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Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Recognition of Stroke by EMS is Associated with


Improvement in Emergency Department Quality
Measures

Michael E. Abboud, Roger Band, Judy Jia, William Pajerowski, Guy David,
Michelle Guo, C. Crawford Mechem, Steven R. Mess, Brendan G. Carr &
Michael T. Mullen

To cite this article: Michael E. Abboud, Roger Band, Judy Jia, William Pajerowski,
Guy David, Michelle Guo, C. Crawford Mechem, Steven R. Mess, Brendan G. Carr &
Michael T. Mullen (2016) Recognition of Stroke by EMS is Associated with Improvement in
Emergency Department Quality Measures, Prehospital Emergency Care, 20:6, 729-736, DOI:
10.1080/10903127.2016.1182602

To link to this article: http://dx.doi.org/10.1080/10903127.2016.1182602

Published online: 31 May 2016. Submit your article to this journal

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RECOGNITION OF STROKE BY EMS IS ASSOCIATED WITH IMPROVEMENT
IN EMERGENCY DEPARTMENT QUALITY MEASURES
Michael E. Abboud, MD, Roger Band, MD, Judy Jia, MD, William Pajerowski, BA,
Guy David, PhD, Michelle Guo, BS, C. Crawford Mechem, MD, Steven R. Messe, MD,
Brendan G. Carr, MD, MS, Michael T. Mullen, MD, MS

ABSTRACT time, faster door-to-CT time, and greater odds of receiving


thrombolysis. Quality initiatives to improve EMS recogni-
Objective: Hospital arrival via Emergency Medical Services tion of stroke have the potential to improve hospital-based
(EMS) and EMS prenotification are associated with faster quality of stroke care. Key words: stroke; thrombolysis;
evaluation and treatment of stroke. We sought to determine quality measures; CVA
the impact of diagnostic accuracy by prehospital providers
on emergency department quality measures. Methods: A ret- PREHOSPITAL EMERGENCY CARE 2016;20:729736
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rospective study was performed of patients presenting via


