stroke patients to describe the patient encounter, interventions and timings. Completed surveys were linked with electronic patient care records. Potentially modifiable factors were identified by the study team. Poisson regression analysis quantified the association of selected potentially modifiable factors with OST.

RESULTS

About 2037 suspected stroke patients were conveyed between July and December 2021, resulting in 581 fully completed surveys by 359 different clinicians. The median age of patients was 75 years (interquartile range (IQR) 66-83) and 52% of patients were male. Median OST was 33 min (IQR 26-41). Three potentially modifiable factors were identified as contributors to extended OST. Performing additional advanced neurological assessments added 10% to OST (34 vs 31 min, p = 0.008); intravenous cannulation added 13% (35 vs 31 min, p = <0.001) and ECGs added 22% (35 vs 28 min, p = <0.001).

CONCLUSIONS

This study identified three potentially modifiable factors that increased pre-hospital OST with suspected stroke patients. This type of data can be used to target interventions at behaviours that extend pre-hospital OST but which have questionable patient benefit. This approach will be evaluated in a follow up study in the North East of England.

Early identification and characterisation of stroke to support prehospital decision-making using artificial intelligence: a scoping review protocol

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.

How do interventions to improve the efficiency of acute stroke care affect prehospital times? A systematic review and narrative synthesis

Background

Emergency medical services (EMS) are the first point of contact for most acute stroke patients. EMS call to hospital times have increased in recent years for stroke patients in the UK which is undesirable due to the relationship between time and effectiveness of reperfusion treatment. This review aimed to identify and describe interventions devised to improve the efficiency of acute stroke care which reported an impact on ground-based EMS call to hospital times.

Methods

A systematic review of published literature identified from five databases (Medline, EMBASE, CINAHL, the Cochrane library and the Database of Research in Stroke (DORIS)) from January 2000 to December 2020 with narrative synthesis was conducted. Inclusion criteria were primary studies of ground-based EMS, focused on stroke and aiming to improve EMS times. Papers published before 2000, focussing on mobile stroke units or in languages other than English were excluded. Two reviewers independently screened prospective titles. Cochrane ROB2 and ROBINS-I tools were used to assess for risk of bias. This review was funded by a Stroke Association fellowship.

Results

From 3767 initial records, 11 studies were included in the review. Included studies were categorised into three groups: studies targeting EMS dispatch and EMS clinicians (n = 4); studies targeting EMS clinicians only (n = 4); and studies targeting whole system change (n = 3). Suspected stroke patients were the primary population studied and most (n = 10) interventions involved clinician education. Only one study (9%) reported a significant decrease in call to hospital time in one subgroup whereas two studies (18%) reported a significant increase in call to hospital time and all other studies (73%) reported no significant change.

Conclusions

Based on the included studies, interventions intended to improve the efficiency of the acute stroke pathway rarely improved EMS call to hospital times. Included studies were heterogenous and rarely focussed on the review topic which limits the usability of the findings. Further research is needed to explore the trade-off between changes to EMS stroke care and call to hospital times and subsequent impacts on in-hospital care and patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00713-6.

Effects of the COVID-19 pandemic on prehospital emergency care for adults with stroke and transient ischaemic attack: A protocol for a systematic review and meta-analysis

Background: The COVID-19 pandemic impacted on health service provision worldwide, including care for acute time sensitive conditions. Stroke and transient ischaemic attacks (TIA) are particularly vulnerable to pressures on healthcare delivery as they require immediate diagnosis and treatment. The global impact of the COVID-19 pandemic on prehospital emergency care for stroke/TIA is still largely unknown. Thus, the aim of this study is to conduct a systematic review and meta-analysis to investigate the impact of the COVID-19 pandemic on prehospital emergency care for stroke and TIA.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, the review is registered on PROSPERO (registration number CRD42022315260). Peer-reviewed quantitative studies comparing prehospital emergency care for adults with stroke/TIA before and during the COVID-19 pandemic will be considered for inclusion. The outcomes of interest are ambulance times and emergency call volumes for stroke/TIA. A systematic search of databases including PubMed, Embase and Scopus will be conducted. Two authors will independently screen studies for inclusion based on predetermined inclusion and exclusion criteria. Data extraction and quality assessment will be conducted by two authors. Meta-analysis will be performed to calculate overall pooled estimates of ambulance times (primary outcome) and stroke/TIA call volumes (secondary outcome), where appropriate.  Where heterogeneity is low a fixed-effects model will be used and where heterogeneity is high a random-effects model will be used. Subgroup and sensitivity analyses will include location, stroke/TIA diagnosis and COVID-19 case numbers.

Results: Data on primary and secondary outcomes will be provided. Results of subgroup/sensitivity analyses and quality assessment will also be presented.

Conclusions: This review will identify existing evidence reporting the impact of the COVID-19 pandemic on prehospital emergency care for adult patients with stroke/TIA and provide summary estimates of effects on ambulance response times.

Hyperacute stroke thrombolysis via telemedicine: a multicentre study of performance, safety and clinical efficacy

OBJECTIVES

Timely thrombolysis of ischaemic stroke improves functional recovery, yet its delivery nationally is challenging due to shortages in the stroke specialist workforce and large geographical areas. One solution is remote stroke specialist input to regional centres via telemedicine. This study evaluates the usage and key metrics of performance of the East of England Stroke Telemedicine Partnership-the largest telestroke service in the UK-in providing hyperacute stroke care.

