Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

Sheppard, James P; Lindenmeyer, Antje; Mellor, Ruth M; Greenfield, Sheila; Mant, Jonathan; Quinn, Tom; Rosser, Andy; Sandler, David; Sims, Don; Ward, Matthew; McManus, Richard J

doi:10.1136/emermed-2014-204392

Cited by 10 publications

(18 citation statements)

References 23 publications

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“…Substantial evidence suggests that EMS use is associated with faster ED stroke evaluations 2,4 and increased opportunity for treatment with tPA. 3 Our results identified opportunity to improve EMS provider recognition by reducing the rate of missed strokes and false positives through more consistent application of the CPSS.…”

Section: Discussionmentioning

confidence: 99%

“…A mong patients with acute ischemic stroke (IS), transport by emergency medical services (EMS) has been associated with earlier arrival, 1 faster emergency department (ED) evaluations, [2][3][4] and improved rates and speed of tissue-type plasminogen activator (tPA) delivery. 3 These benefits stem, at least in part, from prearrival activation of stroke teams as a result of hospital prenotification by EMS.…”

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confidence: 99%

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Clinical Predictors of Accurate Prehospital Stroke Recognition

Oostema

Konen

Chassee

et al. 2015

Stroke

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Background and Purpose-Prehospital activation of in-hospital stroke response hastens treatment but depends on accurate emergency medical services (EMS) stroke recognition. We sought to measure EMS stroke recognition accuracy and identify clinical factors associated with correct stroke identification. Methods-Using EMS and hospital records, we assembled a cohort of EMS-transported suspect, confirmed, or missed ischemic stroke or transient ischemic attack cases. The sensitivity and positive predictive value (PPV) for EMS stroke recognition were calculated using the hospital discharge diagnosis as the gold standard. We used multivariable logistic regression analysis to determine the association between Cincinnati Prehospital Stroke Scale use and EMS stroke recognition. Results-During a 12-month period, 441 EMS-transported patients were enrolled; of which, 371 (84.1%) were EMSsuspected strokes and 70 (15.9%) were EMS-missed strokes. Overall, 264 cases (59.9%) were confirmed as either ischemic stroke (n=186) or transient ischemic attack (n=78). The sensitivity of EMS stroke recognition was 73.5% (95% confidence interval, 67.7-78.7), and PPV was 52.3% (95% confidence interval, 47.1-57.5). Sensitivity (84.7% versus 30.9%; P<0.0001) and PPV (56.2% versus 30.4%; P=0.0004) were higher among cases with Cincinnati Prehospital Stroke Scale documentation. In multivariate analysis, Cincinnati Prehospital Stroke Scale documentation was independently associated with EMS sensitivity (odds ratio, 12.0; 95% confidence interval, 5.7-25.5) and PPV (odds ratio, 2.5; 95% confidence interval, 1.3-4.7). Conclusions-EMS providers recognized 3 quarters of the patients with ischemic stroke and transient ischemic attack;however, half of EMS-suspected strokes were false positives. Documentation of a Cincinnati Prehospital Stroke Scale was associated with higher EMS stroke recognition sensitivity and PPV.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Clinical Predictors of Accurate Prehospital Stroke Recognition

Oostema

Konen

Chassee

et al. 2015

Stroke

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“…Sheppard et al identified a lower proportion of patients were not pre-alerted for stroke who should have been than those who were pre-alerted who shouldn't have been. (17) Pre-alerts were shown to take up staff time and generate interruptions to caring for patients already in the department. Although we did not quantify time 'wasted', unnecessary interruptions and inappropriate pre-alerts were a source of frustration to ED staff.…”

Section: [Ed30_consultant]mentioning

confidence: 99%

How do Emergency Departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alert in six UK Emergency Departments

