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.     

Advance Hospital Notification by EMS in Acute Stroke Is Associated with Shorter Door-to-Computed Tomography Time andIncreased Likelihood of Administration of Tissue-Plasminogen Activator

Background. Rapid brain imaging is a critical step in facilitating the use of intravenous (IV) tissue-plasminogen activator (tPA) or catheter-based thrombolysis. We hypothesized that advance notification by emergency medical services (EMS) would shorten emergency department (ED) arrival-to-computed tomography (CT) time andincrease the use of IV andintra-arterial thrombolysis, even at a tertiary care stroke center with high baseline rates of tPA use. Methods. We analyzed data on all acute stroke patients transported from March 2004 to June 2005 by EMS from the scene to our facility arriving ≤6 hours from symptom onset. We reviewed digital voice recordings of all EMS communications to our hospital andin-hospital time intervals andoutcomes from our stroke database. Results. Among the 118 patients who met criteria, there were no significant differences between those with notification (n = 44) andthose without (n = 74) in terms of age, gender, history of prior stroke, median National Institutes of Health Stroke Scale (NIHSS) score in the ED, proportion with mild stroke (NIHSS score ≤4), or mean onset-to-ED arrival time. Door-to-CT time was 17% shorter (40 vs. 47 minutes, p = 0.01) in the advance-notification group, andthrombolysis occurred twice as often (41% vs. 21%, p = 0.04). Conclusion. Advance notification of patient arrival by EMS shortened time to CT andwas associated with a modest increase in the use of thrombolysis at our hospital. This occurred even with protocols in place to shorten the time to CT for all acute stroke patients. Further research is needed to understand how to increase rates of advance notification by EMS in potential tPA candidates.     

An Analysis of EMS and ED Detection of Stroke

Background and Purpose: Studies have shown a reduction in time-to-CT and improved process measures when EMS personnel notify the ED of a “stroke alert” from the field. However, there are few data on the accuracy of these EMS stroke alerts. The goal of this study was to examine diagnostic test performance of EMS and ED stroke alerts and related process measures. Methods: The EMS and ED records of all stroke alerts in a large tertiary ED from August 2013–January 2014 were examined and data abstracted by one trained investigator, with data accuracy confirmed by a second investigator for 15% of cases. Stroke alerts called by EMS prior to ED arrival were compared to stroke alerts called by ED physicians and nurses (for walk-in patients, and patients transported by EMS without EMS stroke alerts). Means ± SD, medians, unpaired t-tests (for continuous data), and two-tailed Fisher's exact tests (for categorical data) were used. Results: Of 260 consecutive stroke alerts, 129 were EMS stroke alerts, and 131 were ED stroke alerts (70 called by physicians, 61 by nurses). The mean NIH Stroke Scale was higher in the EMS group (8.1 ± 7.6 vs. 3.0 ± 5.0, p < 0.0001). The positive predictive value of EMS stroke alerts was 0.60 (78/129), alerts by ED nurses was 0.25 (15/61), and alerts by ED physicians was 0.31 (22/70). The PPV for EMS was better than for nurses or physicians (both p < 0.001), and more patients in the EMS group had final diagnoses of stroke (62/129 vs. 24/131, p < 0.001). The positive likelihood ratio was 1.53 for EMS personnel, 0.45 for physicians, and 0.77 for nurses. The mean time to order the CT (8.5 ± 7.1 min vs. 23.1 ± 18.2 min, p < 0.0001) and the mean ED length of stay (248 ± 116 min vs. 283 ± 128 min, p = 0.022) were shorter for the EMS stroke alert group. More EMS stroke alert patients received tPA (16/129 vs. 6/131, p = 0.027). Conclusions: EMS stroke alerts have better diagnostic test performance than stroke alerts by ED staff, likely due to higher NIH Stroke Scale scores (more obvious presentations) and are associated with better process measures. The fairly low PPV suggests room for improvement in prehospital stroke protocols.     

