Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) – a programme of research to facilitate recognition of stroke by emergency medical dispatchers

Abstract

BackgroundRapid access to emergency stroke care can reduce death and disability by enabling immediate provision of interventions such as thrombolysis, physiological monitoring and stabilisation. One of the ways that access to services can be facilitated is through emergency medical service (EMS) dispatchers. The sensitivity of EMS dispatchers for identifying stroke is < 50%. Studies have shown that activation of the EMSs is the single most important factor in the rapid triage and treatment of acute stroke patients.ObjectivesTo facilitate recognition of stroke by emergency medical dispatchers (EMDs).DesignAn eight-phase mixed-methods study. Phase 1: a retrospective cohort study exploring stroke diagnosis. Phase 2: semi-structured interviews exploring public and EMS interactions. Phases 3 and 4: a content analysis of 999 calls exploring the interaction between the public and EMDs. Phases 5–7: development and implementation of stroke-specific online training (based on phases 1–4). Phase 8: an interrupted time series exploring the impact of the online training.SettingOne ambulance service and four hospitals.ParticipantsPatients arriving at hospital by ambulance with stroke suspected somewhere on the stroke pathway (phases 1 and 8). Patients arriving at hospital by ambulance with a final diagnosis of stroke (phase 2). Calls to the EMSs relating to phase 1 patients (phases 3 and 4). EMDs (phase 7).InterventionsStroke-specific online training package, designed to improve recognition of stroke for EMDs.Main outcome measuresPhase 1: symptoms indicative of a final and dispatch diagnosis of stroke. Phase 2: factors involved in the decision to call the EMSs when stroke is suspected. Phases 3 and 4: keywords used by the public when describing stroke and non-stroke symptoms to EMDs. Phase 8: proportion of patients with a final diagnosis of stroke correctly dispatched as stroke by EMDs.ResultsPhase 1: for patients with a final diagnosis of stroke, facial weakness and speech problems were significantly associated with an EMD code of stroke. Phase 2: four factors were identified – perceived seriousness; seeking and receiving lay or professional advice; caller’s description of symptoms and emotional response to symptoms. Phases 3 and 4: mention of ‘stroke’ or one or more Face Arm Speech Test (FAST) items is much more common in stroke compared with non-stroke calls. Consciousness level was often difficult for callers to determine and/or communicate. Phase 8: there was a significant difference (p = 0.003) in proportions correctly dispatched as stroke – before the training was implemented 58 out of 92 (63%); during implementation of training 42 out of 48 (88%); and after training implemented 47 out of 59 (80%).ConclusionsEMDs should be aware that callers are likely to describe loss of function (e.g. unable to grip) rather than symptoms (e.g. weakness) and that callers using the word ‘stroke’ or describing facial weakness, limb weakness or speech problems are likely to be calling about a stroke. Ambiguities and contradictions in dialogue about consciousness level arise during ambulance calls for suspected and confirmed stroke. The online training package improved recognition of stroke by EMDs. Recommendations for future research include testing the effectiveness of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) training package on the recognition of stroke across other EMSs in England; and exploring the impact of the early identification of stroke by call handlers on patient and process outcomes.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Identifying Key Words in 9-1-1 Calls for Stroke: A Mixed Methods Approach

“…One key barrier may be the words and phrases used by 9–1-1 callers. A prior study of emergency calls for stroke, conducted in the ethnically and linguistically homogenous region of North West England, found that only 25% of callers conveyed a concern for stroke and even fewer described focal neurologic deficits 22,23,27. Our results confirm these prior findings for a diverse, urban population in the United States.…”

“…Limiting EMD protocols to classical stroke descriptors, such as focal weakness, slurred speech, and facial droop, may not account for commonly used words and phrases used by lay callers and may hamper stroke recognition by EMDs 22,23. Our goal was to describe the words and phrases commonly used during 9–1-1 calls for acute stroke in a large United States city using both qualitative and quantitative methodologies.…”

Improving post-stroke recovery: the role of the multidisciplinary health care team

“… 39 – 42 Recognition of stroke and TIA symptoms by members of the public is often poor, and coordination of Emergency Medical Services (EMS) and ED services, although improving, remains variable. 39 – 45 Mass media campaigns, including in the UK, the Face, Arms, Speech, Time (FAST) campaign, had some effect in increasing public awareness of stroke and TIA but have largely been proven ineffective in changing the behavior. 39 , 41 – 43 In the Barriers to the Early Assessment of TIA and Stroke (BEATS) study 41 and in qualitative studies, 42 , 46 reasons given for not seeking urgent medical attention included nonrecognition of symptoms, failure to appreciate the seriousness of symptoms, and uncertainty about the appropriateness of seeking urgent help, especially when symptoms were mild or transient.…”

“…Time to specialist assessment is critical in reducing mortality and improving outcomes after stroke and TIA. In the Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT) 40 , 45 study, researchers analyzed calls (n=592) to EMS to determine the relationship between callers’ description of potential stroke symptoms to EMS dispatchers and subsequent classification and prioritization of EMS responses. Jones et al 40 reported that callers who identified the patient was having a stroke were correct in 89% of cases.…”

“…A coordinated and streamlined process that involves public education, education of EMS dispatchers, and collaboration between paramedic teams and stroke teams in EDs is essential. 40 , 42 , 44 , 45 In addition to EMS and paramedic staff, hyperacute stroke teams must include a stroke physician, a stroke specialist nurse working closely with ED staff, and an imaging team led by a radiologist/neuroradiologist. Therefore, as a minimum, an MDT approach is fundamental to assessment and management of stroke and TIA in the ED.…”