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  • 1
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    Online Resource
    Dispatcher Stroke Recognition Using a Stroke Screening Tool: A Systematic Review
    S. Karger AG ; 2016
    In:  Cerebrovascular Diseases Vol. 42, No. 5-6 ( 2016), p. 370-377
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 42, No. 5-6 ( 2016), p. 370-377
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Emergency dispatchers represent the first point of contact for patients activating an acute stroke response. Accurate dispatcher stroke recognition is associated with faster emergency medical services response time; however, stroke is often unrecognized during initial emergency calls. Stroke screening tools such as the Cincinnati Prehospital Stroke Scale have been shown to improve on-scene stroke recognition and thus have been proposed as a means to improve dispatcher accuracy. We conducted a systematic review of the accuracy of emergency dispatcher stroke recognition when employing stroke screening tools. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 We conducted a comprehensive search of Medline, EMBASE, CINAHL, and Cochrane databases to identify studies of dispatcher stroke recognition accuracy. Those that specifically reported dispatcher utilization of any validated stroke screening tools in isolation or in the context of a comprehensive screening algorithm such as the Medical Priority Dispatch System (MPDS) were potentially eligible. Studies that reported data sufficient for calculation of dispatcher sensitivity or positive predictive value (PPV) using a hospital-based stroke/transient ischemic attack diagnosis as the reference standard were included. Two independent reviewers determined study eligibility, assessed quality using the QUADAS 2 instrument, and abstracted data. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 We identified 1,413 potential studies; 54 underwent full text review. Three retrospective and 4 prospective cohort studies enrolling a total of 16,382 patients met the inclusion criteria. Stroke screening tools included MPDS (n = 4), Face Arm Speech Time (n = 2), and a novel screening algorithm developed after analysis of emergency calls for stroke (n = 1). Regardless of the screening tool employed, dispatcher stroke recognition sensitivity was suboptimal (5 studies, range 41-83%) as was the PPV (7 studies, range 42-68%). Primary study limitations included application of variable reference standards and questions regarding exclusion of subjects. No studies directly compared stroke screening algorithms and no studies specifically examined stroke recognition among potential candidates for acute stroke therapies. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Even when utilizing a stroke screening tool, the accuracy of stroke recognition by emergency dispatchers was suboptimal. More research is needed to identify the causes of poor dispatcher stroke recognition and should focus on potential candidates for time-dependent stroke treatment.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000447459
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2016
    detail.hit.zdb_id: 1482069-9
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  • 2
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    Abstract WP93: Providing Stroke Reports to Emergency Medical Services (EMS) Agencies Improves Data Quality in Michigan's Statewide EMS Data Repository
    Ovid Technologies (Wolters Kluwer Health) ; 2024
    In:  Stroke Vol. 55, No. Suppl_1 ( 2024-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 55, No. Suppl_1 ( 2024-02)
    Abstract: Intro: The Michigan Stroke Program (MiSP) monitors statewide EMS stroke care performance and data quality. Starting in 2018, quarterly performance and outcome benchmark data were shared with EMS agency partners to support prehospital quality improvement (QI) for stroke patients. Objective: To improve EMS data quality and prehospital stroke care performance. Methods: This is a retrospective before and after study of the impact of tailored QI interventions to improve EMS compliance with three prehospital stroke quality metrics selected by MiSP EMS partners: (prehospital stroke scale documentation, last known well documentation, and prehospital notification). Five MiSP EMS partners participated in the intervention which consisted of provision of quarterly performance reports generated from linked data from Michigan’s EMS Information System and the Michigan Stroke Registry. The MiSP team reviewed agency performance with EMS leadership to select the target measures for intervention and then assisted in development of a QI plan to improve agency performance. Measure compliance was compared from three months prior to and six months after data quality solutions were implemented. Results: Through data sharing and communication with EMS agencies and EMS software data vendors, common themes were identified related to poor data quality beginning in January 2020. A sample of agencies and resolutions to address these issues are displayed in the Table. Compliance with the targeted metric improved significantly at each agency at three and six months following intervention. Conclusions: Analysis of EMS data and sharing performance data directly with EMS agency partners identified correctable data quality issues negatively impacting EMS quality measures. Correcting these issues led to dramatic and sustained improvement in EMS quality metric compliance. This approach may serve as a model for improving the accuracy of EMS performance data in state-level EMS registries.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.WP93
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Abstract TP131: Computed Tomography Perfusion Imaging Patterns Are Similar Before and After Interfacility Transfer of Ischemic Stroke Patients
    Ovid Technologies (Wolters Kluwer Health) ; 2024
