An emergency clinical pathway for stroke patients – results of a cluster randomised trial (isrctn41456865)

Luca, Assunta De; Toni, Danilo; Lauria, Laura; Sacchetti, Maria Luisa; Rossi, Paolo Giorgi; Ferri, Marica; Puca, Emanuele; Prencipe, Massimiliano; Guasticchi, Gabriella

doi:10.1186/1472-6963-9-14

Cited by 39 publications

(67 citation statements)

References 21 publications

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“…[7][8][9] Therefore, improving the communication between EMDs and callers to increase the likelihood that stroke is recognised would promote the initiation of the pre-hospital pathways that are known to expedite patients' access to specialist assessment and treatment. 27 There is evidence to suggest that the EMSs are more likely to be contacted by the public for suspected stroke if the person's symptoms include speech problems, weakness, decreased level of consciousness and dizziness/loss of co-ordination. 28 There is less evidence of an association between the different types of stroke symptoms and the response of the EMSs.…”

Section: -18mentioning

confidence: 99%

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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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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Section: -18mentioning

confidence: 99%

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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“…21 The aim of the trial was to assess the impact of an Emergency Clinical Pathway (ECP) for acute stroke patients. The study involved both emergency medical services (EMS) and emergency departments.…”

Section: Prehospital and Disaster Medicinementioning

confidence: 99%

“…In the intervention group 8 of 44 (18.2%) were receiving thrombolysis, and in the control group 0 of 22 (0%) were In the ECP study, the outcome of interest was time from callto-hospital for EMS suspected stroke patients. 21 This analysis used data from the "metropolitan area" where the distance to the hospital did not differ much. The intervention group spent four minutes less time during the transport (p < 0.05).…”

Section: Prehospital and Disaster Medicinementioning

confidence: 99%

Decision-Support Tool in Prehospital Care: A Systematic Review of Randomized Trials

Hagiwara

Henricson

Jönsson

et al. 2011

Prehosp. Disaster med.

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Objective: The objective of this study was to evaluate the effects of the decision support tool (DST) on the assessment of the acutely ill or injured out-of-hospital patient. Methods: This study included systematic reviews of randomized controlled trials (RCT) where the DST was compared to usual care in and out of the hospital setting. The databases scanned include: (1) Cochrane Reviews (up to January 2010); (2) Cochrane Controlled Clinical Trials (1979 to January 2010); (3) Cinahl (1986 to January 2010); and (4) Pubmed/ Medline (1926 to January 2010). In addition, information was gathered from related magazines, prehospital home pages, databases for theses, conferences, grey literature and ongoing trials. Results: Use of the DST in prehospital care may have the possibility to decrease "time to definitive care" and improve diagnostic accuracy among prehospital personnel, but more studies are needed. Conclusions:The amount of data in this review is too small to be able to draw any reliable conclusions about the impact of the use of the DST on prehospital care. The research in this review indicates that there are very few RCTs that evaluate the use of the DST in prehospital care. IntroductionPrehospital patient assessment is different compared to assessments provided in hospitals. Often, the ambulance personnel are sent to medical emergencies with very little background information. The person who initiates the call for help sometimes is not able to describe the situation, and therefore, the ambulance personnel have difficulties preparing themselves for the task. The ambulance personnel's work situation has been described as "extreme". "They have routinely required working in environments of extreme and constant uncertainty." 1 These environmental factors lead to great strain on the prehospital caregiver's ability when assessing patients. In addition, there have been very few randomized controlled trials (RTC) that have evaluated prehospital care. 2 When 14 ambulance nurses in Sweden were asked about factors that influence their decision-making, several factors that were crucial for the decision were elicited. Important factors included: (1) time of day; (2) season and weather; (3) amount of time before other resources could arrive to the scene; (4) if there was threat of security; (5) stress; (6) environment; (7) diagnosis and; (8) type of patient assessed. 3 A qualitative study by Wireklint Sundström described the need of an "open mind" in the performance of prehospital assessments, and noted that prehospital caregivers must put their preconceived ideas aside when they meet and assess patients. 4 As assessments and treatments of patients in prehospital emergency medical care are becoming more advanced and complex, prehospital emergency care is on the eve of a new and emerging role. 5 Many organizations are searching for alternatives to Accident and Emergency (A&E) treatments, 6 but according to a recent systematic review, prehospital personnel's preparedness for this task is poor. 7 Another future task ...

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“…Therefore, our results agree with other studies in this subject. Luca and colleagues investigated transfer time after and before training course for technicians on stroke and reported its decline from 31.8 to 35.8 minutes [62]. Harbison et al reported that an accurate diagnosis could assist in rapid transfer to appropriate medical center.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Stroke Patients’ Status and Their Transfer Time by Emergency Medical Services to Valiasr Hospital in Arak City, Iran

Bahrampouri¹,

Khankeh²,

Dalvandi³

2016

HDQ

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Background: Stroke is a major cause of death and disability in the world and these complications can be decreased by competent emergency care. Emergency medical service (EMS) transfer half of the stroke patients to hospitals. This study aimed to determine diagnosis of status and transfer time of stroke patients by EMS to a main hospital (Valiasr) in Arak City. Materials and Methods:This study was a descriptive analytic study and conducted on 43 patients with a diagnosis of stroke that transferred by EMS to Valiasr Hospital in Arak City. Data were collected through a checklist which contained information about age, sex, type of accident, response time, scene time, transfer time, and total time from inpatients records and Emergency Center statistics. Regarding data analysis, descriptive statistical tests were performed by SPSS 19. Results:The mean(SD) age of patients was 73.7(3.8) years and 51.2% of them were women. The stroke diagnosis by EMS technicians was correct in 15(34.9%) cases. In 20(46.5%) cases, the diagnosis was wrong and in 8(18.6%) cases, there were not any diagnosis. The most common non-stroke condition was confusion. The mean response time and arrival time to location, transfer time, and total time were 6.9, 16.9, 9.1, and 35.3 minutes, respectively. In patients with correct diagnosis and wrong or no diagnosis, these mean times were 7, 17.1, 3.9, and 35.7 minutes and 6.9, 16.8, 9.7, and 33.5 minutes, respectively. Conclusion:The results of this study showed that an accurate diagnosis by EMS technicians could be an indicator for faster transfer of the patient to treatment center. It is recommended that more appropriate pre-hospital diagnosis tools of stroke be developed and handed to EMS staff, for more accurate diagnosis of strokes and their better treatment.

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An emergency clinical pathway for stroke patients – results of a cluster randomised trial (isrctn41456865)

Abstract: Background: Emergency Clinical Pathways (ECP) for stroke have never been tested in randomized controlled trials (RCTs).

Cited by 39 publications

References 21 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

Decision-Support Tool in Prehospital Care: A Systematic Review of Randomized Trials

Assessment of Stroke Patients’ Status and Their Transfer Time by Emergency Medical Services to Valiasr Hospital in Arak City, Iran

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