Prehospital time intervals and management of ischemic stroke patients

ObjectiveQuantify prehospital time intervals, describe prehospital stroke management, and estimate potential time saved if certain procedures were performed en route to the emergency department (ED).MethodsAcute ischemic stroke patients who arrived via emergency medical services (EMS) between 2012 and 2016 were identified. We determined the following prehospital time intervals: chute, response, on-scene, transport, and total prehospital times. Proportions of patients receiving the following were determined: Cincinnati Prehospital Stroke Scale (CPSS) assessment, prenotification, glucose assessment, vascular access, and 12-lead electrocardiography (ECG). For glucose assessment, ECG acquisition, and vascular access, the location (on-scene vs. en route) in which they were performed was described. Difference in on-scene times among patients who had these three interventions performed on-scene vs. en route was assessed.ResultsData from 870 patients were analyzed. Median total prehospital time was 39 min and comprised the following: chute time: 1 min; response time: 9 min; on-scene time: 15 min; and transport time: 14 min. CPSS was assessed in 64.7% of patients and prenotification was provided for 52.0% of patients. Glucose assessment, vascular access initiation, and ECG acquisition was performed on 84.1%, 72.6%, and 67.2% of patients, respectively. 59.0% of glucose assessments, 51.2% of vascular access initiations, and 49.8% of ECGs were performed on-scene. On-scene time was 9 min shorter among patients who had glucose assessments, vascular access initiations, and ECG acquisitions all performed en route vs. on-scene.ConclusionsOn-scene time comprised 38.5% of total prehospital time. Limiting on-scene performance of glucose assessments, vascular access initiations, and ECG acquisitions may decrease prehospital time.     

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.     

Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool

Background and Purpose: A simple, easily adoptable scale with good performance characteristics is needed for EMS providers to appropriately triage suspected stroke patients to comprehensive stroke centers (CSC). Many existing tools are complex, require substantial training, or have not been prospectively validated in the prehospital setting. We describe the feasibility and effectiveness of prehospital implementation of our previously retrospectively derived and validated Cincinnati Stroke Triage Assessment Tool (C-STAT) to identify subjects with severe stroke (NIHSS ≥15) among all prehospital patients with clinical suspicion of stroke/TIA. Secondarily, we evaluated the tool's ability to identify subjects with NIHSS ≥10, large vessel occlusion (LVO), or needing services available only at a CSC. Methods: Without formalized training, Cincinnati Fire Department providers performed standard stroke screening (“face, arm, speech, time;” FAST) and C-STAT as part of their assessment of suspected stroke/TIA patients. Outcomes for patients brought to the region's only CSC or assessed by the regional stroke team were determined through structured chart review by a stroke team nurse. C-STAT test characteristics for each outcome were calculated with 95% confidence intervals. Results: Complete prehospital and outcome data were available for 58 FAST-positive subjects among 158 subjects with prehospital suspicion for stroke/TIA. Subjects were excluded if FAST was negative (n = 22), FAST or C-STAT was incompletely documented (n = 24), if the patient was taken to a non-CSC and did not receive a stroke team consult (n = 48), or if outcome data were missing (n = 6). C-STAT sensitivity and specificity for each outcome were: NIHSS ≥ 15, 77% (95% CI 46–95) and 84% (95% CI 69–93); NIHSS ≥10, 64% (95% CI 41–83) and 91% (95% CI 76–98); LVO, 71% (95% CI 29–96) and 70% (95% CI 55–83); overall CSC need 57% (95% CI 34–78) and 79% (95% CI 61–91). Conclusion: In this pilot prospective evaluation performed in the prehospital setting by EMS providers without formalized training, C-STAT is comparable to other published tools in test characteristics and may inform appropriate CSC triage beyond LVO ascertainment alone.     

Prehospital Triage of Acute Ischemic Stroke Patients to an Intravenous tPA-Ready versus Endovascular-Ready Hospital: A Decision Analysis

