Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial

Experiences from a cluster‐randomized trial (ParaNASPP) exploring triage and diagnostic accuracy in paramedic‐suspected stroke: a qualitative interview study

“…Prehospital stroke assessment with the NIHSS may not be more time consuming than with FAST [13]; still longer on-scene time was found for the intervention group in the ParaNASPP trial [20]. Pandemic restrictions were argued to have confounded the prehospital time variables in the trial, and our participants experienced prehospital NIHSS to be time-efficient, supporting this interpretation.…”

“…Our participants recognized these benefits. The detection of more posterior circulation strokes was not confirmed in the clinical trial; however, there was an increased identification of strokes with a more subtle symptom presentation [20]. Timely stroke recognition and facilitated communication are reasonable arguments to pursue the implementation of prehospital NIHSS.…”

“…The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) clinical trial assessed whether the eSTROKE intervention of a mobile application with NIHSS to communicate and transfer the results of the prehospital assessment to the stroke physicians could improve triage and diagnostic accuracy of acute stroke patients (Appendix S3). The control was a standard paramedic stroke protocol consisting of FAST and ordinary telephone communication with the stroke physician for triage decisions [20]. The intervention did not increase the positive predictive value for final diagnosis of stroke and overtriage remained high, meaning that a large proportion of patients admitted with suspected acute stroke did not have a final diagnosis of stroke.…”

Prehospital Stroke Detection in Women Is More Than Identifying LVOs

“…Recent studies show that up to 52% of acute strokes are missed 2 and the identification of specific subtypes such as large vessel occlusion (LVO) stroke is even more challenging. Besides the well-established National Institutes of Health Stroke Scale, recently investigated in a prehospital clinical trial, 3 multiple clinical scores exist to support emergency medical service personnel in quantifying and standardizing stroke symptoms into ordinal data results. 4 Information available on sex inequity in prehospital stroke care is growing 5 ; however, no clinical scale has incorporated sex differences.…”

“…Most clinical studies investigated the scales with teams of well-trained paramedics/emergency medical technicians or even emergency physicians. 3,[14][15][16][17] Second, without increasing the knowledge about stroke of prehospital teams, all those patients with symptoms not captured by simplistic scales will always be disadvantaged and may miss out on adequate treatments. Ultimately, diagnostic identification of patients with stroke relies on the knowledge and competence of the prehospital teams involved.…”