Prehospital Identification Of Patients Research Articles

Implementation of a Thrombectomy Stroke Center Triage Program in New York City Emergency Medical Services

Background Due to the increased morbidity and mortality associated with acute cerebral ischemia caused by large vessel occlusions, the New York City (NYC) 9‐1‐1 Emergency Medical Services system implemented the NYC Stroke Triage Protocol with the intention of improving access to endovascular therapy for patients with suspected severe stroke. Methods Successful collaboration between multiple stakeholders enabled the NYC region to develop and implement a new stroke system of care for patients treated by Emergency Medical Services. Descriptive statistics including medians (interquartile range) and proportions were used as appropriate. Continuous data were compared using Mann–Whitney tests for medians and categorical data were compared by using Pearson chi‐square test. Results Between April 1, 2019 and March 31, 2022, 1337 (83.5%) patients directly transported under the NYC Stroke Triage Protocol by the NYC 9‐1‐1 Emergency Medical Services system to a Thrombectomy Stroke Center had a stroke diagnosis. Patients transported to a more distant Thrombectomy Stroke Center traveled an average of 5.7 minutes longer compared with those who were delivered to the closest Primary Stroke Center but the overall time between first patient contact and first pass at a Thrombectomy Stroke Center was an estimated 98.2 minutes shorter. Approximately 24% of directly transported patients with a stroke diagnosis underwent a thrombectomy. Conclusions The NYC Stroke Triage Protocol increased access to advanced interventional stroke care for eligible patients by decreasing time to treatment through prehospital identification of patients with severe stroke and directly transporting them to a stroke center capable of providing endovascular therapy.

ELECTRA-STROKE: Electroencephalography controlled triage in the ambulance for acute ischemic stroke-Study protocol for a diagnostic trial.

BackgroundEndovascular thrombectomy (EVT) is the standard treatment for large vessel occlusion stroke of the anterior circulation (LVO-a stroke). Approximately half of EVT-eligible patients are initially presented to hospitals that do not offer EVT. Subsequent inter-hospital transfer delays treatment, which negatively affects patients' prognosis. Prehospital identification of patients with LVO-a stroke would allow direct transportation of these patients to an EVT-capable center. Electroencephalography (EEG) may be suitable for this purpose because of its sensitivity to cerebral ischemia. The hypothesis of ELECTRA-STROKE is that dry electrode EEG is feasible for prehospital detection of LVO-a stroke.MethodsELECTRA-STROKE is an investigator-initiated, diagnostic study. EEG recordings will be performed in patients with a suspected stroke in the ambulance. The primary endpoint is the diagnostic accuracy of the theta/alpha ratio for the diagnosis of LVO-a stroke, expressed by the area under the receiver operating characteristic (ROC) curve. EEG recordings will be performed in 386 patients.DiscussionIf EEG can be used to identify LVO-a stroke patients with sufficiently high diagnostic accuracy, it may enable direct routing of these patients to an EVT-capable center, thereby reducing time-to-treatment and improving patient outcomes.Clinical trial registrationClinicalTrials.gov, identifier: NCT03699397.

Positive predictive value of stroke identification by ambulance clinicians in North East England: a service evaluation

Introduction/backgroundAccurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had...

The prehospital assessment of patients with a final hospital diagnosis of sepsis: Results of an observational study

BackgroundSepsis is a severe condition which affects 300–800/100,000 persons each year. There are indications that the prehospital identification of patients with sepsis is difficult. The aim of the study was, among patients with a final hospital diagnosis of sepsis, to compare emergency medical service (EMS) field assessments of patients in whom there was a prehospital suspicion of sepsis with those without this suspicion. MethodsThe study had a retrospective, observational design. The data used in the study were retrieved from the prehospital and hospital medical records of patients with a final hospital diagnosis of sepsis, transported to hospital by the EMS within a region in the south west of Sweden during a period of one year. ResultsAmong patients with a final diagnosis of sepsis (n=353), the EMS identified the condition in 36% of the cases. These patients were characterised by more abnormal vital signs (a higher respiratory rate and heart rate and more frequent temperature abnormalities) and were more ambitiously assessed (more lung auscultations and more assessments of the degree of consciousness). ConclusionThe EMS was already able to identify 36% of patients with a final diagnosis of sepsis in the prehospital phase. There were minor differences in the prehospital assessment between patients who were identified by the EMS nurse and those who were not.

QSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.

Abstract WMP65: A Dichotomized Cincinnati Prehospital Stroke Score is Correlated With Revascularization Therapy in Acute Stroke

Introduction: Early revascularization improves outcomes in patients with acute stroke, and prehospital identification of patients with large vessel occlusions can result in preferential transport to centers with endovascular capability. Several stroke severity scales have been developed to assist with prehospital triage, but emergency medical services (EMS) provider training on new assessment scales presents challenges. Hypothesis: A dichotomized Cincinnati Prehospital Stroke Scale (CPSS) with a cut-off of 2 correlates with acute stroke revascularization in a large US city. Methods: Patients with confirmed stroke arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large urban city with a single municipal EMS provider were identified. Demographics, prehospital CPSS, initial NIH stroke scale score (NIHSS) at hospital arrival, and type of revascularization (intravenous tissue plasminogen activator [IVtPA] or endovascular) were captured. Spearman’s rank correlation and Mann-Whitney U Test were performed after applying skewness/kurtosis tests. The Youden index was used to identify the optimal cut-off for the dichotomized CPSS. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for revascularization. Results: A total of 144 patients were included; 51% were male, 57% were white, and 33% were black. The mean age was 68.8 years (SD 16.1). A total of 31 patients (21.5%) underwent revascularization, most often with IVtPA alone (n=30). CPSS was ≥2 in 42% of patients, and the median NIHSS in patients with CPSS <2 vs CPSS ≥2 was 2 vs 8 (p<0.0001). CPSS and NIHSS in patients presenting within 4.5 hours were strongly correlated (Spearman's rho = 0.57, p<0.0001). The optimum CPSS cut-off that predicted revascularization was 2, with a sensitivity of 0.79, specificity of 0.81, and a Youden index of 0.61. CPSS ≥2 was strongly associated with revascularization (adjusted OR 14.5, 95% CI 5.0-42.4). Conclusions: Prehospital dichotomized CPSS with a cut-off of 2 is well correlated with acute stroke revascularization in a large US city. Further studies should investigate how the dichotomized CPSS performs in the prehospital identification of stroke patients with large vessel occlusions.

Abstract WMP64: Prehospital Triage To Comprehensive Stroke Centers: GCS Identifies Patients At Increased Risk For Death, ICH, Or SAH

INTRODUCTION: Regionalization of stroke care is occurring nationwide, but evidence-based criteria for prehospital triage to comprehensive stroke centers are lacking. We assessed the hypothesis that a prehospital clinical decision rule can identify a group of patients more likely to require comprehensive stroke services--those with an increased risk of in-hospital mortality, ICH, or SAH. METHODS: This study represents a retrospective cohort of patients seen by an urban EMS system from 2000-2003. Subjects were included if they had either a prehospital diagnosis of “stroke/TIA” or a prehospital diagnosis of “decreased level of consciousness” or “headache” and signs and symptoms suggestive of a cerebrovascular event. The primary outcome was a composite of in-hospital mortality, ICH, or SAH. Multivariate logistic regression was used to derive a clinical prediction rule. RESULTS: In 1682 subjects, the discharge diagnoses included TIA (n = 282, 17%), ischemic stroke (n = 433, 26%), ICH (n = 102, 6%), and SAH (n = 30, 2%). There were 221 patients (13%) who experienced the primary outcome: 67 (4%) with non-fatal ICH or SAH and 154 (9%) who died. Using GCS score alone, the area under ROC curve was 0.72, and GCS ≤ 10 resulted in a sensitivity of 0.48 (95%CI 0.42, 0.55) and specificity of 0.88 (95%CI 0.87, 0.90). A six-point prehospital stroke triage score (PSTS) was also derived: nausea/vomiting (1 point), systolic BP ≥ 175 (1 point), GCS 7-10 (2 points) and GCS 3-6 (4 points). The area under ROC curve for the PSTS was 0.74. Test characteristics for PSTS and GCS were similar (Table). CONCLUSION: GCS alone performed similarly to a six-point clinical decision rule for the prehospital identification of patients at increased risk of death, ICH or SAH. GCS has potential utility as a criterion for the prehospital triage to comprehensive stroke centers.

