Abstract
Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom duration <6 h. In a multivariable model, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5-9, OR 2.62, 95% CI 1.41-4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29-9.09) and weakness (OR 2.28, 95% CI 1.35-3.85), and negatively associated with symptom duration >270 min (OR 0.41, 95% CI 0.25-0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration <6 h. Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification.
Highlights
To be maximally effective, stroke therapies, including tissue plasminogen activator and endovascular thrombectomy (ET), must be delivered as quickly as possible [1]
We evaluated for differences between subjects with a vascular event who were correctly identified by dispatchers, but not Emergency Medical Services (EMS) crews, and all other subjects with a vascular event
There were 725 suspected stroke patients transported by the Philadelphia Fire Department (PFD) to Hospital of the University of Pennsylvania (HUP) from September 2009 to October 2012
Summary
Stroke therapies, including tissue plasminogen activator (rt-PA) and endovascular thrombectomy (ET), must be delivered as quickly as possible [1]. The American Heart Association recommended development of regionalized systems of care, preferentially transporting patients to the nearest stroke center, rather than the nearest hospital [2, 3]. These recommendations are being adopted across the US [4]. Regionalized systems of care are dependent on early and accurate identification of stroke patients by Emergency Medical Services (EMS). We aimed to determine prehospital diagnostic accuracy of EMS dispatchers and crews for stroke overall, for acute stroke patients with National Institutes of Health Stroke Scale (NIHSS) ≥5, and which clinical features were associated with correct prehospital identification of stroke. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city
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