Factors Related to the Sensitivity of Emergency Medical Service Impression of Stroke

Gropen, Toby; Gokaldas, Reshma; Poleshuck, Rebecca; Spencer, Jeffrey R.; Janjua, Nazli; Szarek, Michael; Brandler, Ethan S.; Levine, Steven R.

doi:10.3109/10903127.2013.864359

Cited by 33 publications

(22 citation statements)

References 18 publications

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“…Other factors associated with EMS sensitivity were early presentation (OR, 2.22) and increasing NIHSS (OR, 1.09 for each 1 point increase). These findings have also been described previously 18 and suggest that paramedics are more likely to recognize patients with more obvious stroke presentations or those perceived to be possible candidates for tPA therapy. An emergency dispatcher impression of possible stroke was also associated with a marginally significant increased likelihood of accurate EMS provider stroke recognition in the multivariable analysis (OR, 1.94).…”

Section: Discussionsupporting

confidence: 64%

“…A recent meta-analysis of 3 validation studies of the CPSS found sensitivities ranging from 79% to 95% 15 ; however, a recently published study conducted in New York demonstrated EMS sensitivity of only 50% despite CPSS education and incorporation into local stroke protocols. 18 In our cohort of EMS-transported cases, EMS sensitivity for stroke recognition was 74%, slightly lower than the observed range in previous CPSS validation studies. 15 Furthermore, PPV of EMS suspicion of stroke was only 52%, suggesting that there is opportunity for improvement by reducing both the over-and under-recognition of stroke by EMS providers.…”

Section: Discussionmentioning

confidence: 43%

“…Our results corroborate those of a recently published analysis of prehospital stroke recognition, which reported a similarly strong association between CPSS use and sensitivity. 18 To our knowledge, this is the first study to report higher PPV among EMS cases with a documented CPSS as opposed to no documented stroke scale. Although this supports the hypothesis that use of CPSS improves overall diagnostic accuracy, we suspect that paramedics may use and document a CPSS preferentially among patients with more obvious stroke signs who are already recognized as suspect stroke/TIA cases.…”

Section: Discussionmentioning

confidence: 98%

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Clinical Predictors of Accurate Prehospital Stroke Recognition

Oostema

Konen

Chassee

et al. 2015

Stroke

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Background and Purpose-Prehospital activation of in-hospital stroke response hastens treatment but depends on accurate emergency medical services (EMS) stroke recognition. We sought to measure EMS stroke recognition accuracy and identify clinical factors associated with correct stroke identification. Methods-Using EMS and hospital records, we assembled a cohort of EMS-transported suspect, confirmed, or missed ischemic stroke or transient ischemic attack cases. The sensitivity and positive predictive value (PPV) for EMS stroke recognition were calculated using the hospital discharge diagnosis as the gold standard. We used multivariable logistic regression analysis to determine the association between Cincinnati Prehospital Stroke Scale use and EMS stroke recognition. Results-During a 12-month period, 441 EMS-transported patients were enrolled; of which, 371 (84.1%) were EMSsuspected strokes and 70 (15.9%) were EMS-missed strokes. Overall, 264 cases (59.9%) were confirmed as either ischemic stroke (n=186) or transient ischemic attack (n=78). The sensitivity of EMS stroke recognition was 73.5% (95% confidence interval, 67.7-78.7), and PPV was 52.3% (95% confidence interval, 47.1-57.5). Sensitivity (84.7% versus 30.9%; P<0.0001) and PPV (56.2% versus 30.4%; P=0.0004) were higher among cases with Cincinnati Prehospital Stroke Scale documentation. In multivariate analysis, Cincinnati Prehospital Stroke Scale documentation was independently associated with EMS sensitivity (odds ratio, 12.0; 95% confidence interval, 5.7-25.5) and PPV (odds ratio, 2.5; 95% confidence interval, 1.3-4.7). Conclusions-EMS providers recognized 3 quarters of the patients with ischemic stroke and transient ischemic attack;however, half of EMS-suspected strokes were false positives. Documentation of a Cincinnati Prehospital Stroke Scale was associated with higher EMS stroke recognition sensitivity and PPV.

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Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 43%

Section: Discussionmentioning

confidence: 98%

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Clinical Predictors of Accurate Prehospital Stroke Recognition

Oostema

Konen

Chassee

et al. 2015

Stroke

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“…Results from previous studies addressing the issue of ACE mimics are not uniform. The most frequent misdiagnoses have included seizures (7-21%), vertigo (2-5%), brain tumours (4-15%), metabolic and electrolyte disturbances (4-24%), infections (7-16%) and functional disorders (1-8%), which only partially overlap with our results (vertigo followed by metabolic and electrolyte disturbances, headache, seizures and brain tumours without any functional disorders) [10,11,[26][27][28][29][30][31].…”

Section: Discussionsupporting

confidence: 72%

Stroke and TIA mimics in patients referred to a neurological emergency department by non-ambulance physicians, ambulance physicians and paramedics.