Background: American Stroke Association guidelines for prehospital acute ischemic stroke recommend against bypassing an intravenous tPA-ready hospital (IRH), if additional transportation time to an endovascular-ready hospital (ERH) exceeds 15–20 min. However, it is unknown when the benefit of potential endovascular therapy at an ERH outweighs the harm from delaying intravenous therapy at a closer IRH, especially since large vessel occlusion (LVO) status is initially unknown. We hypothesized that current time recommendations for IRH bypass are too short to achieve optimal outcomes for certain patient populations. Methods: A decision analysis model was constructed using population-based databases, a detailed literature review, and interventional trial data containing time-dependent modified Rankin Scale distributions. The base case was triaged by Emergency Medical Services (EMS) 110 min after stroke onset and had a 23.6% LVO rate. Base case triage choices were (1) transport to the closest IRH (12 min), (2) transport to the ERH (60 min) bypassing the IRH, or (3) apply the Cincinnati Stroke Triage Assessment Tool and transport to the ERH if positive for LVO. Outcomes were assessed using quality-adjusted life years (QALYs). Sensitivity analyses were performed for all major variables, and alternative prehospital stroke scales were assessed. Results: In the base case, transport to the IRH was the optimal choice with an expected outcome of 8.47 QALYs. Sensitivity analyses demonstrated that transport to the ERH was superior until bypass time exceeded 44 additional minutes, or when the onset to EMS triage interval exceeded 99 min. As the probability of LVO increased, ERH transport was optimal at longer onset to EMS triage intervals. The optimal triage strategy was highly dependent on specific interactions between the IRH transportation time, ERH transportation time, and onset to EMS triage interval. Conclusions: No single time difference between IRH and ERH transportation optimizes triage for all patients. Allowable IRH bypass time should be increased and acute ischemic stroke guidelines should incorporate the onset to EMS triage interval, IRH transportation time, and ERH transportation time.     

Evaluating Target: Stroke guideline implementation on assessment and treatment times for patients with suspected stroke

ObjectivesImmediate ischemic stroke treatment improves outcomes and early alteplase administration is recommended for patients within window. We implemented stroke guidelines through a neuro-resuscitation initiative (NRI) and hypothesized that the intervention would decrease times to assessment and treatment.MethodsWe analyzed quality assurance data for EMS and triage patients arriving to our academic emergency department with suspected ischemic stroke to compare outcomes 12 months before to 6 months after initiative implementation at an academic certified primary stroke center in the U.S. Southwest. We examined four time-based outcomes: neurology at bedside, CT head without contrast, CT head angiogram, and alteplase administration. We summarized times with median and IQR values and compared pre and post times to event (in minutes) with Wilcoxon rank sum tests and Kaplan-Meier survival curves.ResultsWe identified 203 EMS (83 pre, 120 post) and 66 (11 pre, 55 post) triage Stroke Alert patients. We observed decreased times for all outcomes in both the EMS and triage samples; however, only those in the EMS sample were significant. In the EMS sample, neurology at bedside median times decreased from 20 min to 2 min (p < 0.001); median minutes to CT head without contrast decreased from 16 min to 9 min (p < 0.001); median minutes to CT head angiogram decreased from 71 min to 21 min (p = 0.007); and, median minutes to alteplase decreased from 72 min to 49.5 min (p = 0.04).ConclusionsAn academic ED led stroke care initiative streamlined evaluation and care with significantly shortened times to all four events.     

Establishing biennial paramedic experience benchmarks

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.     

Emergency Medical Services Provider Experiences of Hospice Care

Background: Growing numbers of emergency medical services (EMS) providers respond to patients who receive hospice care. The objective of this investigation was to assess the knowledge, attitudes, and experiences of EMS providers in the care of patients enrolled in hospice care. Methods: We conducted a survey study of EMS providers regarding hospice care. We collected quantitative and qualitative data on EMS provider's knowledge, attitudes, and experiences in responding to the care needs of patients in hospice care. We used Chi-squared tests to compare EMS provider's responses by credential (Emergency Medical Technician [EMT] vs. Paramedic) and years of experience (0–5 vs. 5+). We conducted a thematic analysis to examine open-ended responses to qualitative questions. Results: Of the 182 EMS providers who completed the survey (100% response rate), 84.1% had cared for a hospice patient one or more times. Respondents included 86 (47.3%) EMTs with Intermediate and Advanced training and 96 (52.7%) Paramedics. Respondent's years of experience ranged from 0–10+ years, with 99 (54.3%) providers having 0–5 years of experience and 83 (45.7%) providers having 5+ years of experience. There were no significant differences between EMTs and Paramedics in their knowledge of the care of these patients, nor were there significant differences (p < 0.05) between those with 0–5 and 5+ years of experience. Furthermore, 53 (29.1%) EMS providers reported receiving formal education on the care of hospice patients. A total of 36% respondents felt that patients in hospice care required a DNR order. In EMS providers' open-ended responses on challenges in responding to the care needs of hospice patients, common themes were family-related challenges, and the need for more education. Conclusion: While the majority of EMS providers have responded to patients enrolled in hospice care, few providers received formal training on how to care for this population. EMS providers have expressed a need for a formal curriculum on the care of the patient receiving hospice.     

