Professional Documents
Culture Documents
Received January 13, 2015; final revision received March 6, 2015; accepted March 27, 2015.
From the Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI (J.A.O.), Department of Emergency Medicine, Michigan State
University College of Human Medicine, Grand Rapids (J.A.O., J.K., T.C.); Kent County Emergency Medical Services, MI (T.C.); and Department of
Epidemiology, Michigan State University, East Lansing (M.N., M.J.R.).
Presented in part at the International Stroke Conference, Nashville, TN, February 1113, 2015.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
115.008650/-/DC1.
Reprint requests to J. Adam Oostema, MD, Department of Emergency Medicine, Michigan State University College of Human Medicine, Secchia
Center, Room 425, 15 Michigan, NE, Grand Rapids, MI 49503. E-mail oostema@msu.edu
2015 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.008650
2StrokeJune 2015
measure the prevalence of CPSS in this cohort, analyze the
relationship between CPSS use and EMS diagnostic accuracy,
and describe errors in prehospital stroke recognition.
Methods
194
177
EMS
Suspected
70
78 (6386)
<60
87 (19.5)
6069
68 (15.2)
7079
85 (19.0)
8089
125 (28.0)
Results
During a 1-year period, 371 cases were transported by EMS as
suspected stroke or TIA, whereas another 70 stroke cases were
transported by EMS for other reasons and so were designated
as missed cases. Characteristics of all 441 cases are summarized in Table1. The median age was 78 years, and 59%
were women. A total of 264 cases (59.9%) were confirmed as
76 (17.0)
Sex, female
263 (58.8)
Dispatcher-suspected stroke
318 (72.1)
EMS-suspected IS/TIA
371 (84.1)
70 (15.9)
Effects
Confirmed TIA
78 (17.7)
Confirmed IS
186 (42.2)
Sensitivity
PPV
n=441 (%)
EMS-missed IS/TIA
371
264
>90
Not
Ischemic Stroke/TIA
EMS Missed
The methods used to establish the registry have been published previously.16 Briefly, this observational registry was conducted in a single
county in Southwest Michigan, which is served by 3 independent advanced life support transporting EMS agencies that collectively provide >50000 transports per year. Patients who were transported by
EMS with an impression of suspected stroke or who were diagnosed
with IS or TIA after hospital arrival were included, thus capturing
EMS-suspected (false positive), confirmed (true positive), and missed
(false negative) stroke transports. Patients who were transported by
EMS to either of 2 participating primary stroke center hospitals with
a primary or secondary impression of suspected stroke/TIA were
identified from electronic EMS records. We captured EMS-missed
strokes by searching hospital records for patients with a final hospital
discharge diagnosis of stroke or TIA who were transported by EMS.
Hemorrhagic strokes were excluded. All EMS and hospital medical
records were then manually linked. We abstracted data on patient demographics, prehospital care, ED diagnostic testing and treatment,
in-hospital mortality, discharge disposition, and discharge diagnosis.
Because the local stroke transport protocol directs EMS providers to
conduct a CPSS, we recorded the explicit documentation of the CPSS
in the EMS record. This study was approved by the Spectrum Health
Institutional Review Board.
The final diagnosis for all cases was based on the final hospital
discharge diagnosis. Two authors (J.A.O. and T.C.) independently
validated the final hospital discharge diagnoses based on review of
medical records. Inter-rater agreement for a stroke/TIA diagnosis was
high (=0.89). The sensitivity and positive predictive value (PPV) of
EMS stroke recognition were calculated using a final hospital discharge diagnosis as the gold standard. Because of the fact that the
number of true negatives could not be ascertained from our design,
specificity and negative predictive value could not be calculated.