EMS between September 2009 and December 2012 with a dis-
charge diagnosis of transient ischemic attack (TIA), ischemic INTRODUCTION
stroke (IS), or intracerebral hemorrhage (ICH). Hospital and
EMS databases were used to determine EMS impression, pre- Stroke is a time-sensitive medical emergency with ef-
hospital and in-hospital time intervals, EMS prenotification, fective acute therapies, including intravenous throm-
NIH stroke scale (NIHSS), symptom duration, and throm- bolysis with tissue plasminogen activator (rt-PA) and
bolysis rate. Results: 399 cases were identified: 14.5% TIA, endovascular thrombectomy.12 Every minute of de-
67.2% IS, and 18.3% ICH. EMS providers correctly recog- lay in treating stroke results in an average of 1.8 days
nized 57.6% of cases. Compared to cases missed by EMS, of healthy life lost.3 Delayed arrival at the emergency
correctly recognized cases had longer median on-scene time department (ED) is common after stroke,4,5 and as
(17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. such, only about one in four stroke patients present
15 min, p = 0.001). Cases correctly recognized by EMS were
in time to receive rt-PA.6 Decreasing the time period
associated with shorter door-to-physician time (4 vs. 11 min,
p < 0.001) and shorter door-to-CT time (23 vs. 48 min,
between symptom onset and hospital arrival may re-
p < 0.001). These findings were independent of age, NIHSS, duce morbidity and mortality after stroke by increas-
symptom duration, and EMS prenotification. Patients with ing utilization of acute stroke therapies. Much of the
ischemic stroke correctly recognized by EMS were more delay from symptom onset to presentation is due to
likely to receive thrombolytic therapy, independent of age, delayed activation of EMS by patients, potentially be-
NIHSS, symptom duration both with and without prenotifi- cause of failure to recognize stroke symptoms or fail-
cation. Conclusion: Recognition of stroke by EMS providers ure to recognize the seriousness of these symptoms.7,8
was independently associated with faster door-to-physician While public health interventions are needed to re-
duce these delays, there may also be opportunities
to reduce delays after EMS activation. Prior studies
have shown that faster evaluation after hospital arrival
Received December 2, 2015 from Massachusetts General Hospital, is associated with increased thrombolysis rates.9,10
Emergency Medicine, Boston, Massachusetts (MEA); Brigham and With the establishment of Primary and Comprehen-
Womens Hospital, Emergency Medicine, Boston, Massachusetts sive Stroke Centers throughout the United States and
(MEA); Thomas Jefferson University, Emergency Medicine, Philadel-
with the regionalization of stroke care, Emergency
phia, Pennsylvania (RB, BGC); Wharton School, Healthcare Manage-
ment, Philadelphia, Pennsylvania (WP, GD); Leonard Davis Insti- Medical Services (EMS) have increasingly been trans-
tute of Health Economics, Philadelphia, Pennsylvania (GD, MTM); porting patients with presumed stroke to hospitals that
University of Pennsylvania, Neurology, Philadelphia, Pennsylva- are equipped to diagnose and treat these patients in a
nia (MG, SRM, MTM, JJ); University of Pennsylvania, Emergency timely fashion.1112
Medicine, Philadelphia, Pennsylvania (CCM); Philadelphia Fire De-
For this system to be effective at decreasing de-
partment, Philadelphia, Pennsylvania (CCM). Revision received
April 7, 2016; accepted for publication April 13, 2016. lays in care and delivering patients to hospitals
with stroke systems of care in place, EMS personnel
This work received funding from the Leonard David Institute of
Health Economics. must be trained to accurately identify patients who
are exhibiting symptoms of stroke. Stroke guidelines
Address correspondence to Dr. Michael T. Mullen, Univer- currently recommend the use of quick, streamlined
sity of Pennsylvania Department of Neurology, 3400 Spruce tests to help EMS recognize stroke,13,14 including the
St, 3W Gates Building, Philadelphia, PA 19104, USA. E-mail: Cincinnati Prehospital Stroke Scale (CPSS), the Los
Michael.Mullen@uphs.upenn.edu Angeles Prehospital Stroke Screen (LAPSS), and the
doi: 10.1080/10903127.2016.1182602 Face Arm Speech Time (FAST) scale.1516 Unfortu-