Kozera-Strzelińska

Karliñski

Rak

et al. 2018

Neurol Neurochir Pol.

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Introduction. Our aim was to compare the structure and management of conditions mimicking acute cerebrovascular events (ACE) defined as stroke or transient ischaemic attack between patients referred directly to a neurological emergency department (ED) by non-ambulance physicians, ambulance physicians and paramedics. Methods. This is a retrospective study of 802 consecutive patients referred to a Polish urban neurological ED with a prehospital suspicion of ACE between January and December 2014. Results. After proper neurological assessment, ACE was excluded in 258 (32.2%) patients. The ratios of neurological to non-neurological ACE mimics were similar across all groups (35:93 for non-ambulance physicians, 22:39 for ambulance physicians, and 28:39 for paramedics). The most frequent conditions mimicking ACE were vertigo (14.0%), headache (9.7%), seizures (7.0%), blood hypertension (7.0%), electrolyte and metabolic disturbances (5.4%), infections (4.7%) and syncope (4.3%). There were no major differences between patients with ACE-mimics referred by ambulance physicians and referred by paramedics in terms of demographic, previous medical history, extent of diagnostic workup, final diagnosis or further management (neurological admission in 42.6% and 28.4% of cases). However, the characteristics and management of ACE mimics referred by non-ambulance physicians were slightly different, including a lower need for hospital admission (neurological admission in 21.5% of cases). Conclusions. There seem to be no major differences in the structure, early diagnostic approach or management of ACE mimics between referrals from ambulance physicians and ambulance paramedics, which provides reassurance to healthcare systems that rely solely on paramedics. Mimics referred by non-ambulance physicians appear different in structure and are less resource-consuming.

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“…A study published by Gropen et al found that EMS had the lowest sensitivities in stroke diagnosis in both the lower and higher NIHSS scores. They also found that EMS had greatest difficulty in diagnosing stroke when nonmotor signs predominated including aphasia and neglect [22]. In another study, the most common EMS impressions on missed strokes included generalized weakness, altered mental status, or dizziness.…”

Section: Stroke Recognition By Ems Providersmentioning

confidence: 96%

EMS and Acute Stroke Care: Evidence for Policies to Reduce Delays to Definitive Treatments

Grover

Morales

Brice

2016

Curr Cardiovasc Risk Rep

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Tremendous advances have altered the management of stroke over the past two decades. In a landmark paper in 1995, intravenous tissue plasminogen activator (TPA) was shown to improve outcomes in stroke patients when compared with the standard treatment at the time. Municipalities around the country created destination plans for their EMS systems to direct stroke patients to an appropriate stroke center and therefore prevent the costly time delays associated with interfacility transports. When properly identified as a stroke by EMS, studies show that EMS prenotification to the hospital leads to faster in-hospital times and in some cases faster treatment times. With such an important role of EMS in stroke care, the importance of proper recognition by EMS became paramount. Stroke identification tools were developed to aid in stroke recognition with varying results. Some systems developed mobile stroke units to bring the emergency department to the patient to expedite TPA administration. Recently, five studies published in 2015 demonstrated the benefit of intraarterial thrombolysis (IAT) for patients with large-vessel occlusions (LVO). While primary stroke centers are able to provide TPA management, comprehensive stroke centers are the only centers capable of providing intra-arterial interventions. Should IAT become the standard of care, EMS will have a responsibility to adjust its stroke recognition systems to differentiate patients with LVOs who might benefit from intervention at a comprehensive stroke center (CSC) and appropriately bypass a primary stroke center (PSC) for a CSC to provide them the best opportunity to receive this time-sensitive therapy and prevent the significant interfacility transport delays.

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Factors Related to the Sensitivity of Emergency Medical Service Impression of Stroke

Cited by 33 publications

References 18 publications

Clinical Predictors of Accurate Prehospital Stroke Recognition

Clinical Predictors of Accurate Prehospital Stroke Recognition

Stroke and TIA mimics in patients referred to a neurological emergency department by non-ambulance physicians, ambulance physicians and paramedics.

EMS and Acute Stroke Care: Evidence for Policies to Reduce Delays to Definitive Treatments

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