Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment

Abstract

BACKGROUND: Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care. METHODS: This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan’s EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes. RESULTS: Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2–1.6]), glucose check (1.3 [1.1–1.6]), on-scene time ≤15 minutes (1.6 [1.4–1.9]), hospital prenotification ([2.0 [1.4–2.9]), and intravenous line placement (1.8 [1.5–2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (−9.2 [−10.6 to −7.8] minutes; P <0.001) and thrombolysis (−4.3 [−6.4 to −2.2] minutes; P <0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0–1.2]; P =0.002). CONCLUSIONS: Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.

VALIDATE—Utilization of the Viz.ai mobile stroke care coordination platform to limit delays in LVO stroke diagnosis and endovascular treatment

“…Our results did show that while the median duration of EMS prenotification prior to arrival for AI vs. non-AI was not significantly different, a significant 4.65% (p < 0.001) higher percentage of AI patients arrived by EMS and of all EMS patients a 7.01% (p < 0.001) higher percentage of AI cases experienced prehospital alert. The presence of EMS prehospital alert has been reported by multiple investigators to be associated with faster times for door-to-CT, door-to-needle, and door-to-mechanical thrombectomy along with improved patient outcome (Patel et al, 2011;Lin et al, 2012;Hsieh et al, 2016;Sheng et al, 2018;Fujiwara et al, 2022;Oostema et al, 2023). Therefore, we cannot exclude these imbalances in EMS metrics having some effect on our overall faster Arrival-to-NIR time for AI vs. non-AI.…”

Numerical Cincinnati Stroke Scale versus Stroke Severity Screening Tools for the Prehospital Determination of LVO

“…However, BE-FAST lacks a designated LVO indication threshold. C-STAT evaluates conjugate gaze (0-2), consciousness level (0-1), and arm weakness (0-1), with scores of 2 or higher suggesting LVO and recommending transport to an endovascular center (13). FAST-ED assesses facial palsy, arm weakness, speech changes, eye deviation, and denial/neglect on a scale from 0-9, with a score of 4 or higher indicating LVO and directing patients to specialized centers (14).…”

“…Early prehospital identification of stroke, coupled with transport to a hospital with appropriate therapeutic capabilities, is a pillar of optimal stroke care (1). For patients experiencing a severe form of stroke known as large vessel occlusion (LVO), endovascular treatment has been shown to reduce morbidity and mortality; yet this treatment is available only at specialized centers (2-5).…”

Not a Minute to Spare: Balancing Accuracy and Efficiency in Prehospital Stroke Management

“…Oostema and colleagues evaluated patients with confirmed strokes who had improved outcomes due to early consideration of stroke by a prehospital provider. 7 But, EMS providers also play a role in preventing emergency departments from launching an emergent workup on every patient with a neurological complaint. There is limited data on the decision-making or barriers that go into not obtaining the individual items noted as quality metrics on certain patients, and not activating.…”