DESIGN

Prospective observational study.

SETTING

The East of England Stroke Telemedicine Partnership provides a horizontal 'hubless' model of out-of-hours hyperacute stroke care to a population of 6.2 million across a 7500 square mile semirural region.

PARTICIPANTS

All (2709) telestroke consultations between 1 January 2014 and 31 December 2019.

MAIN OUTCOME MEASURES

Thrombolysis decision, pre-thrombolysis and post-thrombolysis stroke severity (National Institutes of Health Stroke Scale, NIHSS), haemorrhagic complications, and hyperacute pathway timings.

RESULTS

Over the period, 1149 (42.4%) individuals were thrombolysed. Thrombolysis rates increased from 147/379 (38.8%) in 2014 to 225/490 (45.9%) in 2019. Median (IQR) pre-thrombolysis NIHSS was 10 (6-17), reducing to 6 (2-14) 24-hour post-thrombolysis (p<0.001). Post-thrombolysis haemorrhage occurred in 27 cases (2.3%). Over the period, median (IQR) door-to-needle time reduced from 85 (65-108) min to 68 (55-97.5) min (p<0.01), driven by improved imaging-to-needle times from 52.5 (38-72.25) min to 42 (30.5-62.5) min (p<0.01). However, the same period saw an increase in median onset-to-hospital arrival time from 77.5 (60-109.25) min to 95 (70-135) min (p<0.001).

CONCLUSIONS

The results from this large hyperacute telestroke cohort indicate two important points for clinical practice. First, telemedicine via a hubless horizontal model provides a clinically effective and safe method for delivering hyperacute stroke thrombolysis. Second, improved door-to-needle times were offset by a concerning rise in prehospital timings. These findings indicate that although telemedicine may benefit in-hospital hyperacute stroke care, improvements across the whole stroke pathway are essential.

Do methods of hospital pre-alerts influence the on-scene times for acute pre-hospital stroke patients? A retrospective observational study

INTRODUCTION

Stroke is one of the leading causes of death and disability worldwide. The ambulance service is often the first medical service to reach an acute stroke patient, and due to the time-critical nature of stroke, a time-critical assessment and rapid transport to a hyper acute stroke unit are essential. As stroke services have been centralised, different hospitals have implemented different pre-alert admission policies that may affect the on-scene time of the attending ambulance crew. The aim of this study is to investigate if the different pre-alert admission policies affect time on scene.

METHOD

The current study is a retrospective quantitative observational study using data routinely collected by North East Ambulance Service NHS Foundation Trust. The time on scene was divided into two variables; group one was a telephone pre-alert in which a telephone discussion with the receiving hospital is required before they accept admission of the patient. Group two was a radio-style pre-alert in which the attending clinician makes an autonomous decision on the receiving hospital and alerts them via a short radio message of the incoming patient. These times were then compared to identify if there was any difference between them.

RESULTS

Data on 927 patients over a three-month period, from October to December 2019, who had received the full stroke bundle of care, were within the thrombolysis window and recorded as a stroke by the attending clinician, were split into the variable groups and reported on. The mean time on scene for a telephone call pre-alert was 33 minutes and 19 seconds, with a standard deviation of 13 minutes and 8 seconds. The mean on-scene time for a radio pre-alert was 28 minutes and 24 seconds, with a standard deviation of 11 minutes and 51 seconds.

CONCLUSION

A pre-alert given via radio instead of via telephone is shown to have a mean time saving of 4 minutes and 55 seconds, representing an important decrease in time which could be beneficial to patients.

Ambulance service call handler and clinician identification of stroke in North East Ambulance Service

Introduction:

Emergency medical services (EMS) are the first point of contact for most acute stroke patients. The EMS response is triggered by ambulance call handlers who triage calls and then an appropriate response is allocated. Early recognition of stroke is vital to minimise the call to hospital time as the availability and effectiveness of reperfusion therapies are time dependent. Minimising the pre-hospital phase by accurate call handler stroke identification, short EMS on-scene times and rapid access to specialist stroke care is vital. The aims of this study were to evaluate stroke identification by call handlers and clinicians in North East Ambulance Service (NEAS) and report on-scene times for suspected stroke patients.

Methods:

A retrospective service evaluation was conducted linking routinely collected data between 1 and 30 November 2019 from three sources: NEAS Emergency Operations Centre; NEAS clinicians; and hospital stroke diagnoses.

Results:

The datasets were linked resulting in 2214 individual cases. Call handler identification of acute stroke was 51.5% (95% CI 45.3–57.8) sensitive with a positive predictive value (PPV) of 12.8% (95% CI 11.4–14.4). Face-to-face clinician identification of stroke was 76.1% (95% CI 70.4–81.1) sensitive with a PPV of 27.4% (95% CI 25.3–29.7). The median on-scene time was 33 (IQR 25–43) minutes, with call handler and clinician identification of stroke resulting in shorter times.

Conclusion:

This service evaluation using ambulance data linked with national audit data showed that the sensitivity of NEAS call handler and clinician identification of stroke are similar to figures published on other systems but the PPV of call handler and clinician identification stroke could be improved. However, sensitivity is paramount while timely identification of suspected stroke patients and rapid transport to definitive care are the primary functions of EMS. Call handler identification of stroke appears to affect the time that clinicians spend at scene with suspected stroke patients.