Emergency Medical Services Utilization among Patients with ST-Segment Elevation Myocardial Infarction: Observations from the Singapore Myocardial Infarction Registry

Objective: Early activation of emergency medical services (EMS), rapid transport, and treatment of patients experiencing ST-segment elevation myocardial infarction (STEMI) can improve outcomes. The Singapore Myocardial Infarction Registry (SMIR) is a nation-wide registry that collects data on STEMI. We aimed to determine the prevalence, predictors, and outcomes of EMS utilization among STEMI patients presenting to Emergency Departments (ED) in Singapore. Methods: We analyzed STEMI patients enrolled by SMIR from January 2010 to December 2012. We excluded patients who were transferred, developed STEMI in-hospital or suffered cardiac arrest out-of-hospital or in the ED. Primary outcome was process-of-care timings. Secondary outcomes included the occurrence of cardiac complications. Multivariate analysis was used to examine independent factors associated with EMS transport. Results: 6412 patients were enrolled into the study; 4667 patients were eligible for analysis. 49.8% of patients utilized EMS transport. EMS transport was associated with higher rate of reperfusion therapy (74.3% vs. 65.1%, p < 0.01), shorter median symptom-to-door time (119 vs. 182 minutes, p < 0.01), door-to-balloon time (59 vs. 70 minutes, p < 0.01), and symptom-to-balloon time (185 vs. 233 minutes, p < 0.01). EMS transport had more patients with Killip Class 4 (7.5% vs 4.0%, p < 0.01) and was associated with greater presentation of heart failure, arrhythmias, and complete heart block. Independent predictors of EMS transport were age, syncope and Killip score; after-office-hour presentation was a negative predictor. Conclusion: Less than half of STEMI patients utilized EMS and EMS patients had faster receipt of initial reperfusion therapies. Targeted public education to reduce time to treatment may improve the care of STEMI patients.     

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.     

Burden of Emergency Medical Services Usage by Dialysis Patients

Background: Patients receiving chronic dialysis often require emergent and inpatient care; however, only a minimal amount is known about their out-of-hospital/inter-hospital use of Emergency Medical Services (EMS). The purpose of this study was to describe the utilization of EMS in a cohort of dialysis patients. Methods: We analyzed a cohort of adult (≥18 years) chronic dialysis patients within the Nova Scotia Health Authority Central Zone Renal Program who initiated chronic dialysis between January 1, 2009 and June 30, 2013 (last follow up July 1, 2015). Dialysis patient data was linked to regional EMS data. Requests for EMS, including encounter type, day of the week, and patient characteristics were described. Results: The cohort consisted of 468 patients of whom 79% (N = 361) had an EMS encounter. There were a total of 8,774 EMS encounters for the entire cohort. Patients who had an EMS encounter tended to be older (64 ± 14 years), compared to those without an encounter (55 ± 16 years, P < 0.001) and also had a higher burden of comorbidity. Transfers (including those between facilities) accounted for 89% of all encounters (N = 7,826), followed by emergency department (ED) transports (N = 749, 9%). Overall, 79% of all non-transfers underwent transport to the ED. For patients receiving thrice weekly in-center hemodialysis, the highest EMS utilization for ED transport occurred on the first hemodialysis day after the long dialysis break (22%, P < 0.01). The lowest proportion of ED transports occurred on the day after hemodialysis day 3. Conclusion: Utilization of EMS services by dialysis patients is considerable, particularly for transfers. This highlights a potential area to be targeted for reducing resource utilization. Calls requiring transport to the ED occurred most often on Mondays and Tuesdays, the day after the long-dialysis break, and may represent a time of heightened risk for in-center hemodialysis patients.     

Contemporary Prehospital Emergency Medical Services Response Times for Suspected Stroke in the United States