729
730 PREHOSPITAL EMERGENCY CARE NOVEMBER/DECEMBER 2016 VOLUME 20 / NUMBER 6

nately, some published reports suggest that EMS per- Data collected from the PFD for the purposes of this
sonnel may fail to recognize over half of stroke cases, study included the dispatcher impression of diagnosis,
perhaps because prehospital scales are either less effec- EMS provider impression of diagnosis, and three key
tive in clinical practice or are not utilized adequately prehospital time intervals: response interval (time be-
by prehospital providers.1718 However, when they tween 9-1-1 call and arrival on the scene), on-scene in-
make the correct diagnosis of stroke, prenotification terval (time between arrival at the scene and departure
of ED providers at the receiving hospital while en from the scene), and transport interval (time from de-
route has been associated with increased rt-PA uti- parture from the scene to arrival at the hospital). EMS
lization and decreased time from symptom onset to providers were considered to have successfully rec-
in-hospital treatment.1920 Large U.S. registry studies ognized stroke or TIA if the impression included any
show that prenotification occurs in 67% of EMS trans- combination of the words stroke, TIA, or CVA.
ported strokes.21 Total prehospital time after EMS activation was de-
While studies have established the importance of fined as the sum of these three times. PFD data were
prenotification, few have studied whether correct EMS then matched with emergency department and inpa-
impression itself is associated with faster evaluation tient charts for the patient using correlation of name,
and treatment.22 EMS recognition of stroke has the age, date of birth, gender, social security number, ad-
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potential to impact prehospital time intervals. Com- dress, and date/time of EMS visit. Matching was done
paring in-hospital time intervals by EMS prenotifica- manually by correlating date with social security num-
tion, without accounting for EMS recognition of stroke, ber, address, name, date of birth or at least two other
could lead to a misestimate of the impact of preno- patient identifiers (Figure 1). Only PFD patients who
tification, as cases without prenotification represent a could be positively matched with ED and inpatient vis-
mixture of cases where EMS correctly identified stroke its were included in the study.
yet failed to prenotify and cases that were not cor- Clinical chart review was performed to obtain final
rectly recognized by EMS. Quantifying the effect of diagnosis upon hospital discharge (ischemic, hemor-
EMS recognition of stroke with and without preno- rhagic, TIA based on inpatient documentation, neuro-
tification could provide further insights into the im- imaging, and hospital stroke registry data), demo-
portance of prehospital care in stroke outcomes. Us- graphic data, evidence of prehospital notification by
ing data from a metropolitan Comprehensive Stroke EMS, NIH Stroke Scale (NIHSS) at ED presentation,
Center, we sought to determine, among patients with symptom duration at presentation, treatment with
stroke, if correct prehospital recognition of stroke by intravenous recombinant tissue plasminogen activa-
EMS dispatchers and providers impacts the timeli- tor (rt-PA), and key in-hospital time intervals. Stroke
ness of care in the prehospital setting (call to scene and TIA were defined according to the most re-
arrival, on-scene time, and transport time) and in- cent AHA guidelines.23,24 In-hospital time intervals in-
hospital setting (time to physician evaluation, time to cluded door-to-CT time (time between hospital arrival
CT scan and thrombolysis) with and without prenoti- and CT time as documented in the electronic medical
fication. record), door-to-physician time (time between hospi-
tal arrival and a physician entering a note or a nurse
documenting that a physician is at the bedside in the
METHODS electronic medical records), and door-to-thrombolysis
This study was a retrospective single center cohort (time between hospital arrival and the initiation of rt-
study approved by the Institutional Review Board of PA therapy). Door time was obtained from the intake
the University of Pennsylvania Health System and time recorded in the ED electronic medical record sys-
the City of Philadelphia IRB. The study population tem. Prehospital notification was determined by either
was all cases of stroke and TIA treated at the Hospi- a note in the emergency department chart document-
tal of the University of Pennsylvania (HUP) between ing a pre-arrival alert by EMS for stroke, a physician
September 1, 2009 and December 31, 2012, who pre- putting in stroke protocol orders before patient arrival,
sented to the Emergency Department via EMS and or by documentation that the stroke team was present
who could be matched to the Philadelphia Fire Depart- for evaluation at the time of patient arrival in the ED.
ment (PFD) EMS database. The PFD is the sole 9-1-1 Baseline characteristics were summarized and de-
EMS provider for the City of Philadelphia. The PFD scribed using proportions for categorical variables.
maintains an electronic database of all patient encoun- Continuous variables (NIHSS, symptom duration, pre-
ters, including name, age, address, chief complaint, hospital and in-hospital time intervals) were all non-
transport times, impression of diagnosis by both the normally distributed. Consequently, they were sum-
dispatcher and by EMS providers, and a brief synopsis marized using medians and interquartile range. We
of the patient encounter. The PFD uses the Cincinnati evaluated for differences in prehospital and in-hospital
Prehospital Stroke Scale to evaluate potential stroke time intervals across groups by dispatcher impres-
patients. sion and by EMS provider diagnosis using Wilcoxon
M. E. Abboud et al. EMS RECOGNITION OF STROKE IMPROVED ED QUALITY 731
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FIGURE 1. Inclusion criteria flow chart.