Long,

Sampson,

Coster

et al. 2023

Preprint

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BackgroundWhilst pre-alerts have been shown to improve outcomes for some patients requiring immediate time-critical treatment (e.g. stroke), little is known about their usefulness for other patients and what processes are used by Emergency Department (EDs) to respond to them. In the current context of high demand, it is important to understand how pre-alerts affect EDs.MethodsWe undertook non-participation observation (162 hours, 143 pre-alerts) and semi-structured interviews (40 staff) within six UK Emergency Departments (EDs), between August 2022-April 2023. Interview transcripts and observation notes were imported into NVivo™ and analysed using a thematic approach.ResultsPre-alert calls involved significant time and resources for ED staff but enabled staff to prepare for patient’s arrival both practically and psychologically, particularly when demand was high. High demand created additional pre-alerts due to advice or ‘heads up’ calls from ambulance clinicians concerned about handover delay. Despite some pre-alert fatigue regarding patients who did not always require a special response (e.g. sepsis), ED clinicians prioritised and valued pre-alerts, perceiving higher risks from under-alerting than over-alerting. Variation in ED processes for a) senior clinical review of pre-alerted patients not brought into resus and b) receiving, documenting and informing others of pre-alerts resulted in inconsistent response to ambulance clinicians. ED response (where the patient should be taken) largely reflected resources available (beds, staffing, acuity of other patients) rather than appropriateness of the pre-alert.ImplicationsIn the context of high demand, much variation in response to pre-alerts is outside ED staff’s control. There is potential for EDs to increase consistency in reviewing how pre-alert calls are answered, what information is documented and how this is communicated to others, including when they are not accepted into resus. Improved communication between ambulance and ED services may help avoid tension caused by different perceptions or understandings of pre-alerts.What is known on this topic?Ambulance pre-alerts can help Emergency Department staff to prepare for a patient’s arrival and can lead to improved outcomes for patients requiring immediate senior review upon arrival.Research about pre-alert practice focuses on outcomes for patients who have been pre-alerted but there is a lack of evidence about the effect of pre-alerts on ED staff and ED patient management.What this study addsVariation in ED processes, layout and capacity led to different ED responses to pre-alert calls, particularly for patients who were not brought into resus.ED response is primarily dependent upon resources available at the time of the call and assessment of the need for active treatment. Pre-alerted patients who may be suitable for a resus bay may be seen in another area of the ED when the ED is crowded or has higher priority patientsPre-alerts used ED resources but were valued in terms of enabling both practical and psychological preparedness.How this study might affect research, practice or policyStandardisation of processes for improving flow and assessing high risk patients may help reduce variation in ED management and provide more consistent support for ambulance cliniciansUnderstanding that EDs may not be able to provide an expected or consistent response to pre-alert calls is important for ambulance clinicians assessing their own pre-alert practice.

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“…For example, studies have reported that an estimated 13%-28% of patients eligible for pre-alert had not received one and 42%-56% of pre-alerted patients did not meet the established criteria. 3 4 7 Even where there are clear guidelines for pre-alert (e.g. stroke, trauma) 8 , pre-alerts are only used in a proportion of cases.…”

Section: Introductionmentioning

confidence: 99%

“…9 Similarly, Sheppard et al identified disparities in how ambulance clinicians and receiving ED staff interpreted protocols and the need to pre-alert for suspected stroke, leading to frustration for ambulance and ED staff. 7…”

Section: Introductionmentioning

confidence: 99%

What influences ambulance clinician decisions to pre-alert Emergency Departments: a qualitative exploration of decision-making in three UK Ambulance Services

O’Hara,

Sampson,

Long

et al. 2023

Preprint

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BackgroundAmbulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving Emergency Department or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel ‘pre-alert fatigue’ amongst ED staff. This research aims to provide a better understanding of pre-alert decision-making practice.MethodsSemi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis.FindingsPre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement, and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care upon arrival or were at highest risk of deterioration. Ambulance clinicians primarily learned to pre-alert ‘on the job’ and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians.ConclusionWe identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback, and cross-service collaboration to minimise potential sources of tension.

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Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

Cited by 10 publications

References 23 publications

Clinical Predictors of Accurate Prehospital Stroke Recognition

Clinical Predictors of Accurate Prehospital Stroke Recognition

How do Emergency Departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alert in six UK Emergency Departments

What influences ambulance clinician decisions to pre-alert Emergency Departments: a qualitative exploration of decision-making in three UK Ambulance Services

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