Language preference does not influence stroke patients' symptom recognition or emergency care time metrics

IntroductionOur objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time.MethodsWe identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003–05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time.ResultsOf 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157 min, IQR 55–420; EMS utilization: 65% vs. 61.3% p = 0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI ≤ 25 min (overall median 59 min, IQR 29–127; DTI ≤ 25 min 24.3% vs. 21.3% p = 0.29) or DTN time or in likelihood of guideline-recommended DTN ≤ 60 min (overall median 53 min, IQR 36–73; DTN ≤ 60 min 62.5% vs. 58.2% p = 0.60).ConclusionConsistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.     

Effect of Emergency Medical Services Use on Hospital Outcomes of Acute Hemorrhagic Stroke

Background: It is unclear whether the use of emergency medical services (EMS) is associated with enhanced survival and decreased disability after hemorrhagic stroke and whether the effect size of EMS use differs according to the length of stay (LOS) in emergency department (ED). Methods: Adult patients (19 years and older) with acute hemorrhagic stroke who survived to admission at 29 hospitals between 2008 and 2011 were analyzed, excluding those who had symptom-to-ED arrival time of 3 h or greater, received thrombolysis or craniotomy before inter-hospital transfer, or had experienced cardiac arrest, had unknown information about ambulance use and outcomes. Exposure variable was EMS use. Endpoints were survival at discharge and worsened modified Rankin Scale (W-MRS) defined as 3 or greater points difference between pre- and post-event MRS. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for the outcomes were calculated, including potential confounders (demographic, socioeconomic status, clinical parameter, comorbidity, behavior, and time of event) in the final model and stratifying patients by inter-hospital transfer and by time interval from symptom to ED arrival (S2D). ED LOS, classified into short (<120 min) and long (≥120 min), was added to the final model for testing of the interaction model. Results: A total of 2,095 hemorrhagic strokes were analyzed in which 75.6% were transported by EMS. For outcome measures, 17.4% and 41.4% were dead and had worsened MRS, respectively. AORs (95% CIs) of EMS were 0.67 (0.51–0.89) for death and 0.74 (0.59–0.92) for W-MRS in all patients. The effect size of EMS, however, was different according to LOS in ED. AORs (95% CIs) for death were 0.74 (0.54–1.01) in short LOS and 0.60 (0.44–0.83) in long LOS group. AORs (95% CIs) for W-MRS were 0.76 (0.60–0.97) in short LOS and 0.68 (0.52–0.88) in long LOS group. Conclusions: EMS transport was associated with lower hospital mortality and disability after acute hemorrhagic stroke. Effect size of EMS use for mortality was significant in patients with long ED LOS.     

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.     

The Attrition Condition: Use of a Preparatory Course to Reduce EMT Course Attrition and Improve Performance on North Carolina Certification Exams

