Stroke Mimics Transported by Emergency Medical Services to a Comprehensive Stroke Center: The Magnitude of the Problem

Objective: It is imperative that prehospital providers accurately recognize stroke. We assessed the sensitivity of stroke recognition by emergency medical services (EMS) in clinical practice in a major US city, and assessed variables associated with failure to recognize stroke. Methods: Data from the Philadelphia EMS system was linked with data from a single comprehensive stroke center to identify patients diagnosed with transient ischemic attack, ischemic stroke, or intracerebral hemorrhage by EMS dispatchers, EMS providers, or at hospital discharge between September 2009 and October 2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression was used to identify variables associated with EMS recognition of stroke. Results: There were a total of 709 cases, 400 of which were cerebrovascular events (38% infarct, 10% ICH, and 8% TIA). Of these cases, 80 (20%) were not recognized by EMS dispatcher or EMS provider, 90 (23%) were recognized by dispatcher alone, 87 (22%) by EMS provider alone, and 143 (36%) by both. EMS providers recognized stroke with a sensitivity of 58%, PPV 69%. Dispatchers or EMS providers recognized stroke with a sensitivity of 80%, PPV 51%. In a multivariable model, EMS providers were more likely to miss a stroke when NIHSS was low (compared to NIHSS 10+, NIHSS 5-9 OR=1.6, 95% CI 0.9-3.0 & NIHSS<5 OR=4.6, 95% CI 2.7-7.9), when motor signs were absent (OR=2.4, 95% CI 1.5-3.9), and when symptom duration was > 270 minutes (OR=2.4, 95% CI 1.5-3.8). Medics correctly recognized 81% of stroke patients with NIHSS>4 and symptom duration <270 minutes, and dispatcher or EMS providers correctly recognized 90% of these patients. Conclusions: EMS recognized stroke with limited sensitivity, resulting in a high proportion of missed stroke cases. When added to the EMS provider impression, dispatcher impression meaningfully improves the sensitivity for recognizing stroke. Maximizing sensitivity is critical to prehospital interventions which may improve overall stroke care, such as transportation to designated stroke centers or EMS prenotification of receiving hospitals.

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Variability in Criteria for Emergency Medical Services Routing of Acute Stroke Patients to Designated Stroke Center Hospitals

Western Journal of Emergency Medicine ◽

10.5811/westjem.2015.7.26179 ◽

2015 ◽

Vol 16 (5) ◽

pp. 743-746 ◽

Cited By ~ 1

Author(s):

Nikolay Dimitrov ◽

William Koenig ◽

Nichole Bosson ◽

Sarah Song ◽

Jeffrey Saver ◽

...

Keyword(s):

Acute Stroke ◽

Emergency Medical Services ◽

Medical Services ◽

Stroke Patients ◽

Emergency Medical ◽

Stroke Center

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Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2014.01.005 ◽

2014 ◽

Vol 46 (3) ◽

pp. 445

Author(s):

Ben Murphy

Keyword(s):

Emergency Medical Services ◽

Routing Protocols ◽

Medical Services ◽

Emergency Medical ◽

Primary Stroke Center ◽

Stroke Center

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Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California

Stroke ◽

10.1161/strokeaha.113.000940 ◽

2013 ◽

Vol 44 (12) ◽

pp. 3584-3586 ◽

Cited By ~ 10

Author(s):

Sam Schuberg ◽

Sarah Song ◽

Jeffrey L. Saver ◽

William J. Mack ◽

Steven Y. Cen ◽

...

Keyword(s):

Emergency Medical Services ◽

Routing Protocols ◽

Medical Services ◽

Emergency Medical ◽

Primary Stroke Center ◽

Stroke Center

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Abstract TP250: A Substantial Rate of Neurological and Non-Neurological Stroke Mimics Are Transported by Emergency Medical Services for Acute Stroke Evaluation

Stroke ◽

10.1161/str.48.suppl_1.tp250 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Joel N Briard ◽

Rahel T Zewude ◽

Mahesh Kate ◽

Ken Butcher ◽

Laura C Gioia

Keyword(s):