Rank-sum. Subjects were then divided into three not available for incorporation into the models. The
groups: EMS provider did not recognize stroke, EMS analysis was conducted in Stata MP Version 12 (Col-
provider recognized stroke but did not prenotify, and lege Station, TX).
EMS provider recognized stroke and did prenotify. We
compared times across all three groups using Kruskal
Wallis test and then performed pairwise comparisons RESULTS
using Dunns test. Multivariable regression was used In total, 654 patients were transported via Philadel-
to estimate the association of EMS provider recog- phia Fire EMS to HUP between September 1, 2009,
nition of stroke with and without prenotification on and December 31, 2012, and had a discharge diag-
door-to-CT and door-to-physician time while control- nosis of ischemic stroke, hemorrhagic stroke, or TIA.
ling for age, sex, symptom duration, and NIHSS. Be- Of these 654 patients, 399 were successfully matched
cause the time variables were right skewed, Poisson in the Philadelphia Fire Department database using
regression with robust standard error was used.25,26 age, name, social security number, and date of event;
Finally, in patients with ischemic stroke presenting 255 of 654 patients were excluded due to incomplete
within 4.5 hours, logistic regression was used to quan- PFD data making definitive matching impossible. Pa-
tify the effect of EMS provider recognition of stroke tient characteristics and interval times for the entire co-
with and without prenotification on the odds of treat- hort are listed in Table 1. Of these 399 patients, hospi-
ment with rt-PA while controlling for EMS prenotifica- tal discharge diagnosis was ischemic stroke in 67.2%,
tion, age, symptom duration, and NIHSS. NIHSS cat- hemorrhagic stroke in 18.3%, and TIA in 14.5%. Dis-
egories were divided into mild (<5), moderate (59), patchers were able to correctly recognize stroke within
and severe (10+) strokes.2728 Race/ethnicity data was this population with a sensitivity of 58.2% (70.7% of
732 PREHOSPITAL EMERGENCY CARE NOVEMBER/DECEMBER 2016 VOLUME 20 / NUMBER 6

TABLE 1. Demographics (n = 399) tification had significantly shorter door-to-physician


Study Population
times (median 7 minutes vs. 11 minutes, p < 0.014) and
door-to-CT times (median 28 minutes vs. 48 minutes,
Number of Subjects, n 399 p < 0.001) relative to those without an EMS diagnosis
Age, median (IQR) 63 (5377)
<50 16.5% of stroke/TIA. Those with EMS impression of stroke
5074 55.6% as well as prenotification had faster door-to-physician
75+ 27.8% (median 2 minutes vs. 7 minutes, p < 0.001) and door-
Male,% 45.9%
to-CT (median 19 minutes vs. 28 minutes, p < 0.001)
Event Type
TIA 14.5% than those who were diagnosed with stroke/TIA with-
Ischemic Stroke 67.2% out prenotification.
Intracerebral Hemorrhage 18.3% These trends persisted when patients were strati-
NIHSS, median (IQR) 6 (213)
<5 45.7%
fied by severity and type of symptoms (Table 3). The
59 22.6% groups of patients with NIH Stroke Scale < 5 (n = 182)
10+ 31.7% and those with NIH Stroke Scale 5 (n = 217) each had
Symptom onset to ED Arrival, min, 190 (65805) statistically significant decreases in door-to-physician
median (IQR)
<180 min 48.4%
and door-to-CT time with correct EMS impression and
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180270 min 7.5% prenotification. Additionally, the same trends held up


