Feasibility study to assess the use of the Cincinnati stroke scale by emergency medical dispatchers: a pilot study
ABSTRACT The emergency medical dispatcher (EMD) receiving a call via 911 is the first point of contact within the acute care system and plays an important role in early stroke recognition. Published studies show that the diagnostic accuracy of stroke of EMD needs to be improved. Therefore, the National Association of Emergency Medical Dispatchers implemented a stroke diagnostic tool modelled after the Cincinnati stroke scale across 3000 cities worldwide. This is the first time a diagnostic tool that requires callers to test physical findings and report those back to the EMD has been implemented. However, the ability of EMD and 911 callers to use this in real time has not been reported. The goal of this pilot study was to determine the feasibility of an EMD applying the Cincinnati stroke scale tool during a 911 call, and to report the time required to administer the tool.
- SourceAvailable from: Guido Francesco Villa[Show abstract] [Hide abstract]
ABSTRACT: Timely and appropriate hospital treatment of acute cerebrovascular diseases (stroke and Transient Ischemic Attacks - TIA) improves patient outcomes. Emergency Medical Service (EMS) dispatchers who can identify cerebrovascular disease symptoms during telephone requests for emergency service also contribute to these improved outcomes. The Italian Ministry of Health issued guidelines on the management of AC patients in pre-hospital emergency service, including Cincinnati Prehospital Stroke Scale (CPSS) use.We measured the sensitivity and Positive Predictive Value (PPV) of EMS dispatchers' ability to recognize stroke/TIA symptoms and evaluated whether the CPSS improves accuracy. A cross-sectional multicentre study was conducted to collect data from 38 Italian emergency operative centres on all cases identified with stroke/TIA symptoms at the time of dispatch and all cases with stroke/TIA symptoms identified on the scene by the ambulance personnel from November 2010 to May 2011. The study included 21760 cases: 18231 with stroke/TIA symptoms at dispatch and 9791 with symptoms confirmed on the scene. The PPV of the dispatch stroke/TIA symptoms identification was 34.3% (95% CI 33.7-35.0; 6262/18231) and the sensitivity was 64.0% (95% CI 63.0-64.9; 6262/9791). Centres using CPSS more often (>10% of cases) had both higher PPV (56%; CI 95% 57--60 vs 18%; CI 95% 17--19) and higher sensitivity (71%; CI 95% 87--89 vs 52%; CI 95% 51--54).In the multivariate regression a centre's CPSS use was associated with PPV (beta 0.48 p = 0.014) and negatively associated with sensitivity (beta -0.36; p = 0.063); centre sensitivity was associated with CPSS (beta 0.32; p = 0.002), adjusting for PPV. Centres that use CPSS more frequently during phone dispatch showed greater agreement with on-the-scene prehospital assessments, both in correctly identifying more cases with stroke/TIA symptoms and in giving fewer false positives for non-stroke/TIA cases. Our study shows an extreme variability in the performance among OCs, highlighting that form many centres there is room for improvement in both sensitivity and positive predictive value of the dispatch. Our results should be used for benchmarking proposals in the effort to identify best practices across the country.BMC Health Services Research 12/2013; 13(1):513. DOI:10.1186/1472-6963-13-513 · 1.66 Impact Factor
Conference Paper: Prehospital Factors Associated with Stroke Misdiagnosis by EMS Providers[Show abstract] [Hide abstract]
ABSTRACT: Objective: To identify prehospital patient characteristics which are associated with misdiagnosis of stroke.Background: Prehospital identification of stroke with hospital prenotification results in shorter door to needle times and increased thrombolysis rates. Provider accuracy for stroke identification varies.Methods: Clinical data were extracted from electronic prehospital care reports of all patients brought to Long Island College Hospital (LICH) by LICH Emergency Medical Services (EMS) from January 1, 2010 - December 31, 2011. LICH is a New York State Designated Stroke Center and teaching hospital of SUNY Downstate Medical Center. Accuracy of prehospital providers’ diagnosis of stroke was determined by comparing provider impressions with gold standard - Get With The Guidelines (GWTG) Stroke database.Results: Of 10,384 EMS transports (50% males, mean age 49.3 ± 19.4 years), 75 were GWTG-confirmed strokes of which 44 (59%) were correctly identified by EMS. Fifty-one patients were misdiagnosed as stroke. LICH EMS providers had a sensitivity of 59% 95% confidence interval (CI) 47-69, specificity of 99.5% (95%CI 99.4-99.6) with positive and negative likelihood ratios of 119 (95% CI 85-165) and 0.41 (95% CI 0.32-0.54), respectively. Overall, the risk of having a stroke increased 83% with higher prehospital systolic blood pressure quartiles (p=0.04). Of all patients deemed non-strokes by EMS, patients with a dispatch call type of stroke age adjusted odds ratio (AAOR) 9.8 (95% CI 2.2-43.7), p=0.003, history of diabetes AAOR 2.2 (95% CI 1.1-4.6), p=0.026 or stroke AAOR 4.1 (95% CI 1.7-9.83), p=0.002 and those documented as unconscious AAOR 4.4 (95% CI 1.3-15), p=0.017 were more likely to have had an actual stroke.Conclusions: LICH EMS providers missed 41% of strokes and our findings suggest that greater clinical suspicion for stroke should be exercised in patients who have a higher prehospital systolic blood pressure, who have a dispatch call of stroke, past medical history of diabetes or stroke and in those who are unconscious.Study support: NIH grants 1U01NS044364, R01 HL096944, 1U10NS077378 and 1U10NS080377.American Academy of Neurology, 2014, http://www.neurology.org/content/82/10_Supplement/S35.006; 04/2014
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ABSTRACT: Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 07/2015; DOI:10.1016/j.jstrokecerebrovasdis.2015.06.004 · 1.99 Impact Factor