A stroke scale for emergency triage

Abstract

The National Institutes of Health Stroke Scale (NIHSS) is a widely used scale for managing acute ischemic stroke but may be too complicated for health care providers not focused on stroke care. We devised the Emergency Triage Stroke Scale (ETSS) to specifically predict the NIHSS when used by emergency medical service (EMS) providers and triage nurses, who do not have subspecialty training in the neurology of stroke. This scale was designed to match the maximum score in each of the 6 domains of the NIHSS, using information from the routine assessments performed by EMS providers. In all, 48 consecutive patients presenting with symptoms of acute ischemic stroke were assessed. Emergency department (ED) residents, ED nurses, and EMS personnel applied the ETSS while ED attendings and stroke team physicians performed the NIHSS. Scores were analyzed using multivariate analysis of variance, linear regression analysis, the Spearman correlation coefficient, the K statistic for reproducibility, and post hoc reviews. There was excellent agreement between residents and nurses using the ETSS and a strong correlation between the NIHSS and the ETSS performed by residents or nurses. EMS providers performed well but tended to overestimate the NIHSS of sicker patients. Domain scores followed the same general pattern. All ETSS raters showed excellent ability to predict candidacy for thrombolytic therapy based on a predicted NIHSS score of 4 to 23. The ETSS is a simplified prehospital stroke scale that correlates well with the NIHSS. Clearer instructions with a modest increase in education are likely to allow EMS personnel to achieve similar results.