>270 min 44.1% when patients were grouped according to presence of
Prehospital Time, median (IQR) weakness (n = 267) or absence of weakness (n = 132).
Call to Scene Arrival, min 7 (510)
On-scene Time, min 16 (1322) In a multivariable model (Tables 4 and 5), EMS
Transport time, min 13 (819) provider prenotification of stroke was associated with
Prehospital notification 27.8% decreased door-to-physician and door-to-CT time,
Inhospital Intervals, median (IQR) while EMS recognition of stroke without prenotifica-
Door-to-Physician Time, min 6 (219)
Door-to-CT Time, min 30 (1857) tion was associated with decreased door-to-CT times
IV Thrombolysis but not door-to-physician time. These findings were
Door-to-thrombolysis time, min, median 50.5 (4272) independent of NIHSS, symptom duration, and age.
(IQR)
When thrombolysis for ischemic stroke was analyzed
using a multivariable model (Table 6), EMS recog-
nition of stroke without prenotification was associ-
TIAs, 59.0% of ischemic strokes, 45.2% of intracere- ated with increased likelihood of treatment with in-
bral hemorrhages, p = 0.012), while EMS providers travenous rt-PA (OR = 6.67, p = 0.004) independent
correctly recognized stroke with a sensitivity of 57.6% of NIHSS, symptom duration, and age. EMS recogni-
(41.4% of TIAs, 57.8% of ischemic stroke, and 69.9% of tion with prenotification was also independently as-
intracerebral hemorrhages, p = 0.005). There were 80 sociated with greater likelihood of rt-PA treatment
of the 399 stroke cases (20.1%) that were not recognized (OR = 4.47, p = 0.022).
by both the dispatcher and EMS provider.
When patients were stratified by dispatcher impres-
sion, there was no significant difference in prehospi-
DISCUSSION
tal intervals for patients recognized as having stroke This study underscores the importance of prehos-
or TIA versus those given other diagnoses (Table 2). pital providers in stroke systems of care. EMS
However, when stratified by EMS provider impres- recognition of stroke was associated with shorter in-
sion, patients who were recognized as having stroke hospital time intervals with and without prenotifica-
or TIA compared to other impressions had signifi- tion. This finding suggests that training EMS providers
cantly longer on-scene times (median 17 minutes vs. to be more accurate in their recognition of stroke will
15 minutes, p = 0.011) and significantly shorter trans- result in faster triage, shorter time to CT, and increased
port times (median 12 minutes vs. 15 minutes, p = utilization of thrombolytic agents in eligible patients,
0.001). Total prehospital times after EMS activation even when there is failure to prenotify the receiving
were comparable (median 39 minutes vs. 40 minutes, hospital. Previous studies have shown that prenotifi-
p = 0.457). cation of receiving hospitals improves the timeliness
EMS prenotification occurred in 93 of 230 (40.4%) of care provided to stroke patients in the emergency
of the patients who were recognized as having department.13,29,30,31 This study corroborates that find-
stroke/TIA symptoms by EMS providers. When com- ing, demonstrating the shortest door-to-physician and
paring patients who were ultimately given a dis- door-to-CT times in cases with both correct EMS recog-
charge diagnosis of stroke/TIA for whom the hos- nition of stroke and prenotification. The data show
pital did not receive prenotification with patients that these results persist when patients are stratified by
whose stroke/TIA was not recognized in the field, the NIH Stroke Scale and the presence or absence of weak-
group with correct EMS impression without preno- ness, thereby diminishing the confounding effects of
M. E. Abboud et al. EMS RECOGNITION OF STROKE IMPROVED ED QUALITY 733

TABLE 2. Prehospital and In-hospital Times by Dispatcher and EMS Provider Diagnosis
Dispatcher Diagnosis EMS Provider Diagnosis

Stroke/TIA Other Stroke/TIA Other


n = 232 n = 167 P-value n = 230 n = 169 P-value

Prehospital Time Intervals


Call to scene arrival 7(5 10) 7(5 10) 0.553 7(5 10) 7(6 11) 0.195
On-scene time 17(12 22) 16(13 23) 0.890 17(14 22) 15(10 22) 0.011
Transport time 13(8 19) 13(8 19) 0.653 12(7 18) 15(10 21) 0.001
In-hospital Time Intervals
Door-to-physician time, min 6(2 19) 6(2 20) 0.784 4(1 12) 11(3 27) < 0.001
Door-to-CT time, min 27.5(17 51) 35(20 62) 0.010 23(16 37) 48(26 73) < 0.001
Note: Data presented are medians with interquartile range in parenthesis. Wilcoxon Rank Sum used to test for differences between groups.