Background and Purpose: There are no contemporary national-level data on Emergency Medical Services (EMS) response times for suspected stroke in the United States (US). Because effective stroke treatment is time-dependent, we characterized response times for suspected stroke, and examined whether they met guideline recommendations. Methods: Using the National EMS Information System dataset, we included 911 calls for patients ≥ 18 years with an EMS provider impression of stroke. We examined variation in the total EMS response time by dispatch notification of stroke, age, sex, race, region, time of day, day of the week, as well as the proportion of EMS responses that met guideline recommended response times. Total EMS response time included call center dispatch time (receipt of call by dispatch to EMS being notified), EMS dispatch time (dispatch informing EMS to EMS starts moving), time to scene (EMS starts moving to EMS arrival on scene), time on scene (EMS arrival on scene to EMS leaving scene), and transport time (EMS leaving scene to reaching treatment facility). Results: We identified 184,179 events with primary impressions of stroke (mean age 70.4 ± 16.4 years, 55% male). Median total EMS response time was 36 (IQR 28.7–48.0) minutes. Longer response times were observed for patients aged 65–74 years, of white race, females, and from non-urban areas. Dispatch identification of stroke versus “other” was associated with marginally faster response times (36.0 versus 36.7 minutes, p < 0.01). When compared to recommended guidelines, 78% of EMS responses met dispatch delay of <1 minute, 72% met time to scene of <8 minutes, and 46% met on-scene time of <15 minutes. Conclusions: In the United States, time from receipt of 9-1-1 calls to treatment center arrival takes a median of 36 minutes for stroke patients, an improvement upon previously published times. The fact that 22%–46% of EMS responses did not meet stroke guidelines highlights an opportunity for improvement. Future studies should examine EMS diagnostic accuracy nationally or regionally using outcomes based approaches, as accurate recognition of prehospital strokes is vital in order to improve response times, adhere to guidelines, and ultimately provide timely and effective stroke treatment.     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.     

Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting

Introduction. Previous literature has documented that prehospital 12-lead electrocardiography (ECG) decreases the time to reperfusion in patients with an acute ST-segment elevation myocardial infarction (STEMI). Objective. To compare time to ECG, time to angioplasty suite (laboratory), andtime to reperfusion in emergency medical services (EMS) STEMI patients, who received care through three different processes. Methods. The setting was a large suburban community teaching hospital with emergency department (ED)-initiated single-page acute myocardial infarction (AMI) team activation for STEMI patients. The population was STEMI patients transported by EMS from January 2003 to October 2005. Not all EMS agencies had prehospital 12-lead ECG capability. Paramedics interpret andverbally report clinical assessment andECG findings via radio. The AMI team is activated at the discretion of the emergency physician 1) before patient arrival to the ED based on EMS assessment, 2) after ED evaluation with EMS ECG, or 3) after ED evaluation andED ECG. Time intervals were calculated from ED arrival. To assess the impact of interventions on performance targets, we also report the proportion of patients who arrived in laboratory within 60 minutes andreperfusion within 90 minutes of arrival. Parametric andnonparametric statistics are used for analysis. Results. During the study period, there were 164 STEMI patients transported by EMS; mean age was 66.1 years, and56% were male. Of these, 93 (56.7%) had an EMS ECG and31 (33%) had AMI team activation before ED arrival. Mean time to laboratory for all patients was 49.8 ± 34.4 minutes andtime to reperfusion was 93.2 +/? 34.5 min. Patients with prearrival activation were transported to laboratory sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) andreceived reperfusion sooner than all other patients (mean, 70.4 vs. 96.3 minutes; p = 0.007). More prearrival activation patients met performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) andreperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in time to laboratory or to reperfusion for patients who received EMS ECG but no prearrival activation compared with those who received EMS transport alone. Conclusions. A minority of patients with EMS ECGs had prearrival AMI team activation. EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory andreperfusion.     

Impact of a Mass Gathering Alcohol Sobering Facility on Emergency Resources

Objective: Alcohol consumption has been implicated as an important factor driving the demand for medical care at mass gatherings. Patients exhibiting signs of possible alcohol intoxication are frequently diverted from traditional medical support facilities located within mass gathering events due to their disruptive behavior or need for prolonged observation. This conventional strategy can place additional stress on Emergency Medical Services (EMS) and Emergency Department (ED) resources. The purpose of this study was to determine if incorporation of an on-site alcohol sobering facility to supplement existing on-site medical support resources was associated with changes in EMS and ED resource utilization during an annual mass gathering. Methods: This retrospective observational study of a large, annual mass gathering included prospectively collected data from before and after the deployment of an on-site alcohol sobering facility. One year of EMS data along with 2 years of ED data from the pre-deployment time period were compared to 3 years of post-deployment data. The primary outcomes for this study were the number of EMS transports and ED visits. Results: Average single day event attendance was 176,116 during the 2012–13 time period before the ACS was deployed and 183,544 in the 3 years following. The odds of an EMS transport from the event to the ED decreased in the post-deployment period, OR 0.37 (95% CI = 0.16–0.86; p = 0.01). ED volume increased by 7.23% (p = 0.56) and ED LOS increased by 1.29% (p = 0.97) in the post-deployment period. Conclusion: This study reports on a unique strategy to improve resource utilization at large mass gatherings and the impact of this strategy on EMS and ED resource utilization. It appears that the addition of an on-site alcohol sobering facility to existing medical support services was associated with a significant decrease in EMS transports but no change in ED resource utilization. Further work is needed to determine if these findings can be reproduced at other mass gatherings.     

Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions

Background: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions. Design/Methods: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved. Results: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers. Conclusions: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.     

Impact of Electronic Medical Record Alerts on Emergency Physician Workflow and Medical Management

BackgroundElectronic medical record (EMR) alerts are automated messages that notify the physician of important information. However, little is known about how EMR alerts affect the workflow and decision-making of emergency physicians (EPs).Study ObjectivesThis study aimed to quantify the number of EMR alerts EPs receive, the time required to resolve alerts, the types of alerts EPs receive, and the impact of alerts on patient management.MethodsWe performed a prospective observational study at a tertiary care ED with 130,000 visits annually. Research assistants observed EPs on shift from May to December 2018. They recorded the number of EMR alerts received, time spent addressing the alerts, the types of alerts received, and queried the EP to determine if the alert impacted patient management.ResultsSeven residents and six attending physicians were observed on a total of 17 shifts and 153 patient encounters; 78% (119) of patient encounters involved alerts. These 119 patients triggered 530 EMR alerts. EPs spent a mean of 7.06 s addressing each alert and addressed 3.46 alerts per total patient seen. In total, EPs spent approximately 24 s per patient resolving alerts. Only 12 alerts (2.26%) changed clinical management.ConclusionEPs frequently receive EMR alerts, however, most alerts were not perceived to impact patient care. These alerts contribute to the high volume of interruptions EPs must contend with in the clinical environment of the ED.     

Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center

Background: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center. Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center. Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion. Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4–3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2–18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8–2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5–5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1–4 years, 7% 5–9 years, and 2% 10–15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90. Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.     

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.     

Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services

IntroductionThe Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) identifies patients with “severe sepsis” and mandates antibiotics within a specific time window. Rapid time to administration of antibiotics may improve patient outcomes. The goal of this investigation was to compare time to antibiotic administration when sepsis alerts are called in the emergency department (ED) with those called in the field by emergency medical services (EMS).MethodsThis was a multi-center, retrospective review of patients designated as sepsis alerts in ED or via EMS in the field, presenting to four community emergency departments over a six-month period.Results507 patients were included, 419 in the ED alert group and 88 in the field alert group. Mean time to antibiotic administration was significantly faster in the field alert group when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs 44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates, fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic utilization rates were not found to be significantly different.ConclusionsSepsis alerts called in the field via EMS may decrease time to antibiotics and increase the likelihood of antibiotic administration occurring within 60 min of arrival when compared to those called in the ED.     

The Epidemiology of Emergency Medical Services Use by Children: An Analysis of the National Hospital Ambulatory Medical Care Survey

Objective. There is an absence of nationally representative data describing pediatric patients who use emergency medical services (EMS) andthe factors associated with EMS use by children. This study characterizes pediatric emergency department (ED) visits for which the patient arrived by EMS andidentifies factors associated with those visits using a nationally representative database. Methods. A secondary analysis of the ED component of the 1997–2000 National Hospital Ambulatory Medical Care Survey was performed. The dependent variable was the mode of arrival to the ED (EMS vs. not EMS), andindependent variables were grouped into four domains: demographic, clinical, system, andservice characteristics. Bivariate analyses andmultivariate logistic regression analyses were conducted. Results. There were 110.9 million ED visits by children aged <19 years between 1997 and2000. Pediatric patients constituted 27.3% of all ED visits during this time, and7.9 million (7.1%) of these patients arrived via EMS. Pediatric patients represented 13% of all EMS transports. The annual EMS utilization rate by children was 26 per 1,000, compared with 66 per 1,000 in the adult population (p < 0.001). Sixteen percent of children transported by EMS were admitted to the hospital. Sixty-two percent of pediatric patients arriving at the ED by EMS were transported as a result of injury or poisoning. Characteristics significantly associated with arrival by EMS in the final multivariate model included demographic (age, African American race, urban residence), clinical (need for greater immediacy of care, illnesses associated with certain diagnoses), andservice (greater number of diagnostic services) variables. Conclusions. Pediatric patients transported by EMS are more likely to have injuries andpoisoning, andhave higher-acuity illness than those arriving at the ED by other means. The epidemiology of pediatric EMS use may have important operational, training, andpublic health implications andrequires further study.     

