Predictors of Stroke During 9-1-1 Calls: Opportunities for Improving EMS Response

Objective. Only 31%–52% of stroke calls are accurately identified by 9-1-1 dispatchers according to prior studies. Recognizing the time-dependent nature of acute stroke, better identification of stroke patients at the time of their 9-1-1 calls may allow an improved prehospital response. We sought to identify any words/phrases that 9-1-1 dispatchers could use to identify more stroke calls. Methods. Potential stroke calls were identified from emergency medical services run sheets, andthe discharge diagnosis for each of these patients was obtained. The emergency medical services tapes were independently reviewed by two listeners who were blinded to the final diagnosis. Words/phrases previously associated with 9-1-1 stroke calls mentioned by the caller were recorded. Other pertinent words/phrases were also recorded. Using the final diagnosis of stroke as the gold standard, the sensitivity, specificity, andpositive likelihood ratio of each word andphrase were calculated. Cohen's κ was calculated to assess interrater agreement. Data were collected for runs from October 2003 to July 2004. Results. A total of 176 tapes were reviewed (40 strokes, 136 nonstrokes). The presence of at least one of four criteria predicted 80% of all stroke calls: the word “stroke,” facial droop, weakness/fall, andimpaired communication. All criterion elements had very good interrater agreement (κ > 0.7). The word “stroke” was highly predictive of actual stroke (positive likelihood ratio, 2.27). Conclusions. The majority of stroke patients in this study could be identified by 9-1-1 dispatchers if the caller reported any one of the following four complaints: stroke, facial droop, weakness/fall, or impaired communication.     

Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke

Objective: Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. Methods: Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. Results: Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58–81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6–10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3–14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). Conclusions: A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.     

EMS Provider Determinations of Necessity for Transport and Reimbursement for EMS Response,Medical Care,and Transport: Combined Resource Document for the National Association of EMS Physicians Position Statements

Abstract

With increasing demands for emergency medical services (EMS), many EMS jurisdictions are utilizing EMS provider-initiated nontransport policies as a method to offload potentially nonemergent patients from the EMS system. EMS provider determination of medical necessity, resulting in nontransport of patients, has the potential to avert unnecessary emergency department visits. However, EMS systems that utilize these policies must have additional education for the providers, a quality improvement process, and active physician oversight. In addition, EMS provider determination of nontransport for a specific situation should be supported by evidence in the peer-reviewed literature that the practice is safe. Further, EMS systems that do not utilize these programs should not be financially penalized. Payment for EMS services should be based on the prudent layperson standard. EMS systems that do utilize nontransport policies should be appropriately reimbursed, as this represents potential cost savings to the health care system.     

Factors Associated with Prehospital Delay for Acute Stroke in Ulsan, Korea

Background: Early hospital presentation is critical in the treatment of acute ischemic stroke with thrombolysis. Objectives: The aim of this study was to investigate the factors associated with prehospital delay in acute ischemic stroke. Methods: Data were retrospectively collected over a 1-year period from 247 acute ischemic stroke patients who presented to the emergency department (ED) within 7 days after symptom onset. To investigate the factors associated with prehospital delay, sociodemographic data, initial symptoms, risk factor, National Institutes of Stroke Scale in the ED, and use of emergency medical services (EMS) were evaluated. Univariate and multivariate analysis were used to evaluate delay factors. Results: Of 247 patients (mean age 64.4 ± 12.6 years, 149 male patients), the non-delay group (≤ 2 h after symptom onset) included 45 patients (mean age 60.0 ± 13.1 years, 31 male patients) and the delay group (> 2 h after symptom onset) included 202 patients (mean age 65.4 ± 12.3 years, 118 male patients). Advanced age (odds ratio [OR] 1.056, 95% confidence interval [CI] 1.024-1.089), no consciousness disturbance at symptom onset (OR 2.938, 95% CI 1.066-8.104), presentation to ED by self (OR 3.826, 95% CI 1.580-9.624), referral from other hospital (OR 16.787, 95% CI 5.445-51.750), and worsened symptoms at the ED compared to symptom onset (OR 7.708, 95% CI 1.557-38.151) were associated with a prehospital delay. Conclusion: Elderly patients with progressive symptom worsening had delayed arrival, but those who used EMS or had disturbed consciousness at symptom onset had early arrival.     

