Background and Purpose— Recognition of stroke symptoms and hospital prenotification by emergency medical services (EMS) facilitate rapid stroke treatment; however, one-third of patients with stroke are unrecognized by EMS. To promote stroke recognition and quality measure compliant prehospital stroke care, we deployed a 30-minute online EMS educational module coupled with a performance feedback system in a single Michigan county. Methods— During a 24-month study period, a registry of consecutive EMS-transported suspected or unrecognized stroke cases was utilized to perform an interrupted time series analysis of the impact of the EMS education and feedback intervention. For each agency, we compared EMS stroke recognition and quality measure compliance rates, as well as emergency department performance and hospital outcomes during 12 preintervention months with performance in the remaining study months. Results— A total of 1805 EMS-transported cases met inclusion criteria; 1235 (68.4%) of these had ischemic or hemorrhagic strokes or transient ischemic attacks. There were no trends toward improvement in any outcome before the intervention. After the intervention, the EMS stroke recognition rate increased from 63.8% to 69.5% ( P =0.037). Prenotification increased from 60.9% to 77.3% ( P <0.001). Among patients with ischemic stroke/transient ischemic attack, there was a trend toward higher rates of tPA (tissue-type plasminogen activator) delivery (13.9%–17.7%; P =0.096) and a significant increase in tPA delivery within 45 minutes (5.7%–8.9%; P =0.042) after intervention. However, improvements in EMS recognition were limited to the first 3 months following intervention. Conclusions— A brief educational intervention was associated with improved EMS stroke recognition, hospital prenotification, and faster tPA delivery. Gains were primarily observed immediately following education and were not sustained through provision of performance feedback to paramedics.

Background and Purpose— Emergency medical services (EMS) stroke recognition facilitates rapid care, however, prehospital stroke screening tools rely on signs that are often absent in posterior circulation strokes. We hypothesized that addition of the finger-to-nose (FTN) test to the Cincinnati Prehospital Stroke Scale would improve EMS posterior stroke recognition. Methods— In this controlled before and after study of consecutive EMS transported posterior ischemic strokes, paramedics in a single EMS agency received in-person training in the use of the FTN test. Paramedics at 2 other local EMS agencies served as controls. We compared the change in posterior stroke recognition, door-to-CT times, and alteplase delivery between the FTN (intervention) and control agencies. Results— Over 21 months, 51 posterior circulation strokes were transported by the FTN agency and 88 in the control agencies. Following training, posterior stroke recognition improved from 46% to 74% ( P =0.039) in the FTN agency, whereas there was no change in the control agencies (32% before versus 39% after, P =0.467). Mean door-to-CT time in the FTN agency also improved following training (62–41 minutes, P =0.037) but not in the control agencies (58–61 minutes, P =0.771). There was no difference in alteplase delivery. Conclusions— Paramedics trained in the FTN test were more likely to identify posterior stroke. If future studies confirm these findings, such training may expedite the care of posterior stroke patients transported by EMS.

No abstract

Background: Emergency medical services (EMS) stroke recognition is critical for appropriate triage and rapid activation of stroke systems. Posterior strokes represent up to 25% of acute stroke admissions. Prehospital stroke screening tools such as the Cincinnati Prehospital Stroke Scale (CPSS) rely on stroke signs that may not be present in patients with posterior stroke, resulting in delays in diagnosis and treatment. We hypothesized that addition of the finger to nose test (FNT) to the standard CPSS would improve EMS recognition of posterior stroke. Methods: Over a 21-month period consecutive ischemic stroke cases transported by 3 EMS agencies in a single county in southwestern Michigan were identified and classified as anterior, posterior, or indeterminate based upon the final hospital discharge diagnoses. Following a 12-month baseline data collection period, all paramedics in the county completed a 30-minute on-line training module targeting recognition of stroke symptoms. Additionally, paramedics in 1 of the 3 EMS agencies also received in-person training in the performance of the finger to nose test (FNT group). We calculated the change in EMS posterior stroke recognition between the 12-month preintervention period and the 9-month postintervention period in the agency that received FNT training, and compared this to the change in the 2 control agencies that did not received FNT education intervention. Results: Over 21 months, 798 ischemic stroke cases were transported by EMS; 114 (14%) were posterior circulation strokes. Before training, 9/26 (38%) of posterior strokes were recognized by paramedics in the intervention agency and 10/36 (28%) in the 2 control agencies. Following training, the FTN group recognized 12/16 (75%, p=0.02 compared to 38% baseline) posterior strokes while the control group recognized 13/23 (46%, p=0.2 compared to 28% baseline). The net increase in posterior stroke recognition was therefore greater in the CPSS-A group than in the control agencies (37% vs. 18%, p=0.03). Conclusion: Posterior strokes were more likely to be recognized by paramedics when the finger to nose test was added to the CPSS. These encouraging initial results demonstrate the potential value of incorporating this simple test into EMS training.

Background: EMS stroke recognition and hospital prenotification facilitate rapid stroke treatment. However, EMS stroke recognition is suboptimal. To promote stroke recognition, we deployed a 30-minute online EMS educational module in a single southwestern Michigan county. Methods: Following 12 months of baseline data collection, the online module was completed by all paramedics in the study county. An interrupted time series design was used to measure the impact of the educational intervention in the subsequent 9 months. Prehospital and hospital data were collected for all EMS suspected stroke cases and hospital confirmed strokes that were missed by EMS. We compared the sensitivity and overcall (false positive) rate of an EMS stroke impression during the pre- and post-intervention periods. We also compared stroke scale documentation, prehospital notification, and door-to-CT (DTCT) times. Results: Over a 21-month period, 1656 cases were included: 744 EMS identified strokes, 408 EMS missed strokes, and 504 EMS overcalled cases (not strokes). Following the intervention, EMS sensitivity for stroke recognition increased from 65.3% to 71.5% (p=0.048) without change in the proportion of overcalls (39.4% to 40.8%, p=0.65). However, improvement in sensitivity was limited to the first post-intervention quarter (65.3% to 74.0%, p=0.027), and returned to baseline thereafter (figure). Among 1109 confirmed stroke cases, EMS hospital prenotification improved following the intervention (57.1% to 81.6%, p<0.0001) but there was no change in stroke scale documentation (67.4 % vs. 67.8%, p=0.93). A higher likelihood of a DTCT time ≤25 minutes was observed only in the first post-intervention quarter (55.4% vs. 43.5%, p=0.0045). Conclusions: A brief, web-based educational intervention was associated with higher EMS stroke recognition without an increased rate of stroke overcalls. Although improvements were transient, they coincided with improved DTCT times.