stroke severity and symptoms on EMS diagnostic accu- or the use and documentation of prehospital stroke
racy. Overall, the results support the need to maximize scales. Within our dataset documentation across EMS
both EMS recognition of stroke and prenotification of encounters was highly variable. Not surprisingly, a re-
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receiving hospitals. cent study found that EMS providers were more likely
Although prehospital stroke screens are report- to correctly identify stroke when a prehospital stroke
edly highly sensitive for stroke and the Cincinnati scale is documented.31 The use of a prehospital stroke
Prehospital Stroke Scale is recommended by Penn- scale was not reliably documented within our dataset.
sylvania State EMS protocols, we found that more Pennsylvania statewide EMS protocols state that the
than 40% of the 399 patients with a discharge diag- CPSS should be used, but we are not able to deter-
nosis of stroke or TIA that were matched to the EMS mine provider adherence. Efforts to standardize doc-
database were not recognized as stroke/TIA patients umentation and adherence to existing EMS protocols
in the field. Other recent studies have shown vari- may improve the quality of care for stroke patients. In-
ability in the ability of EMS to recognize stroke pa- terestingly, while 40% of strokes were not recognized
tients, with published sensitivity between 50% and by EMS providers, only about 20% of strokes were
80%.29,30 It is unknown why such variability exists. missed by both EMS providers and EMS dispatch-
EMS providers must balance sensitivity and specificity ers. It is possible that giving additional weight to dis-
of diagnosis; maximizing sensitivity is likely to de- patcher impression would improve EMS recognition of
crease specificity. Different EMS systems may have dif- stroke.
ferent thresholds regarding a preliminary diagnosis of We are unable to describe why correct EMS recogni-
stroke. Variability in sensitivities across studies may tion of stroke or TIA hastened in-hospital management
also be related to regional variability in EMS training and treatment. We hypothesize that upon emergency

TABLE 3. Impact of EMS Provider Diagnosis and Prenotification on In-Hospital Times Stratified by NIHSS and Presence or
Absence of Weakness
NIHSS < 5 NIHSS > 5

EMS Provider EMS Provider EMS Provider P-value EMS Provider EMS Provider EMS Provider P-value
Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis
Other Stroke/TIA Stroke/TIA and Other Stroke/TIA Stroke/TIA and
Prenotified Prenotified
(n = 111) (n = 44) (n = 27) (n = 57) (93) (66)
Door-to- 18 (635) 7 (3.521) 2 (15) < 0.001 4.5 (113) 7 (213) 2 (15) < 0.001
Physician
Time, min
Door-to-CT 58 (3596) 31.5 (19.566) 19 (1328) < 0.001 31 (2056) 26 (1642) 20 (1526) < 0.001
Time, min
Weakness Absent Weakness Present
EMS Provider EMS Provider EMS Provider P-value EMS Provider EMS Provider EMS Provider P-value
Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis Diagnosis
Other Stroke/TIA Stroke/TIA and Other Stroke/TIA Stroke/TIA and
Prenotified Prenotified
(n = 80) (n = 37) (n = 15) (n = 89) (n = 100) (n = 78)
Door-to- 11 (3.531) 7 (322) 1 (15) 0.001 11 (322) 6.5 (315.5) 2 (15) < 0.001
Physician
Time, min
Door-to-CT 60.5 32 (2556) 19 (1327) < 0.001 41 (2465) 25 (1744) 20 (1527) < 0.001
Time, min (30.5100.5)
Note: Data presented are medians with interquartile range in parenthesis.
734 PREHOSPITAL EMERGENCY CARE NOVEMBER/DECEMBER 2016 VOLUME 20 / NUMBER 6

TABLE 4. Multivariable Poisson Regression for Door TABLE 6. Multivariable Model for Thrombolysis, Ischemic
to Physician Time (n = 398) Stroke presenting within 4.5 hours only (n = 131)
Door to Physician Time OR 95% CI P-value