EMS Provider and Patient Safety during Response and Transport: Proceedings of an Ambulance Safety Conference

Abstract

The out-of-hospital setting is unique to health care and presents many challenges to providing safe, high-quality medical care in emergency situations. The challenges of the prehospital environment require thoughtful design of systems and processes of care. The unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements. The purposes of this paper are to 1) outline the nature of this problem, 2) introduce a framework for this discussion, 3) provide expert opinion from a two-day ambulance safety conference, and 4) propose a plan of action to address the safety issues identified in the literature and expert opinion at the conference. Utilizing the Haddon Matrix as a framework, we present the safety issues and proposed solutions for factors contributing to an injury event in the emergency medical services (EMS) transport environment: host, agent, physical environment, and social environment. Host refers to the person or persons at risk, in this case, the EMS personnel or the patient. The agent of injury refers to the energy exerted during the course of an injury, and may be modified to include unrestrained equipment that contributes to the injury. The physical environment refers to the characteristics of the setting in which the injury takes place, such as the roadway or the physical design of the ambulance. Finally, the social environment refers to the social, legal, and cultural norms and practices in the society, such as peer pressure and a culture that discourages the use of safety equipment.     

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified.     

Characterizing Strokes and Stroke Mimics Transported by Helicopter Emergency Medical Services

Objective: Stroke is the leading cause of disability in the United States with most of these patients being transported by emergency medical services. These providers are the first medical point of contact and must be able to rapidly and accurately identify stroke and transport these patients to the appropriate facilities for treatment. There are many conditions that have similar presentations to stroke and can be mistakenly identified as potential strokes, thereby affecting the initial prehospital triage. Methods: A retrospective observational study examined patients with suspected strokes transported to a single comprehensive stroke center (CSC) by a helicopter emergency medical service (HEMS) agency from 2007 through 2013. Final diagnosis was extracted from the Get with the Guidelines (GWTG) database and hospital discharge diagnosis for those not included in the database. Frequencies of discharge diagnosis were calculated and then stratified into interfacility vs. scene transfers. Results: In this study 6,243 patients were transported: 3,376 patients were screened as potential strokes, of which 2,527 had a final diagnosis of stroke (2,242 ischemic stroke and 285 transient ischemic attack), 166 had intracranial hemorrhage, and 655 were stroke mimics. Stroke mimics were more common among scene transfers (223, 32%) than among interfacility transfers (432, 16%). Conclusions: In our study approximately 20% of potential stroke patients transported via HEMS were mimics. Identifying the need for CSC resources can be an important factor in creating a prehospital triage tool to facilitate patient transport to an appropriate health care facility.     

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.

Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.

Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.

Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50?seconds [IQR 30,74] and 108?seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.

Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.     

Emergency Dispatcher Stroke Recognition: Associations with Downstream Care

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.     

EMS Provider Assessment of Vehicle Damage Compared with Assessment by a Professional Crash Reconstructionist

Abstract

Objective. To determine the accuracy of emergency medical services (EMS) provider assessments of motor vehicle damage when compared with measurements made by a professional crash reconstructionist. Methods. EMS providers caring for adult patients injured during a motor vehicle crash and transported to the regional trauma center in a midsized community were interviewed upon emergency department arrival. The interview collected provider estimates of crash mechanism of injury. For crashes that met a preset severity threshold, the vehicle's owner was asked to consent to having a crash reconstructionist assess the vehicle. The assessment included measuring intrusion and external automobile deformity. Vehicle damage was used to calculate change in velocity. Paired t-test, correlation, and kappa were used to compare EMS estimates and investigator-derived values. Results. Ninety-one vehicles were enrolled; of these, 58 were inspected and 33 were excluded because the vehicle was not accessible. Six vehicles had multiple patients. Therefore, a total of 68 EMS estimates were compared with the inspection findings. Patients were 46% male, 28% were admitted to hospital, and 1% died. The mean EMS-estimated deformity was 18 inches and the mean measured deformity was 14 inches. The mean EMS-estimated intrusion was 5 inches and the mean measured intrusion was 4 inches. The EMS providers and the reconstructionist had 68% agreement for determination of external automobile deformity (kappa 0.26) and 88% agreement for determination of intrusion (kappa 0.27) when the 1999 American College of Surgeons Field Triage Decision Scheme criteria were applied. The mean (± standard deviation) EMS-estimated speed prior to the crash was 48 ±13 mph and the mean reconstructionist-estimated change in velocity was 18 ± 12 mph (correlation –0.45). The EMS providers determined that 19 vehicles had rolled over, whereas the investigator identified 18 (kappa 0.96). In 55 cases, EMS and the investigator agreed on seat belt use; for the remaining 13 cases, there was disagreement (five) or the investigator was unable to make a determination (eight) (kappa 0.40). Conclusions. This study found that EMS providers are good at estimating rollover. Vehicle intrusion, deformity, and seat belt use appear to be more difficult for EMS to estimate, with only fair agreement with the crash reconstructionist. As expected, the EMS provider –estimated speed prior to the crash does not appear to be a reasonable proxy for change in velocity.     

Educational Outreach to Improve Emergency Medical Services Systems of Care for Stroke in Montana

Abstract

Objective. To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support. Methods. Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n == 988) and 2009 (n == 944), overall and in rural and urban counties. Results. The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69%% vs. 61%%, p == 0.001), training in the use of a stroke screening tool (62%% vs. 42%%, p < 0.001), use of a stroke screening tool (62%% vs. 40%%, p < 0.001), and an adequate level of knowledge about stroke (81%% vs. 66%%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs. Conclusions. Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.     

