Background: A growing number of states are enacting legislation or regulations that direct emergency medical service (EMS) routing to state designated or Joint Commission Certified Stroke Centers, based on prehospital stroke screens performed by EMS providers. Objective: Assess the sensitivity and specificity of the Cincinnati Prehospital Stroke Screen (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) when performed by EMS providers in the context of a state-wide EMS stroke patient transport protocol. Methods: We used a validated method of deterministic matching to link a statewide Prehospital Medical Information System database, that includes prehospital stroke screen results, to a Statewide Emergency Department (ED) Surveillance System database containing ED disposition diagnosis ICD-9 codes. We compared EMS stroke screen results to the ED ICD-9 codes for ischemic and hemorrhagic stroke and TIA. Results: Over a 24 month period, we identified 3,901 linked records with a prehospital impression of acute stroke. This included 2,419 (62%) records with a completed and conclusive stroke screen result. There were 1,202 patients (50%) with a completed CPSS and 1,217 patients (50%) with a completed LAPSS. Ninety-four EMS agencies from 65 of the state’s 100 counties were represented in the complete data. The CPSS was 80% (95% CI 76-83%) sensitive and 46% (95% CI 42-50%) specific, whereas the LAPSS was 73% (95% CI 69-76%) sensitive and 42% (95% CI 38-46%) specific for identifying patients with an ED diagnosis of stroke or TIA. Conclusion: When performed and conclusively recorded by many different EMS agencies across one state, the CPSS and LAPSS had similar test characteristics. If prehospital screening is to be used to determine transport diversion to acute stroke centers, improving the specificity of these screens would be optimum.
Background: Many intracranial hemorrhage (ICH) patients are emergently transferred to tertiary neurosurgical centers by helicopter emergency medical services (HEMS), yet no guidelines exist for HEMS use in acute ICH. The American Stroke Association (ASA) publishes guidelines for neurosurgical intervention in ICH patients. Additionally, high ICH scores have been shown to predict lethal ICHs. We hypothesized that an algorithm including ASA guideline criteria and ICH score would identify patients for whom HEMS transportation might be appropriate. Objectives: To determine, in ICH patients transferred by HEMS, (1) the sensitivity of ASA guidelines for predicting emergent neurosurgical intervention, and (2) the ability of an ICH score ≥4 to predict early mortality and failure to receive intervention. Methods: We conducted a retrospective chart review of ICH patients transported by HEMS to one tertiary care center between September 2008 and February 2011. We reviewed medical records and brain CTs from the hospital of first presentation to calculate ICH scores and to evaluate for the seven ASA guideline criteria: GCS score ≤8, herniation, intraventricular hemorrhage, hydrocephalus, brainstem compression, lobar clot >30 mL within 1 cm of the paranchymal surface, and cerebellar hemorrhage. We reviewed tertiary center records for neurosurgical interventions and in-hospital mortality. Results: Review of 137 patient records identified 86 patients with an ICH and an available initial brain CT. All patients who received an emergent intervention met at least one of the criteria (sensitivity 100%), while 16 (18.6%) patients transferred by HEMS met no ASA criteria. No patient with an ICH score of ≥4 (n=19) received an emergent neurosurgical intervention, and only one such patient survived to hospital discharge. Comparison of this group to all others produced a hazard ratio of 5.86. Thirty-five (40.7%) patients had either no ASA criteria or an ICH score ≥4. Conclusions: The ASA guidelines have high sensitivity for detecting those patients who will receive emergent neurosurgical intervention after transfer, while patients with ICH scores of ≥4 almost uniformly have lethal hemorrhages and do not undergo emergent intervention. An algorithm including the presence of at least one of the seven ASA ICH neurosurgical intervention criteria and an ICH score <4 can be used to screen for appropriate use of HEMS transport in acute ICH.
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