Abstract TMP63: Accuracy of Remote Video Cellphone Evaluation of Stroke Deficits Using California Brief Stroke Scale

Background: Availability of 4G cellular network and video cellphone handsets may allow mobile videophone assessment to be employed in prehospital stroke care. The California Brief Stroke Scale (CABSS) is a 4 item scale designed as a mobile videophone test to evaluate a prehospital telemedicine instrument to rate stroke severity. Potential uses include identifying patients who are likely harboring persisting large vessel occlusions and to characterize baseline deficits prior to enrollment in prehospital trials. Methods: One bedside and one remote CABSS score were independently obtained on 15 ischemic stroke patients with persistent neurologic deficits. The bedside examination was performed by a stroke neurologist. The remote examination was performed by a second stroke neurologist through mobile video phone. A CABSS score of 1 or higher (scale 0-7) was an index of global stroke deficit severity. Kappa coefficients were calculated for concordance between bedside and remote scores. Results: The median National Institutes of Health Stroke Scale score was 6 (interquartile range IQR 4-10). On average the CABSS score evaluation took 25 seconds to perform. The median video CABSS was 2, (IQR1-3) and median bedside CABSS was 3, (IQR 1-3). Based on weighted K coefficients, cortical findings (aphasia, gaze deviation/hemineglect) displayed excellent agreement κ=1 (95% CI 1.0) and non-cortical findings (facial droop, arm drift) displayed substantial agreement κ =0.7 (95% CI 0.4-1.0). There was substantial agreement between bedside and remote methods for the total CABSS κ 0.68 (95% CI 0.44-0.92). The CABSS scores obtained by bedside and remote methods were strongly correlated (r= 0.85, P<0.0001). Conclusion: Our prospective study found that mobile videocell phone evaluation using CABSS is a feasible and reliable means of examining hyperacute stroke patients in the field. A physician can rapidly perform an audiovideo examination to increase the accuracy of prehospital identification of patients harboring persisting large vessel occlusions and characterize baseline deficits prior to enrollment in prehospital clinical trials to a clinically important degree.

Pre-hospital identification of patients with acute myocardial infarction. A pilot study for a mobile coronary care unit.

The aim of this study was to determine what proportion of patients with acute myocardial infarction (AMI) could be identified over the telephone by the staff of a Swedish ambulance center (AC). Over a 12-week period in 1973, the ambulance controllers in the Gothenburg region registered all patients requesting an ambulance whom they suspected to have AMI. Two hundred and fourteen such patients were suspected by the AC staff to have AMI. Forty-seven (22%) had a subsequent hospital diagnosis of AMI and 16 (7%) were dead from ischaemic heart disease on the arrival of the ambulance to the patient. Thus, 63 patients (29%) would probably have benefited from the existence of a mobile coronary care unit. During this period 180 AMI patients arrived alive at the hospital. Fifty-seven per cent arrived by ambulance. The ambulance controller had correctly diagnosed 47% of the AMI patients who requested ambulances, i.e. 27% of all AMI patients. AMI patients who requested ambulances had a significantly higher hospital mortality than AMI patients who arrived at hospital by other means (28 v. 10.8%). During the study period, 81 patients died from ischaemic heart disease outside hospital. Only 16 (20%) of these were identified by the AC staff. Our conclusion must be that the AC staff had a low detection rate for patients dying outside hospital of ischaemic heart disease. However, 47% of AMI patients who requested ambulances were identified and these patients had a high hospital mortality. This group of AMI patients should be an important target group for intensive treatment in the pre-hospital phase, in attempts to reduce AMI mortality.