Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

Abstract

Background: It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians. Methods: We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (r s ) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference. Results: We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (r s =0.70 [95% CI, 0.68–0.72]). Concerning individual items, prehospital assessment of arm (r s =0.68) and leg (r s =0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (r s =0.31), abnormal speech (r s =0.50), and gaze deviation (r s =0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%). Conclusions: The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.

The non‐paretic‐hand‐to‐opposite‐ear test: A simple test to detect aphasia and neglect and an indicator of large anterior vessel occlusion in patients with suspected acute stroke

“…When differentiating between NPE‐right and NPE‐left, no significant difference was found between the detection of LAVO right or LAVO left. Although the sensitivity is rather low for a test performed by neurologists, it is in the upper range of results from other LAVO tests conducted by EMS (Dekker et al., 2023 ). Because the NPE test is simple to understand and easy to apply without neurological expertise, we speculate that EMS may be able to replicate neurologists’ results to a similar extent.…”

“…However, two or more tasks are typically required to test for aphasia and neglect, respectively (Lima et al., 2016 ; Pérez de la Ossa et al., 2014 ; Teleb et al., 2017 ), making the assessment complex and time‐consuming. Appropriately, it has recently been shown that aphasia and neglect—as assessed with a validated prehospital severity score by EMS—had the weakest correlations with the corresponding NIHSS items “Best Language” and “Extinction/Inattention” assessed by trained physicians in the emergency department (Dekker et al., 2023 ). To improve this unsatisfactory situation, we propose the NPE test as a simple, dichotomous, short, and easy‐to‐remember test that does not require any additional materials or a long observation period.…”

“…Prehospital detection of LAVO in patients with suspected acute stroke has an increased priority for emergency medical services (EMS), as the recent American Heart Association/American Stroke Association stroke triage algorithm for EMS recommends the use of a prehospital stroke severity tool to assess for potential LAVO in stroke (Jauch et al., 2021 ). Although routinely diagnosed by stroke physicians using the National Institutes of Health Stroke Scale (NIHSS) (National Institutes of Health, National Institute of Neurological Disorders & Stroke, 2003 ) in emergency departments and stroke units, aphasia and neglect are often overlooked in the prehospital setting in acute stroke patients (Dekker et al., 2023 ; Jia et al., 2017 ). The examination and correct identification with the NIHSS requirements are perceived by EMS personnel to be difficult and laborious (Birnbaum et al., 2021 ; Larsen et al., 2022 ; Purrucker et al., 2017 ; Wasyliw et al., 2022 ).…”