The Quality of Prehospital Ischemic Stroke Care: Compliance with Guidelines and Impact on In-hospital Stroke Response

Abstract

A number of emergency medical services (EMSs) performance measures for stroke have been proposed to promote early stroke recognition and rapid transportation to definitive care. This study examined performance measure compliance among EMS-transported stroke patients and the relationship between compliance and in-hospital stroke response. Eight quality indicators were derived from American Stroke Association guidelines. A prospective cohort of consecutive, EMS-transported patients discharged from 2 large Midwestern stroke centers with a diagnosis of acute ischemic stroke was identified. Data were abstracted from hospital and EMS records. Compliance with 8 prehospital quality indicators was calculated. Univariate and multivariable logistic regression analysis were performed to measure the association between prehospital compliance and a binary outcome of door-to-computed tomography (CT) time less than or equal to 25 minutes. Over the 12 month study period, 186 EMS-transported ischemic stroke patients were identified. Compliance was highest for prehospital documentation of a glucose level (86.0%) and stroke screen (78.5%) and lowest for on-scene time less than or equal to 15 minutes (46.8%), hospital prenotification (56.5%), and transportation at highest priority (55.4%). After adjustment for age, time from symptom onset, and stroke severity, transportation at highest priority (odds ratio [OR], 13.45) and hospital prenotification (OR, 3.75) were both associated with significantly faster door-to-CT time. No prehospital quality metric was associated with tissue-plasminogen activator delivery. EMS transportation at highest priority and hospital prenotification were associated with faster in-hospital stroke response and represent logical targets for EMS quality improvement efforts.