Acute Stroke ◽

Emergency Medical Services ◽

Final Diagnosis ◽

Medical Services ◽

Cross Sectional ◽

Stroke Mimics ◽

Emergency Medical ◽

Number Of Patients ◽

Suspected Stroke ◽

The Impact

Introduction: The impact of prehospital triage of stroke mimics to designated stroke centers may be considerable, yet little information exists regarding stroke mimics in the prehospital setting. We aimed to describe the rate and clinical characteristics of neurological and non-neurological stroke mimics transported by Emergency Medical Services (EMS) to the Emergency Department (ED) for acute stroke evaluation. Methods: A retrospective, cross-sectional, observational analysis of a centralized EMS database of patients transported by EMS to the ED for suspected stroke during an 18-month period. Hospital charts and neuroimaging were utilized to determine the final diagnosis (acute stroke, stroke mimic, as well as specific underlying diagnoses). Results: A total of 960 patients were transported by EMS to the ED with suspected stroke, among whom 405 (42.2%) were stroke mimics (mean age ± SD: 66.9 ± 17.1 years; 54% male). Stroke mimics were neurological in origin in 223 (55.1%) patients and non-neurological in 182 (44.9%). Most common neurological diagnoses were seizures (n=44,19.7%), migraines (n=42,18.8%) and peripheral neuropathies (n=25, 11.2%). Most common non-neurological mimics included cardiovascular (15.9%), psychiatric (11.9%), and infectious (8.9%) diagnoses. Neurological mimics were younger (64.1 ± 17.3 years) than non-neurological mimics (70.5 ± 16.1 years, p<0.001). Median prehospital Glasgow Coma Scale scores were similar between groups (15 vs. 15, p=0.26). Mean prehospital systolic blood pressure was slightly higher in neurological (147.8±24.2 mmHg) than non-neurological mimics (141.2±26.2 mmHg, p=0.01). Conclusions: Stroke mimics represent a substantial number of patients transported by EMS for suspected stroke, with a considerable amount being non-neurological in origin. Prospective prehospital studies are warranted to help refine prehospital identification of acute stroke and thus minimize the number of stroke mimics transported by EMS for acute stroke evaluation.

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Abstract WP373: Emergency Medical Service Stroke Education in a Rural Community: Need for Improvement

Stroke ◽

10.1161/str.48.suppl_1.wp373 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Pauline M Rankin ◽

Dianne Marsh ◽

James McLaughlin

Keyword(s):

Emergency Medical Services ◽

Emergency Medical Service ◽

Medical Service ◽

Signs And Symptoms ◽

Stroke Patients ◽

Emergency Medical ◽

Primary Stroke Center ◽

Stroke Education ◽

Comprehensive Stroke Center ◽

Stroke Center

According to The Journal of Emergency Medical Services (EMS) the goal of stroke care is to minimize brain injury and maximize recovery. The stroke chain of survival links actions taken by patients, family, EMS and healthcare providers. Recent innovations in stroke treatment require accurate identification and appropriate triage to the appropriate treatment facility. Evidence in the literature demonstrates variability with EMS correct identification of stroke patients between 30% and 80%. Our 164 bed primary stroke center in rural Pennsylvania has been active in providing stroke education on an annual basis to emergency medical services within a two county radius. As part of our ongoing process improvement we wanted to evaluate the emergency medical technicians and paramedics knowledge of stroke signs and symptoms, their understanding of the evaluation, treatment and triage of stroke patients. A standard questionnaire with 14 variables was developed using the American Heart and Stroke Association prehospital guidelines. The questionnaire included 16 stroke and non stroke symptoms, identifying transport to primary verses comprehensive stroke centers and initial evaluation. A sample population of 90 emergency medical service staff were asked to complete the questionnaire with 28 (31%) responses received. All participants indicated they were confident to recognize stroke signs and symptoms but 6 of the non stroke items were chosen as stroke symptoms. All participants indicated they were confident in the initial evaluation of a stroke patient but 14 (50%) appropriately identified airway, breathing, circulation as the first evaluation. Evaluating triage knowledge, 26 (93%) stated confidence in decision to transport to a primary stroke center and 22 (79%) to a comprehensive stroke center, however, appropriate decision to transport to a primary stroke center was identified correctly by 46% a comprehensive stroke center 66%. In conclusion, results from this study suggest that in this rural setting, barriers exist in prehospital recognition and evaluation of the stroke patient for which proper education may be remediable. Our goal is to use this information to revise our current EMS stroke education program and enhance prehospital assessment and triage.

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Impact of COVID-19 on Emergency Medical Services for Patients with Acute Stroke Presentation in Busan, South Korea

Journal of Clinical Medicine ◽

10.3390/jcm11010094 ◽

2021 ◽

Vol 11 (1) ◽

pp. 94

Author(s):

Jiyoung Kim ◽

Choongrak Kim ◽

Song Yi Park

Keyword(s):

South Korea ◽

Acute Stroke ◽

Emergency Medical Services ◽

Processing Time ◽

Medical Services ◽

Processing Times ◽

Emergency Medical ◽

Number Of Patients ◽

Comprehensive Stroke Center ◽

The Impact

The purpose of this retrospective observational study was to identify the impact of COVID-19 on emergency medical services (EMS) processing times and transfers to the emergency department (ED) among patients with acute stroke symptoms before and during the COVID-19 pandemic in Busan, South Korea. The total number of patients using EMS for acute stroke symptoms decreased by 8.2% from 1570 in the pre-COVID-19 period to 1441 during the COVID-19 period. The median (interquartile range) EMS processing time was 29.0 (23–37) min in the pre-COVID-19 period and 33.0 (25–41) minutes in the COVID-19 period (p < 0.001). There was a significant decrease in the number of patients transferred to an ED with a comprehensive stroke center (CSC) (6.37%, p < 0.001) and an increase in the number of patients transferred to two EDs nearby (2.77%, p = 0.018; 3.22%, p < 0.001). During the COVID-19 pandemic, EMS processing time increased. The number of patients transferred to ED with CSC was significantly reduced and dispersed. COVID-19 appears to have affected the stroke chain of survival by hindering entry into EDs with stroke centers, the gateway for acute stroke patients.

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