Activation of Emergency Medical Services for Acute Stroke in a Nonurban Population

BackgroundRapid access to emergency stroke care can reduce death and disability by enabling immediate provision of interventions such as thrombolysis, physiological monitoring and stabilisation. One of the ways that access to services can be facilitated is through emergency medical service (EMS) dispatchers. The sensitivity of EMS dispatchers for identifying stroke is < 50%. Studies have shown that activation of the EMSs is the single most important factor in the rapid triage and treatment of acute stroke patients.ObjectivesTo facilitate recognition of stroke by emergency medical dispatchers (EMDs).DesignAn eight-phase mixed-methods study. Phase 1: a retrospective cohort study exploring stroke diagnosis. Phase 2: semi-structured interviews exploring public and EMS interactions. Phases 3 and 4: a content analysis of 999 calls exploring the interaction between the public and EMDs. Phases 5–7: development and implementation of stroke-specific online training (based on phases 1–4). Phase 8: an interrupted time series exploring the impact of the online training.SettingOne ambulance service and four hospitals.ParticipantsPatients arriving at hospital by ambulance with stroke suspected somewhere on the stroke pathway (phases 1 and 8). Patients arriving at hospital by ambulance with a final diagnosis of stroke (phase 2). Calls to the EMSs relating to phase 1 patients (phases 3 and 4). EMDs (phase 7).InterventionsStroke-specific online training package, designed to improve recognition of stroke for EMDs.Main outcome measuresPhase 1: symptoms indicative of a final and dispatch diagnosis of stroke. Phase 2: factors involved in the decision to call the EMSs when stroke is suspected. Phases 3 and 4: keywords used by the public when describing stroke and non-stroke symptoms to EMDs. Phase 8: proportion of patients with a final diagnosis of stroke correctly dispatched as stroke by EMDs.ResultsPhase 1: for patients with a final diagnosis of stroke, facial weakness and speech problems were significantly associated with an EMD code of stroke. Phase 2: four factors were identified – perceived seriousness; seeking and receiving lay or professional advice; caller’s description of symptoms and emotional response to symptoms. Phases 3 and 4: mention of ‘stroke’ or one or more Face Arm Speech Test (FAST) items is much more common in stroke compared with non-stroke calls. Consciousness level was often difficult for callers to determine and/or communicate. Phase 8: there was a significant difference (p = 0.003) in proportions correctly dispatched as stroke – before the training was implemented 58 out of 92 (63%); during implementation of training 42 out of 48 (88%); and after training implemented 47 out of 59 (80%).ConclusionsEMDs should be aware that callers are likely to describe loss of function (e.g. unable to grip) rather than symptoms (e.g. weakness) and that callers using the word ‘stroke’ or describing facial weakness, limb weakness or speech problems are likely to be calling about a stroke. Ambiguities and contradictions in dialogue about consciousness level arise during ambulance calls for suspected and confirmed stroke. The online training package improved recognition of stroke by EMDs. Recommendations for future research include testing the effectiveness of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) training package on the recognition of stroke across other EMSs in England; and exploring the impact of the early identification of stroke by call handlers on patient and process outcomes.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…20 The patient was rarely the caller (2% of all calls), consistent with other series 12,20,41 and phase 2 of our research (reported earlier).…”

supporting

confidence: 90%

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Watkins

Jones

Leathley

et al. 2014

Programme Grants for Applied Research

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“…Prehospital delay might also occur because patients not activate emergency medical service but rather directly access emergency department, contact first a family member or the family doctor [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

Awareness Of Stroke Risk Factors And Warning Signs And Attitude To Acute Stroke

Duque

Fernandes²,

Correia

et al. 2015

Int Arch Med

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Background: Stroke is a leading cause of death and disability worldwide. Knowledge of stroke risk factors and warning signs might improve its prevention and ensure prompt activation of emergency medical services and access to thrombolysis. Educational campaigns have been held in Portugal though its impact on knowledge of medical patients has not been assessed. Methods:A cross-sectional observational study was performed to medical outpatients, through an interview. Main objectives were to assess the extent of knowledge on risk factors and warning signs and the attitude to stroke and to identify predictive factors of strokerelated knowledge. Two sub-groups were studied: hypertensive and elderly.

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“…However, it has been estimated that only 38 to 65% of all stroke patients arrive to the hospital via the EMS system (Wein et al 2000, Lacy et al 2001, Adeoye et al 2009 waited for the symptoms to go away or contacted friends, relatives, local general practioner or hospital staff for advice (Wester et al 1999, Mackintosh et al 2012. As many as 24% to 54% of the patients do not seek help within one hour after symptom onset and many fail to seek help at all (Rosamond et al 1998, Wester et al 1999, Mosley et al 2007.…”

Section: The Emergency Telephone Call and Ems System Activationmentioning

confidence: 99%

Stroke and the emergency medical services – enhancing performance within the chain of survival

Puolakka

2017

Acta Anaesthesiol Scand

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Activation of Emergency Medical Services for Acute Stroke in a Nonurban Population

Abstract: Background and Purpose-Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives.

Cited by 122 publications

References 17 publications

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Awareness Of Stroke Risk Factors And Warning Signs And Attitude To Acute Stroke

Stroke and the emergency medical services – enhancing performance within the chain of survival

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