    In:  Stroke Vol. 55, No. Suppl_1 ( 2024-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 55, No. Suppl_1 ( 2024-02)
    Abstract: Background: Large vessel occlusion (LVO) stroke patients are often transferred from regional hospitals to comprehensive stroke centers (CSC) for thrombectomy. The need for repeat imaging at CSCs prior to intervention is unclear. We compared regional hospital and CSC perfusion imaging results for interfacility transfers in a single health system. Methods: We analyzed a cohort of patients in western Michigan who received CT perfusion imaging before and after transfer to a CSC. Perfusion mismatch (MM), core infarct volume (CIV), and favorability of imaging for mechanical thrombectomy (MT) candidacy were compared between the regional and CSC studies. A favorable imaging profile was defined as the presence of LVO, MM volume 〉 10 mL, and MM/CIV ratio of 〉 1.2. Linear regression was used to examine predictors of infarct growth during transfer. Results: Over a 10-month period, 25 patients met inclusion criteria. The median age was 76 (IQR 66-81), 60% were male, median NIHSS was 11 (IQR 2-18), and most patients had occlusion of the internal carotid or middle cerebral arteries (72%). The median time from last known well to initial CT was 250 minutes (IQR 85-620). Regional median MM volume was 52 mL (IQR 8-97), CIV was 0 mL (IQR 0-13), and hypoperfusion intensity ratio (HIR) was 0.25 (IQR 0-0.34). The median time between CTs was 152 minutes (IQR 139-226). The median change in MM volume was -3 mL (IQR -27-3) and median CIV growth rate was 0 mL/hr (IQR 0-2.0). In a multivariable regression model, higher HIR (β=23.2, p=0.012) and minutes between imaging studies (β=0.10, p=0.021) were associated with CIV growth. Sixteen patients (64%) had favorable imaging profiles for MT at the regional hospital. Of these, 15 (93.8%) continued to have a favorable CSC imaging profiles and 9 (56.2%) underwent MT. Of the 9 patients without favorable regional imaging profiles, 1 (11.1%) had a favorable CSC imaging profile and 2 (22.2%) underwent MT. Conclusion: In our sample, regional and CSC perfusion imaging patterns were similar and patients infrequently crossed thresholds for MT candidacy between studies. Initial HIR and longer delays between were independently associated with infarct growth during transfers, however overall infarct growth was very small.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.TP131
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
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  • 4
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    Abstract NS4: Impact Of System-wide Implementation Of Tenecteplase For Ischemic Stroke Thrombolysis On Quality Metrics And Outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. Suppl_1 ( 2023-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. Suppl_1 ( 2023-02)
    Abstract: Background and Purpose: Tenecteplase (TNK) has recently been demonstrated to be an effective thrombolytic agent in patients with acute ischemic stroke. Our 9-hospital stroke network transitioned to tenecteplase as the standard stroke thrombolytic in April 2022. We assessed the impact of TNK use in routine clinical practice on quality metrics and outcomes. Methods: System Stroke Committee (Vascular Neurology, Emergency Medicine, Pharmacy, Nursing) evaluated the scientific evidence, performed a cost analysis and decided to implement TNK system wide. Proposal was submitted to Pharmacy and Therapeutics (P & T) committee. Education plan for providers, nursing and pharmacy was developed and training provided. A before and after analysis was conducted to compare consecutive patients who received thrombolysis for acute ischemic stroke between Jan 2022 to July 2022 before and after the transition to tenecteplase. Quality metrics of National Institute of Health Stroke Scale (NIHSS) on presentation, door to thrombolysis; door in door out of the regional facility; safety outcome of any hemorrhagic transformation and functional outcome of NIHSS at discharge are compared between patients who received TNK versus tPA. Results: A total of 121 ischemic stroke patients treated with thrombolysis were included: 62 patients received TNK and 59 patients received tPA. NIHSS on presentation was similar between the groups (TNK 8 IQR [2-10] vs. tPA 7 IQR [3-11] p=0.73). Door to thrombolysis was similar (TNK 60.3±40.9 min vs. 60.1±44 min; p=0.98) as was door-in-door out time (TNK 186±68.4 min vs. tPA 145±70 min p=0.09) between the groups. Intracerebral hemorrhage rates were not different (TNK 8% vs. tPA 6% p=0.78). Discharge NIHSS was similar between the groups (TNK 1 IQR [0-5] vs. tPA 1 IQR [0-4] ; p=0.85). Conclusion: Tenecteplase implementation as stroke thrombolytic of choice in a large stroke network did not impact performance on quality metrics, safety and outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.54.suppl_1.NS4
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 1467823-8
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  • 5
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    Abstract TP324: Early Termination of Acute Stroke Randomized Controlled Trials Published Between 2013 and 2018: A Systematic Review