Coef 95% CI P-value EMS 0.017


Did not recognize Ref
EMS < 0.001 stroke
Did not recognize Ref Recognized stroke 6.43 (1.74, 23.73) 0.005
stroke Recognized and 4.44 (1.23, 16.01) 0.023
Recognized stroke 0.25 ( 0.52, 0.02) 0.070 prenotified
Recognized and 1.15 ( 1.51, 0.79) < 0.001 NIHSS < 0.001
prenotified <5 Ref
NIHSS < 0.001 5 9 25.64 (4.82, 136.46) < 0.001
<5 Ref 10+ 31.16 (5.97, 162.2) < 0.001
5 9 0.53 ( 0.79, 0.26) < 0.001 Symptom onset to ED 0.236
10+ 0.71 ( 1.0, 0.39) < 0.001 Arrival
Symptom onset to ED 0.375 <180 min Ref
Arrival 180 270 min 0.45 (0.12, 1.69) 0.204
<180 min Ref Female 0.83 (0.32, 2.15) 0.694
180 270 min 0.13 ( 0.60, 0.33) 0.575
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Age 0.078
270+ 0.14 ( 0.15, 0.43) 0.333 <50 Ref
Female 0.32 (0.06, 0.57) 0.015 50 74 0.27 (0.07, 1.02) 0.054
Age 0.807 75+ 0.19 (0.04, 0.82) 0.027
<50 Ref
50 74 0.11 ( 0.43, 0.22) 0.517
75+ 0.09 ( 0.42, 0.25) 0.611

to arrival. Given the limitations of our data, we are not


able to test this hypothesis. It is also possible that there
department arrival, verbalization of the concern for di- is something fundamentally different about the strokes
agnosis of stroke by EMS to the triage nurse may trig- that EMS providers recognize compared to those that
ger emergency department providers to hasten care by they do not recognize. We attempted to minimize this
seeing the patient faster, preparing the CT scanner for by controlling for NIHSS, age, and symptom duration,
more rapid imaging, and notifying the neurology or but it is possible that residual confounding could be
stroke service in a timelier manner. In this way EMS influencing the results.
recognition of stroke may function like prenotification, Prospective studies of prehospital stroke care are
except that it occurs immediately after EMS personnel needed to identify variability in EMS provider per-
arrive at the emergency department, rather than prior formance and to form the basis of quality improve-
ment initiatives for regionalized systems of care.
Ideally, such a program would provide targeted
TABLE 5. Multivariable Poisson Regression for Door to CT feedback to EMS providers in order to ensure high
Time (n = 398) compliance with key performance metrics, including
Door to Physician Time
on-scene time, transportation time, performance and
documentation of a prehospital stroke screen, and
Coef 95% CI P-value
diagnostic accuracy. There are, however, significant
EMS < 0.001 barriers to this work. Accurate data recording and
Did not recognize Ref subsequent collection of data from a large number of
stroke
EMS providers (who are under time constraints due to
Recognized stroke 0.36 ( 0.57, 0.15) 0.001
Recognized and 0.85 ( 1.06, 0.64) < 0.001 pressure to care for critically ill patients) could be dif-
prenotified ficult. Additionally, linkage to inpatient data is nec-
NIHSS < 0.001 essary to quantify EMS diagnostic accuracy and the
<5 Ref
5 9 0.28 ( 0.52, 0.04) 0.023
impact of prehospital interventions on outcomes. Col-
10+ 0.49 ( 0.69, 0.29) < 0.001 lecting data across multiple hospitals in a region
Symptom onset to ED 0.106 is challenging, although collaborative projects eval-
Arrival uating regional stroke outcomes have been success-
<180 min Ref
180 270 min 0.16 ( 0.51, 0.19) 0.362
ful in the past.32 It may be possible to leverage
270+ 0.15 (0.05, 0.34) 0.140 existing resources to accomplish this goal. The Na-
Female 0.12 ( 0.06, 0.31) 0.186 tional EMS Information System (NEMSIS) project aims
Age 0.910 to create a series of common data elements to be
<50 Ref
50 74 0.03 ( 0.29, 0.23) 0.823 collected by EMS agencies across the U.S., which
75+ 0.02 ( 0.26, 0.29) 0.915 could potentially be linked to administrative claims
or registry data to provide final hospital diagno-
M. E. Abboud et al. EMS RECOGNITION OF STROKE IMPROVED ED QUALITY 735

sis and clinical outcome across a large number of References


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as the time-sensitive nature of stroke may have led to tional stroke trial [IST-3]): a randomised controlled trial. Lancet.
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