ABSTRACT
OBJECTIVES: The current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers. PATIENTS AND METHODS: The prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers. RESULTS: In Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage. CONCLUSIONS: FPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.
Subject(s)
Brain Ischemia , Emergency Medical Services , Stroke , Humans , Finland , Brain Ischemia/therapy , Prospective Studies , Stroke/diagnosis , Stroke/therapy , Stroke/etiology , Triage , Predictive Value of TestsABSTRACT
BACKGROUND: Prehospital stroke triage is challenged by endovascular treatment for large vessel occlusion (LVO) being available only in major stroke centers. Conjugate eye deviation (CED) is closely related to LVO, whereas common stroke signs (face-arm-leg-speech-visual) screen stroke. We hypothesized that combining CED with common stroke signs would yield a prehospital stroke scale for identifying both LVO and stroke in general. METHODS AND RESULTS: We retrospectively analyzed consecutive patients (n = 856) with prehospital Code Stroke (recanalization candidate). The National Institutes of Health Stroke Scale (NIHSS) and computed tomography were administered to patients on arrival. Computed tomography angiography was performed on patients with NIHSS score of 8 or greater and considered to benefit from endovascular treatment. With random forest analysis and deviance analysis of the general linear model we confirmed the superiority of the NIHSS "Best Gaze" over other NIHSS items in detecting LVO. Based on this and commonly used stroke signs we presented the Finnish Prehospital Stroke Scale (FPSS) including dichotomized face drooping, extremity weakness, speech difficulty, visual disturbance, and CED. FPSS detected LVO with a sensitivity of 54%, specificity of 91%, positive predictive value of 48%, negative predictive value of 93%, and likelihood ratio of 6.2. CONCLUSIONS: Based on CED and universally used stroke signs, FPSS recognizes stroke in general and additionally, LVO as a stroke subtype comparably to other scales intended to detect LVO only. As the FPSS items are dichotomized, it is likely to be easy for emergency medical services to implement.
Subject(s)
Brain Ischemia/diagnosis , Decision Support Techniques , Emergency Medical Services , Stroke/diagnosis , Thrombectomy , Thrombolytic Therapy , Aged , Aged, 80 and over , Brain Ischemia/physiopathology , Brain Ischemia/psychology , Brain Ischemia/therapy , Clinical Decision-Making , Computed Tomography Angiography , Disability Evaluation , Facial Paralysis/diagnosis , Facial Paralysis/physiopathology , Female , Finland , Fixation, Ocular , Humans , Likelihood Functions , Linear Models , Male , Middle Aged , Motor Activity , Muscle Weakness/diagnosis , Muscle Weakness/physiopathology , Odds Ratio , Patient Selection , Predictive Value of Tests , Propensity Score , Retrospective Studies , Risk Assessment , Risk Factors , Speech , Speech Disorders/diagnosis , Speech Disorders/physiopathology , Stroke/physiopathology , Stroke/psychology , Stroke/therapy , Triage , Vision, OcularABSTRACT
BACKGROUND: Traditionally, neurologists have been in charge of thrombolytic treatment of ischemic stroke. In 2013, emergency medicine residents started working in the frontline at the Central Hospital of Central Finland (CHCF). They were trained to evaluate and give thrombolytic treatment to acute ischemic stroke patients out of hours, with the possibility of consulting a neurologist. MATHERIALS AND METHODS: Retrospective study of acute stroke patients in CHCF, who received thrombolytic therapy during 2012 and 2014. In 2012 thrombolytic treatment was initiated by neurologists only, In 2014 emergency medicine registrars initiated thrombolytic therapy out of hours. RESULTS: The annual number of tissue plasminogen activator treatment (tPA) increased and door-to needle time significantly decreased from 2012 to 2014. There were no significant differences in complications and overall functional capacity at 3 months. CONCLUSIONS: This study indicated that training of emergency medicine physicians to give thrombolytic treatment to acute ischemic stroke is feasible and may shorten in-hospital delays.
Subject(s)
Brain Ischemia/drug therapy , Emergency Medicine/education , Internship and Residency , Stroke/drug therapy , Thrombolytic Therapy/methods , Tissue Plasminogen Activator/administration & dosage , After-Hours Care , Education, Medical, Graduate , Female , Finland , Humans , Length of Stay/statistics & numerical data , Male , Referral and Consultation , Retrospective Studies , Time-to-TreatmentABSTRACT
Emergency department is a showroom of its organization and an entry point to the hospital. The negative impact of sluggish processes and overcrowding in the ED is well acknowledged. Several tools can be used to improve patient flow in the ED. The specialty of emergency medicine is a crucial element which enables the establishment of stable, well-educated staff in the ED.