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Introduction: A priori sample size determination is an essential step in designing randomized controlled trials (RCTs). Failure to reach pre-planned sample size introduces risk of both falsely negative and spuriously positive findings. We undertook a systematic review of contemporary acute stroke trials to document the prevalence and reasons for termination of trials prior to completion of enrollment. Methods: We searched MEDLINE for RCTs of acute stroke therapy published between 2013 and 2018 in 9 major journals. Manuscripts describing the final primary results of phase 3 and large phase 2 trials of any therapeutic intervention were eligible for inclusion. Study characteristics, including the presence of a data monitoring committee (DMC) and stopping rules, risk-of-bias assessment, funding sources and conflicts of interest, were abstracted from published manuscripts and trial protocols by two independent reviewers. The prevalence of and reasons for early termination were quantified. Multivariable logistic regression was used to identify study-level predictors of early termination. Results: Of 756 hits, 60 were eligible for inclusion, 21 (35%) of which were terminated early. Among the trials stopped early, 10 (48%) reported stopping for benefit or newly available evidence while 11 (52%) were terminated for futility; 20 (95%) reported a DMC and 17 (81%) reported the use of a pre-specified statistical stopping rule. Factors associated with early termination included study location in North America, larger planned sample size, and industry funding (Table). Study location in North America and larger planned sample size retained statistical significance in a multivariable model. Conclusions: One in three contemporary stroke trials were terminated prior to completion of enrollment. Reasons for termination were evenly split between benefit and futility. Further study is needed to understand the reasons for and impact of early termination on study results.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.TP324
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 6
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    Abstract TP278: Paramedic Ischemic Stroke Recognition Predicts Favorable Outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Background: Emergency Medical Services (EMS) transport facilitates rapid ischemic stroke treatment. We hypothesized that EMS stroke recognition is critical to delivery of optimal stroke care and favorably impacts downstream outcomes. Methods: We identified consecutive EMS-transported ischemic stroke (IS) and transient ischemic attack (TIA) patients at 4 primary stroke center hospitals over a 2-year period. Cases were categorized as EMS recognized or unrecognized based on documented EMS impression. Compliance with EMS performance measures (stroke screen use, onset time documentation, prenotification), hospital-based measures (door-to-CT [DTCT] times, t-PA delivery), and hospital discharge disposition were compared among EMS recognized and unrecognized cases. Logistic regression was used to adjust for confounders such as age, gender, stroke severity, and clustering by agency or hospital. Results: EMS transported 1,056 IS/TIA patients during the study period; 719 (68%) were recognized and 337 (32%) unrecognized. EMS recognized cases were more likely to receive recommended prehospital care, early CT, and t-PA (Table). EMS recognized cases also had higher odds of being discharged home and lower odds of death in adjusted analysis. Conclusion: EMS recognition of IS/TIA was associated with prehospital quality measure compliance, faster ED evaluations, t-PA delivery, and superior outcomes. Quality improvement efforts should focus on improving EMS stroke recognition.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.TP278
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Abstract TP233: Clinical Predictors of Endovascular Stroke Treatment Among Emergency Department Patients Screened With Multimodal Computed Tomography
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Background: Endovascular therapy (EVT) offers dramatic benefit to selected patients with large vessel occlusion (LVO) ischemic stroke. However, identification of EVT candidates requires advanced imaging and often interfacility transfer. We sought to quantify the yield of such testing as well as identify clinical predictors of EVT candidacy. Methods: This retrospective cohort study identified consecutive Emergency Department (ED) patients with stroke symptoms who underwent CT angiogram and brain perfusion (CTA/P) imaging to assess for EVT candidacy. Demographics, medical history, clinical characteristics, final diagnosis, and outcomes were abstracted. We compared clinical characteristics among those who did and did not undergo EVT. Multivariable logistic regression was used to identify independent clinical predictors of EVT and derive a clinical prediction rule to quantify the probability of EVT. Results: Over a 12-month period, 835 patients underwent CTA/P imaging in the ED. EVT was undertaken for 116 (13.9%) patients; 321 (38.4%) ultimately received a non-stroke diagnosis. Patients who received EVT were older and had higher stroke scores (Table). Patients with an unknown last known well (LKW) time were less likely to receive EVT, however increasing time form LKW to door did not predict EVT (test for trend p=0.976). Multivariable analysis results are presented in the Table. A clinical decision rule based on the regression coefficients demonstrated moderately high discrimination for predicting EVT with an AUC of 0.79 (0.74 to 0.83). Among 102 patients transferred for CTA/P, 24 (24%) had and a score 〈 1, none of whom received EVT. Conclusions: EVT Candidates are common among ED patients screened with CTA/P. Clinical factors can predict the likelihood of EVT candidacy. If validated in other populations, a simple clinical prediction rule may assist in triaging patients in need of urgent transfer to a thrombectomy-capable facility.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.TP233
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 1467823-8
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  • 8
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    The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke
    Wiley ; 2019
    In:  Academic Emergency Medicine Vol. 26, No. 7 ( 2019-07), p. 744-751
    Details
    In: Academic Emergency Medicine, Wiley, Vol. 26, No. 7 ( 2019-07), p. 744-751
    Abstract: The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department ( ED ) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large‐vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high‐performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.