Association between EMS Question Bank Completion and Passing Rates on the EMS Certification Examination

Introduction: A board review question bank was created to assist candidates in their preparation for the 2015 EMS certification examination. We aimed to describe the development of this question bank and evaluate its successes in preparing candidates to obtain EMS subspecialty board certification. Methods: An online question bank was developed by 13 subject matter experts who participated as item writers, representing eight different EMS fellowship programs. The online question bank consisted of four practice tests, with each of the tests comprised of 100 questions. The number of candidates who participated in and completed the question bank was calculated. The passing rate among candidates who completed the question bank was calculated and compared to the publicly reported statistics for all candidates. The relationship between candidates' performance on the question bank and subspecialty exam pass rates was determined. Results: A total of 252 candidates took at least one practice test and, of those, 225 candidates completed all four 100-question practice tests. The pass rate on the 2015 EMS certification exam was 79% (95%CI 74–85%) among candidates who completed the question bank, which is 12% higher than the overall pass rate (p = 0.003). Candidates' performance on the question bank was positively associated with overall success on the exam (X² = 75.8, p < 0.0001). Achieving a score of ≥ 70% on the question bank was associated with a higher likelihood of passing the exam (OR = 17.8; 95% CI: 8.0–39.6). Conclusion: Completing the question bank program was associated with improved pass rates on the EMS certification exam. Strong performance on the question bank correlated with success on the exam.     

The National EMS Research Strategic Plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, andfunding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation andtreatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, andtraumatic brain injury. The plan calls for developing, evaluating, andvalidating improved measurement tools andtechniques. Additional research to improve the education of EMS personnel as well as system design andoperation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services andthe care of individuals who access the emergency medical system.     

Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers

Background: An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority. Objectives: To determine if system-wide pain management improvement efforts (i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time. Methods: This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods. Results: 15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time (13% [95%CI 12–15%] to 32% [95%CI 31–34%] to 29% [95 CI 27–30%] to 19% [95%CI 18–21%]). Opioid administration also improved between the time periods and was maintained over time (7% [95%CI 6–8%] to 18% [95%CI 16–19%] to 24% [95%CI 22–25%] to 23% [95% CI 22–24%]). Conclusions: In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.     

The Association Between Emergency Medical Technician-Basic (EMT-B) Exam Score, Length of EMT-B Certification, and Success on the National Paramedic Certification Exam

Objectives: Factors that affect success on the national paramedic certification examination have been identified. However, there are no known studies that have examined success on the paramedic exam with respect to either Emergency Medical Technician‐Basic (EMT‐B) examination score or length of EMT‐B certification (which may reflect field experience gained prior to enrolling in paramedic training). The objectives of this study included assessing the relationship of EMT‐B examination score and length of EMT‐B certification to success on the national paramedic certification examination. Methods: Study data were obtained from the National Registry of EMTs (NREMT). First attempts of the NREMT paramedic certification exam from 2002 to 2006 were included. To assure that EMT‐B certification exam scores were recorded, analysis was limited to individuals in the 14 states that have utilized NREMT for initial certification of both EMT‐Bs and paramedics since January 1, 1997. This also facilitated accurate calculations of the length of EMT‐B certification. Results: There were 11,163 individuals meeting inclusion criteria, and a complete case analysis was performed on 9,148, of whom 5,826 (63.7%) passed the national paramedic exam. The mean (±SD) score on the EMT‐B cognitive exam was 75.5 (±6.4%), and the mean (±SD) length of EMT‐B certification prior to paramedic testing was 3.2 (±2.3) years. When placed in a logistic regression model, the EMT‐B exam score variable was categorized in quartiles (≤71%, 72%–75%, 76%–79%, and ≥80%), and the length of EMT‐B certification variable was dichotomized (≤1.6 years vs. >1.6 years). With respect to paramedic exam success, after controlling for known confounders, there was an increase in the odds ratio (OR) across each of the quartiles of EMT‐B exam score. The largest difference was seen when comparing the lowest and highest quartiles (paramedic exam pass rates of 45.6 and 80.8%, respectively; OR = 5.4, 95% confidence interval [CI] = 4.7 to 6.2). Individuals whose length of EMT‐B certification was >1.6 years had increased odds of passing the paramedic examination (OR = 1.2, 95% CI = 1.1 to 1.3). The multivariable logistic regression model demonstrated good fit (p = 0.62). Conclusions: Both EMT‐B examination score and ength of EMT‐B certification are associated with success on first attempt at the cognitive portion of the national paramedic certification exam. Educators may wish to consider these two factors when determining paramedic program admission standards and/or consider these variables when determining how to allocate program resources.