Abstract

Introduction. A growing concern in emergency medical services (EMS) education is student attrition. Perchance, there is a population of nonmatriculate students lacking prerequisite academic skills or who are otherwise ill prepared for the unique requirements of the EMS profession. Consequently, addressing these issues could promote academic and occupational preparedness, thereby reducing emergency medical technician (EMT) course attrition. Objective. To measure the impact of a preparatory course designed to address academic and psychosocial skills affecting EMT course completion. Methods. We conducted a retrospective analysis of a 24-hour preparatory course using a before-and-after nonexperimental design. The course included the EMT preparatory curriculum, program orientation, work-force-preparedness skills, and an academic skills assessment. All students who were enrolled in an EMT course at a single study site between July 2008 and December 2011 were included. Chi-square analysis was performed on attrition categories defined by CoAEMSP (Academic, Disciplinary, Attendance, Health, Financial, Personal, Never Attended) and state exam categories (Airway, Medical, Trauma, Operations, Pediatrics, Preparatory, Assessment). A logistic regression model calculated the odds ratio (OR) of course completion as a function of preparatory course completion while controlling for demography. Results. The historical control group consisted of 117 (58.5%) students enrolled prior to implementation of the preparatory course, while the remaining 83 (41.5%) students in the intervention group completed the course. Overall attrition was 115 (57.5%) students, with lower rates observed in the intervention group (32.5 vs. 75.2%, p < 0.01). Among noncompleters, the majority originated from the control groups in attrition categories of Academic (4.8 vs. 39.3%, p < 0.01) and Never Attended (1.2 vs. 14.5%, p < 0.01). Students who took the preparatory course were more likely to achieve course completion (OR = 5.17, p < 0.01). The use of the preparatory course produced a higher first-time test-taker pass rate despite showing little difference in individual categories. Conclusions. Students who participated in an EMS preparatory course were 5 times more likely to achieve course completion and perform higher on most portions of the state exam; and the proportion of students that enrolled but never attended an EMT course was reduced. Unlike prior studies, we did not observe a paradoxical increase in other attrition categories after addressing academic preparedness. These findings may prove useful for EMS educators tasked with program planning.     

Facilitators of and barriers to emergency medical service use by acute ischemic stroke patients: A retrospective survey

ObjectiveThe objective of the study was to identify facilitators and barriers to emergency medical service use among acute ischemic stroke patients in Korea.MethodsThis paper presents a secondary analysis of a retrospective survey that collected data from questionnaires and medical records. Among 233 acute ischemic stroke patients enrolled in a large-scale study, 160 patients who had arrived at a hospital within 72 h after symptom onset were included in the data analysis.ResultsUsers of emergency medical services needed a shorter time than non-users to arrive at hospital (140 min vs. 625 min., p = 0.001) and were more likely to arrive at hospital within 3 h of symptom onset (51.9% vs. 31.5%, p = 0.013). For those who first contacted emergency medical service, the facilitators of emergency medical service use were the presence of hemiparesis (p = 0.003), bilateral paralysis (p = 0.040), and loss of balance (p = 0.021). The predominant barrier was the failure to recognize the urgency of symptoms (p = 0.006).ConclusionsThe use of emergency medical services reduced prehospital delay and increased the likelihood of patient arrival at hospital within 3 h. Given that experiencing typical stroke symptoms was a facilitator of emergency medical service use yet failure to recognize the urgency of symptoms was a barrier, public awareness should be raised as regards stroke symptoms and the benefits of using emergency medical services.     

Neurological Favorable Outcomes Associated with EMS Compliance and On-Scene Resuscitation Time Protocol

Purpose: Korean national emergency care protocol for EMS providers recommends a minimum of 5 minutes of on-scene resuscitation before transport to hospital in cases of Out-of-Hospital Cardiac Arrest (OHCA). We compared survival outcome of OHCA patients according to scene time interval (STI)-protocol compliance of EMS. Methods: EMS treated adult OHCAs with presumed cardiac etiology during a two-year period were analyzed. Non-compliance was defined as hospital transport with STI less than 6 minutes without return of spontaneous circulation (ROSC) on scene. Propensity score for compliance with protocol was calculated and based on the calculated propensity score, 1:1 matching was performed between compliance and non-compliance group. Univariate analysis as well as multivariable logistic model was used to evaluate the effect of compliance to survival outcome. Results: Among a total of 28,100 OHCAs, EMS transported 7,026 (25.0%) cardiac arrests without ROSC on the scene with an STI less than 6 minutes. A total of 6,854 cases in each group were matched using propensity score matching. Overall survival to discharge rate did not differ in both groups (4.6% for compliance group vs. 4.5 for non-compliance group, p = 0.78). Adjusted odds ratio of compliance for survival to discharge were 1.12 (95% CI 0.92–1.36). More patients with favorable neurological outcome was shown in compliance group (2.5% vs. 1.7%, p < 0.01) and adjusted odds ratio was 1.91 (95% CI 1.42–2.59). Conclusions: Although survival to discharge rate did not differ for patient with EMS non-compliance with STI protocol, lesser patients survived with favorable neurological outcomes when EMS did not stay for sufficient time on scene in OHCA before transport.