    Type of Medium: Online Resource
    ISSN: 1069-6563 , 1553-2712
    URL: Issue
    URL: Article
    DOI: 10.1111/acem.2019.26.issue-7
    DOI: 10.1111/acem.13698
    Language: English
    Publisher: Wiley
    Publication Date: 2019
    detail.hit.zdb_id: 2029751-8
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  • 9
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    A survey of stroke‐related capabilities among a sample of US community emergency departments
    Wiley ; 2022
    In:  Journal of the American College of Emergency Physicians Open Vol. 3, No. 4 ( 2022-08)
    Details
    In: Journal of the American College of Emergency Physicians Open, Wiley, Vol. 3, No. 4 ( 2022-08)
    Abstract: Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non‐academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital‐level stroke‐related capabilities among a sample of community EDs participating in the Emergency Quality Network (E‐QUAL) stroke collaborative. Methods Among E‐QUAL‐participating EDs, we conducted a survey to collect data on ED and hospital stroke‐related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web‐based submission portal. We present descriptive statistics of self‐reported capabilities. Results Of 154 participating EDs in 30 states, 97 (63%) completed the survey. Many were rural (33%); most (82%) were not certified stroke centers. Although most reported having stroke protocols (67%), many did not include hemorrhagic stroke or transient ischemic attack (45% and 57%, respectively). Capability to perform emergent head computed tomography and to administer thrombolysis were not universal (absent in 4% and 5%, respectively). Access to neurologic consultants varied; 18% reported no 24/7 availability onsite or remotely. Of those with access, 48% reported access through telemedicine only. Admission capabilities also varied with patient transfer commonly performed (79%). Conclusion Stroke‐related capabilities vary substantially between community EDs and are different from capabilities typically found in larger stroke centers. These data may be valuable for identifying areas for future investment. Additionally, the design of stroke quality improvement interventions and metrics to evaluate emergency stroke care delivery should account for these key structural differences.
    Type of Medium: Online Resource
    ISSN: 2688-1152 , 2688-1152
    URL: Issue
    URL: Article
    DOI: 10.1002/emp2.v3.4
    DOI: 10.1002/emp2.12762
    Language: English
    Publisher: Wiley
    Publication Date: 2022
    detail.hit.zdb_id: 3005425-4
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  • 10
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    Online Resource
    Abstract T P313: Sensitivity of ICD-9 Discharge Codes to Identify TIA Cases in 4 Community-Based Emergency Departments
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. suppl_1 ( 2014-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. suppl_1 ( 2014-02)
    Abstract: Introduction: The diagnosis of TIA is often challenging in the emergency department (ED) setting. ICD-9 discharge code 435 is often used to identify TIA cases; however, its accuracy is unclear. Our objective was to determine the sensitivity of ICD-9 code 435 to identify confirmed TIA cases treated in 4 community-based EDs. Methods: Over a 12 month period suspect TIA cases were prospectively identified using hot-pursuit mechanisms in 4 EDs. A time-based definition of TIA was used (i.e., acute onset focal unilateral symptoms with duration 〈 24 hours and no alternative diagnosis). All cases had a final clinical diagnosis of TIA confirmed following an independent physician panel review. Data were abstracted from medical charts and the primary ICD-9 discharge code was obtained from the hospital or ED billing records. ICD-9 discharge codes were neither used to identify cases or confirm the final diagnosis. Results: Of 366 subjects with suspected TIA, 336 (92%) had a confirmed final diagnosis of TIA. Mean age was 66 years, 54% female, 31% non-white and 83% were hospitalized. The relative frequency of primary ICD-9 discharge codes at each of the 4 EDs are shown in the Table. The overall sensitivity of the 435 code was 64.3% (95% CI 58.9-69.4). Alternative codes used included stroke-related (8.0%), other CVD-related (2.7%), miscellaneous (8.3%) and non-specific symptoms codes (16.7%). The frequency of 435 coding varied non-significantly between sites (56% to 72%; p= 0.13); however, sites varied substantially in their use of non-specific symptoms codes (4.8% to 26.7%; p=0.002). Conclusions: In this series of confirmed TIA cases, more than 1/3 rd would not have been identified if the 435 code was used. These findings suggest that the 435 code should not be relied upon to identify TIA cases. Future studies should determine the causes of the variation in coding between sites, and also measure both sensitivity and specificity of the 435 code.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.45.suppl_1.tp313
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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