Acute stroke is a medical emergency. Identifying patients suffering a stroke is crucial if paramedics are to maximise delivery of appropriate management. One suggested screening tool to identify stroke is ‘FAST’ (Face, Arms, Speech, Time), but the accuracy of identifying pre-hospital stroke is unknown.
Objectives
We aimed to: a) examine how well stroke is identified by paramedics using the emergency department (ED) discharge diagnosis as the comparator; and b) assess compliance with ambulance clinical practice guidelines.
Methods
A retrospective cohort study was conducted in the Perth metropolitan area in Western Australia between July 2012 and June 2014 using linked data from ambulance and ED databases. Patients aged 45 years and over, transported to the ED by road ambulance and assigned the ambulance problem code or ED discharge diagnosis of stroke, were selected. Positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity were calculated. Text fields were examined for documentation that patients met FAST criteria.
Results
There were 2,217 patients were identified as stroke by paramedics. Of 1834 patients diagnosed as stroke in ED, 876 patients were not identified as stroke by paramedics. Sensitivity for identification of stroke was 958/1834 (52.2%). Of 2,096 patients who were identified as stroke by paramedics and had an ED record, 958 patients were identified as stroke by paramedics and in ED. PPV was 958/2096 (45.7%), NPV 99.5% and specificity 99.4%. Paramedics recorded 2 or 3 stroke signs and symptoms in 1,137 (51%) patients.
Conclusion
A systematic approach is needed to better identify patients with stroke in the prehospital setting.
Government of Western Australia Department of Health.Model of Stroke Care 2012.Perth: Health Networks Branch, Department of Health, Western Australia.2012.
2.
National Stroke Foundation.Clinical Guidelines for Stroke Management.Melbourne: National Stroke Foundation; 2010.
3.
SheppardJ.P., MellorR.M., GreenfieldS.The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study.Emerg Med J2015; 32: 93–9.
4.
PatelM.D., RoseK.M., O'BrienE.C., RosamondW.D.Prehospital notification by emergency medical services reduces delays in stroke evaluation: findings from the North Carolina stroke care collaborative.Stroke2011; 42: 2263–8.
5.
IosifC., PapathanasiouM., StaboulisE., GouliamosA.Social factors influencing hospital arrival time in acute ischemic stroke patients.Neuroradiology2012; 54: 361–7.
6.
SilvestrelliG., ParnettiL., PaciaroniM.Early admission to stroke unit influences clinical outcome.Eur J Neurol2006; 13: 250–5.
7.
IST-3 collaborative group, SandercockP., WardlawJ.The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.Lancet2012; 379: 2352–63.
8.
EbingerM., WinterB., WendtM.Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial.Jama2014; 311: 1622–31.
9.
LeesK.R., BluhmkiE., von KummerR.Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.Lancet2010; 375: 1695–703.
10.
KothariR., JauchE., BroderickJ.Acute stroke: delays to presentation and emergency department evaluation.Ann Emerg Med1999; 33: 3–8.
11.
LacyC.R., SuhD.C., BuenoM., KostisJ.B.Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.).Stroke2001; 32: 63–9.
ChenkinJ., GladstoneD.J., VerbeekP.R.Predictive value of the Ontario prehospital stroke screening tool for the identification of patients with acute stroke.Prehosp Emerg Care2009; 13: 153–9.
17.
BrayJ.E., MartinJ., CooperG., BargerB., BernardS., BladinC.An interventional study to improve paramedic diagnosis of stroke.Prehosp Emerg Care2005; 9: 297–302.
18.
de la OssaN.P., CarreraD., GorchsM.Design and validation of a prehospital stroke scale to predict large arterial occlusion: The Rapid Arterial oCclusion Evaluation Scale.Stroke2014; 45: 87–91.
19.
St John Ambulance Western Australia.Clinical practice guidelines for ambulance care in Western Australia Version 24.Belmont: St John Ambulance-Western Australia2013.
20.
BrayJ.E., CoughlanK., BargerB., BladinC.Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field.Stroke2010; 41: 1363–6.
21.
JaroM.A.Probabilistic linkage of large public health data files.Stat Med1995; 14: 491–8.
22.
Australasian College for Emergency Medicine.The Australasian Triage Scale.Emerg Med (Fremantle)2002; 14: 335–6.
Association of Amulance Chief Executives, Joint Royal Colleges Ambulance Liaison Committee, The University of Warwick.UK Ambulance Service Clinical Practice Guidelines 2013.Bridgwater, UK: Class Professional Publishing Ltd; 2013.
25.
KosterR.W.Modern BLS, dispatch and AED concepts.Best Pract Res Clin Anaesthesiol2013; 27: 327–34.
26.
KidwellC.S., StarkmanS., EcksteinM., WeemsK., SaverJ.L.Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS).Stroke2000; 31: 71–6.
27.
Department of Health Western Australia (2007).Information Management and Reporting. Emergency Department Data Collection Data Dictionary Version 1.0. Available at: www.health.wa.gov.au/healthdata/docs/EDDC_dictionary.pdf [Accessed 2 October 2010].
28.
WilliamsT.A., FinnJ., CelenzaA., TengT-H, JacobsI.G.Paramedic Identification of Acute Pulmonary Edema in a Metropolitan Ambulance Service.Prehosp Emerg Care2013; 17: 339–47.
29.
Commonwealth of Australia.The International Statistical Classification of Diseases and Realted Health Problems, Tenth Revision, Australian Modification (ICD-10-AM)5th Ed.Sydney, NSW: National Centre for Classification in Health; 2006.
30.
Australian Institute of Health and Welfare.Stroke and its management in Australia: an update. Cardiovascular disease series no. 37. Cat. no. CVD 61. Canberra: AIHW, 2013.
31.
FothergillR.T., WilliamsJ., EdwardsM.J., RussellI.T., GompertzP.Does use of the recognition of stroke in the emergency room stroke assessment tool enhance stroke recognition by ambulance clinicians?Stroke2013; 44: 3007–12.
FrendlD.M., StraussD.G., UnderhillB.K., GoldsteinL.B.Lack of impact of paramedic training and use of the cincinnati prehospital stroke scale on stroke patient identification and on-scene time.Stroke2009; 40: 754–6.
34.
RamanujamP., GulumaK.Z., CastilloE.M.Accuracy of stroke recognition by emergency medical dispatchers and paramedics–San Diego experience.Prehosp Emerg Care2008; 12: 307–13.
MerinoJ.G., LubyM., BensonR.T.Predictors of acute stroke mimics in 8187 patients referred to a stroke service.J Stroke Cerebrovasc Dis2013; 22: e397–403.
37.
BrayJ.E., MartinJ., CooperG., BargerB., BernardS., BladinC.Paramedic identification of stroke: community validation of the Melbourne Ambulance Stroke Screen.Cerebrovasc Dis2005; 20: 28–33.
38.
BladinC.Stroke thrombolysis: per ardua, ad astra.Intern Med J2014; 44: 111–3.
39.
WilliamsT., FinnJ., FatovichD., PerkinsG., SummersQ., JacobsI.Paramedic differentiation of asthma and COPD in the prehospital setting is difficult.Prehosp Emerg Care2015; 19: 535–43.
