Emergency Medical Services Prenotification is Associated with Reduced Odds of In-Hospital Mortality in Stroke Patients

BACKGROUND: Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care. METHODS: This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan’s EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes. RESULTS: Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2–1.6]), glucose check (1.3 [1.1–1.6]), on-scene time ≤15 minutes (1.6 [1.4–1.9]), hospital prenotification ([2.0 [1.4–2.9]), and intravenous line placement (1.8 [1.5–2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (−9.2 [−10.6 to −7.8] minutes; P <0.001) and thrombolysis (−4.3 [−6.4 to −2.2] minutes; P <0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0–1.2]; P =0.002). CONCLUSIONS: Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.

Section: Discussionmentioning

confidence: 99%

Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment

Oostema,

Nickles,

Allen

et al. 2024

“…The use of stroke-specific scales in the field and prehospital notification are associated with shorter times to stroke diagnosis in the ED 57,58 for all stroke and ICH and reduced time to hospital arrival and stroke unit admission for all patients with stroke. 59 Currently, performing a prehospital stroke screen is the only stroke-specific quality metric established by the National EMS Quality Alliance. 18 Prehospital differentiation between ICH and AIS is limited, and there is not 1 stroke-specific screening tool that can accurately differentiate between hemorrhage and ischemia without neuroimaging.…”

Section: Denominatormentioning

confidence: 99%

2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association

Ruff,

de Havenon,

Bergman

et al. 2024

The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.

“…Prenotification has been associated with reduced in-hospital mortality. 52 Effective stroke prenotification includes the patient's age, PSS and stroke severity screen findings, vital signs, blood glucose measurement, any obvious contraindications to thrombolysis, last known well time, and symptom discovery time. Although typical prenotification is performed via nonencrypted radio, if secured channels are available, communicating patient identifiers and power of attorney contact information can facilitate prearrival registration and review of the patient's electronic medical record.…”

Section: Prenotification Of the Receiving Stroke Centermentioning

confidence: 99%

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners

Richards

Oostema

Chapman

et al. 2023

Self Cite

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.