Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review

Oostema, John A; Carle, Trevor; Talia, Nadine; Reeves, Mathew J.

doi:10.1159/000447459

Cited by 33 publications

(34 citation statements)

References 26 publications

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“…Notably, out of all dispatcher missed acute stroke/TIA patients, confusion and/or a fall at onset were present in 49.1% of cases. In addition, in the whole stroke/TIA cohort (n ¼ 625), confusion and a fall at onset were both associated with a higher median NIHSS score on hospital admission in univariate analysis (NIHSS 4 [2][3][4][5][6][7][8][9] for patients without a fall vs. 10 [4][5][6][7][8][9][10][11][12][13][14][15][16] for patients with a fall at onset, p < 0.001; NIHSS 5 [2][3][4][5][6][7][8][9][10][11] for patients without confusion vs. 9 [4][5][6][7][8][9][10][11][12][13][14][15] for patients with confusion, p ¼ 0.001).…”

Section: Resultsmentioning

confidence: 99%

“…Multivariate analysis demonstrated that patients' older age, a fall, confusion, and a bystander caller are independent predictors of failed stroke identification. Review of call recordings with failed International Journal of Stroke, 14 (4) identification uncovered inconsistent screening for FAST-symptoms, failure to identify apparent speech disturbance, and failure to thoroughly evaluate symptoms. These are all modifiable areas for improvement, and delineate concrete steps for improving dispatcher training and stroke identification algorithms.…”

Section: Speed Is Essential In Early Patientmentioning

confidence: 99%

“…3 Conversely, overly broad activation of the acute stroke dispatch code will unnecessarily burden EMS, tying down valuable resources and causing unwarranted use of lights and sirens, which increases the risk of accidents. A recent systematic review of dispatcher screening tools found stroke recognition sensitivities between 41% and 83%, and positive predictive values (PPV) between 42% and 68%, 4 underscoring the modest accuracy of current protocols and suggesting that significant improvements can still be achieved.…”

Section: Introductionmentioning

confidence: 99%

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Targets for improving dispatcher identification of acute stroke

Mattila

Puolakka

Ritvonen

et al. 2019

International Journal of Stroke

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Background: Accurate identification of acute stroke by Emergency Medical Dispatchers (EMD) is essential for timely and purposeful deployment of Emergency Medical Services (EMS), and a prerequisite for operating mobile stroke units. However, precision of EMD stroke recognition is currently modest. Aims: We sought to identify targets for improving dispatcher stroke identification. Methods: Dispatch codes and EMS patient records were cross-linked to investigate factors associated with an incorrect dispatch code in a prospective observational cohort of 625 patients with a final diagnosis of acute stroke or transient ischemic attack (TIA), transported to our stroke center as candidates for recanalization therapies. Call recordings were analyzed in a subgroup that received an incorrect low-priority dispatch code indicating a fall or unknown acute illness (n ¼ 46). Results: Out of 625 acute stroke/TIA patients, 450 received a high-priority stroke dispatch code (sensitivity 72.0%; 95% CI, 68.5-75.5). Independent predictors of dispatcher missed acute stroke included a bystander caller (aOR, 3.72; 1.48-9.34), confusion (aOR, 2.62; 1.59-4.31), fall at onset (aOR, 1.86; 1.24-2.78), and older age (aOR [per year], 1.02; 1.01-1.04). Of the analyzed call recordings, 71.7% revealed targets for improvement, including failure to recognize a Face Arm Speech Time (FAST) test symptom (21/46 cases, 18 with speech disturbance), or failure to thoroughly evaluate symptoms (12/46 cases). Conclusions: Based on our findings, efforts to improve dispatcher stroke identification should primarily focus on improving recognition of acute speech disturbance, and implementing screening of FAST-symptoms in emergency phone calls revealing a fall or confusion.

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Section: Resultsmentioning

confidence: 99%

Section: Speed Is Essential In Early Patientmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Targets for improving dispatcher identification of acute stroke

Mattila

Puolakka

Ritvonen

et al. 2019

International Journal of Stroke

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“…A current problem for efficient use of MSUs is the suboptimal dispatch accuracy for stroke in general, which means that the MSU team sees a high percentage of non-stroke cases. Indeed, poor accuracy of the detection of stroke in the EMS dispatch office is increasingly being recognized, and sensitivities ranging between 41 and 73% have recently been reported in a meta-analysis of 5 large studies [19].…”

Section: Discussionmentioning

confidence: 99%

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

Grunwald¹,

Phillips²,

Sexby³

et al. 2020

Cerebrovasc Dis

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Background: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. Objective: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Methods: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. Results: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40–60). Conclusion: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

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“…As a result, it has become critical to develop objective pre-hospital triage criteria that appropriately identify patients who are most likely to benefit from services only available at CSC and therefore should be considered for direct transportation, while also facilitating the proper triage of less complex or lower acuity patients to the nearest stroke center (5, 36).…”

Section: Pre-hospital Scales To Detect Large Vessel Occlusion Ischemimentioning

confidence: 99%

Pre-hospital Assessment of Large Vessel Occlusion Strokes: Implications for Modeling and Planning Stroke Systems of Care

et al. 2019

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The social and financial burden of stroke is remarkable. Stroke is a leading cause of death and long-term disability worldwide. For several years, intravenous recombinant tissue plasminogen activator (IV rt-PA) remained as the only proven therapy for acute ischemic stroke. However, its benefit is hampered by a narrow therapeutic window and limited efficacy for large vessel occlusion (LVO) strokes. Recent trials of endovascular therapy (EVT) for LVO strokes have demonstrated improved patient outcomes when compared to treatment with medical treatment alone (with or without IV rt-PA). Thus, EVT has become a critical component of stroke care. As in IV rt-PA, time to treatment is a crucial factor with high impact on outcomes. Unlike IV rt-PA, EVT is only available at a limited number of centers. Considering the time sensitive benefit of reperfusion therapies of acute ischemic stroke, costs and logistics associated, it is recommended that regional systems of acute stroke care should be developed. These should include rapid identification of suspected stroke, centers that provide initial emergency care, including administration of IV rt-PA, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate. In the pre-hospital setting, the development of scales easier and quicker to perform than the NIHSS yet with a maintained accuracy for detecting LVO strokes is of paramount importance. Several scales have been developed. On the other hand, the decision whether to transport to a primary stroke center (PSC) or to a comprehensive stroke center (CSC) is complex and far beyond the simple diagnosis of a LVO. Ongoing studies will provide important answers to the best transfer strategy for acute stroke patients. At the same time, the development of new technologies to aid in real time the decision-making process will simplify the logistics of regional systems for acute stroke care and, likely improve patients' outcomes through tailored selection of the most appropriate recanalization strategy and destination center.

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Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review

Cited by 33 publications

References 26 publications

Targets for improving dispatcher identification of acute stroke

Targets for improving dispatcher identification of acute stroke

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

Pre-hospital Assessment of Large Vessel Occlusion Strokes: Implications for Modeling and Planning Stroke Systems of Care

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