Emergency Medical Services Education,Community Outreach,andProtocols for Stroke andChest Pain in North Carolina

Objective. Prehospital care of stroke andchest pain patients is dependent on adequate emergency medical services (EMS) education andevidence-based protocols. We sought to describe the amount of education offered, community outreach implemented, andprotocols established for stroke andfor chest pain among North Carolina EMS agencies andpersonnel. Methods. A survey was developed to measure EMS system characteristics regarding the prehospital care of stroke andchest pain patients. Each of the 83 primary EMS agencies in North Carolina was asked to participate. Results. Of the 83 agencies surveyed, 72 (87%) responded. Both advanced life support (ALS) andbasic life support (BLS) services were provided by 54% of agencies; 44% offered ALS only and1% offered BLS only. While 89% of the EMS agencies provided stroke education to EMS personnel and96% chest pain education to EMS personnel in the previous two years, the median hours devoted to stroke was one-half that for chest pain (6.0 vs. 12.0 hours, respectively). In the previous six months, 14% of EMS agencies had conducted community outreach programs for stroke compared with 17% for chest pain. The majority of EMS agencies had protocols specifically for managing stroke (83%) andfor managing chest pain (99%). Diagnostic scales to identify stroke patients were used by 54% of agencies (20% Los Angeles Prehospital Stroke Screen, 20% Cincinnati Prehospital Stroke Scale, and14% a locally developed scale). Thrombolytic checklists were used to identify eligible stroke patients at 37% of the EMS agencies, compared with 28% for eligible chest pain patients. Conclusions. In North Carolina, primary EMS agencies appear to have stroke andchest pain protocols in approximately the same frequency, yet their personnel receive only one-half as much education about stroke as they do about chest pain. Many stroke protocols were lacking basic components andwould benefit from standardization across the state. Community outreach programs for both stroke andchest pain are minimal.     

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.     

Factors Related to the Sensitivity of Emergency Medical Service Impression of Stroke

Abstract

Objectives. To examine factors related to sensitivity of emergency medical services (EMS) stroke impression. Methods. We reviewed ambulance and hospital records of all patients transported to Long Island College Hospital between January 1, 2009 and January 1, 2011 by the hospital-based EMS with a discharge diagnosis of stroke or a confounding diagnosis, and compared EMS impression to hospital discharge diagnosis. We examined relationships between EMS diagnostic sensitivity and age, gender, ethnicity, NIH Stroke Scale (NIHSS), motor signs, aphasia, neglect, lesion side, circulation, stroke type, EMS provider level, and documented Cincinnati Pre-hospital Stroke Scale (CPSS) with contingency analysis and logistic regression. Results. Stroke was validated in 18% (56/310) of patients and 50% (28/56) of these were missed by EMS. EMS diagnostic sensitivity was 50% (95% CI: 36–64%), and was related to NIHSS quartile (p = 0.014), with higher sensitivities in 2nd (69%; 95% CI: 44–86%) and 3rd (75%; 95% CI: 47–91%) vs. 1st (20%; 95% CI: 7–45%) and 4th (45%; 95% CI: 21–72%) quartiles, motor signs (62 vs. 14%, p = 0.002), and documented CPSS (84 vs. 32%, p = 0.0002). EMS impression was independently related to NIHSS quartile (1st vs. 2nd adjusted OR = 9.61, 1.13–122.03, p = 0.038) and CPSS (adjusted OR = 12.58, 2.22–111.06, p = 0.003). Conclusion. Stroke was missed more frequently when CPSS was not documented, in patients without motor signs, and in patients with moderate–severe stroke. The sensitivity of prehospital screening for patients with moderate–severe stroke might be improved by including additional non-motor signs and by stressing indications for when screens should be performed.