To characterize the role of the CPSS in EMS stroke recognition, we
compared the accuracy of EMS stroke recognition between cohorts
of patients with and without a documented CPSS. The differences in
Characteristics
Ischemic Stroke/TIA
OR (95% CI)
12.02 (5.6625.51)
Age, y
1.00 (0.971.02)
90 (48.4)
0.82 (0.411.65)
7 (317)
1.09 (1.041.15)
tPA
23 (12.4)
2.22 (1.124.39)
Endovascular therapy
10 (5.4)
1.94 (0.914.12)
EMS Recognized,
n=141
EMS Missed,
n=45
P Value
79 (64.588)
82 (64.588)
0.936
107 (57.5)
79 (56.0)
28 (62.2)
0.464
White
163 (87.6)
123 (87.2)
40 (88.9)
0.769
Black
15 (8.1)
11 (7.8)
4 (8.9)
0.816
Hispanic
3 (1.6)
3 (2.1)
0.324
Asian
2 (1.1)
2 (1.4)
0.422
Hypertension
154 (82.8)
115 (81.6)
39 (86.7)
0.429
Dyslipidemia
119 (64.5)
91 (64.5)
28 (62.2)
0.778
Previous stroke/TIA
73 (39.2)
59 (41.8)
14 (31.1)
0.199
Atrial fibrillation
69 (37.1)
51 (36.2)
18 (40.0)
0.643
Diabetes mellitus
59 (31.7)
44 (31.2)
15 (33.3)
0.79
56 (30.1)
41 (29.1)
15 (33.3)
0.588
Smoking
20 (10.8)
14 (9.9)
6 (13.3)
0.521
Statin
82 (44.1)
66 (46.8)
16 (35.6)
0.186
Antiplatelet (any)
94 (50.5)
74 (52.5)
20 (44.4)
0.348
Anticoagulation (any)
29 (15.6)
22 (15.6)
7 (15.6)
0.994
Demographics
Age, y, median, IQR
Sex
79 (64.588)
Ethnicity
Pre-event treatment
Clinical presentation
NIHSS, median, IQR
7 (318)
10 (419)
4 (19)
<0.001
126 (67.7)
104 (73.8)
22 (48.9)
0.002
128 (68.8)
104 (73.8)
24 (53.3)
0.010
Aphasia
71 (38.2)
55 (39.0)
16 (35.6)
0.678
Dysarthria
88 (47.3)
69 (48.9)
19 (42.2)
0.432
Vision complaints
42 (22.6)
31 (22.0)
11 (25.6)
0.731
36 (19.4)
28 (19.9)
8 (18.6)
0.758
Ataxia
31 (16.7)
18 (12.8)
13 (30.2)
0.011
Headache
27 (14.5)
18 (12.8)
9 (20.9)
0.230
Vertigo
15 (8.1)
8 (5.7)
7 (16.3)
0.034
Dizziness (nonvertigo)
12 (6.5)
8 (5.7)
4 (9.3)
0.445
Vomiting
11 (5.9)
6 (4.3)
5 (11.6)
0.090
ED treatment
Door-to-CT time, min
34.6
84.7
<0.001
tPA delivery
14.9
4.4
0.074
CT indicates computed tomography; ED, emergency department; EMS, emergency medical services; IQR,
Interquartile range; NIHSS, National Institutes of Health Stroke Scale; TIA, transient ischemic attack; and tPA,
tissue-type plasminogen activator.
4StrokeJune 2015
60%
EMS Recognized
50%
EMS Missed
40%
30%
20%
10%
0%
0 to 4
5 to 9
10 to 14
15 to 19
20 or more
NIHSS
95% confidence interval, 1.304.69) among the 371 EMSsuspected stroke cases.
The clinical characteristics of the 141 EMS-recognized
IS cases and the 45 missed IS cases are described in Table3.
Demographics and past medical history were similar between
the 2 groups. A complaint of unilateral weakness (73.8% versus 48.9%; P=0.002) and unilateral weakness on examination
(73.8% versus 53.3%; P=0.01) was more common among EMSrecognized than missed IS, whereas vertigo (5.7% versus 16.3%;
P=0.034) and ataxia (12.8% versus 30.2%; P=0.02) were more
common among EMS-missed strokes. The sensitivity of EMS
stroke recognition was the highest among patients who presented with symptoms and signs included in the CPSS (Table I
in the online-only Data Supplement). EMS-recognized strokes
had faster door-to-computed tomographic times (34.6 versus
84.7 minutes; P<0.001), and there was a trend toward greater
likelihood of tPA delivery (14.9% versus 4.4%; P=0.074). EMSrecognized stroke cases had higher stroke severity (median
NIHSS 10 versus 4; MannWhitney U test; P<0.001). The frequency distribution of NIHSS categories is shown in Figure2.
The most common EMS impressions among the 70 missed
stroke transports included generalized weakness (22.9%),
altered mental status (14.3%), and dizziness (10.0%; Table4).
Seven EMS-missed cases (10%) were transported for a focal
neurological complaint, such as unilateral weakness or aphasia
without explicitly identifying the patient as a suspected stroke.
The final diagnoses of the 177 cases transported by EMS as
suspected strokes who were subsequently given a nonstroke
diagnosis are also shown in Table4. Discharge diagnoses were
highly varied among EMS false-positive cases, and more than
1 quarter received a nonspecific, symptom-based discharge
diagnosis after diagnostic workup failed to identify a specific cause. The most common stroke mimics were infections
(12.4%), seizures (11.3%), and syncope (10.2%).
Discussion
Transportation by EMS is an important predictor of improved
in-hospital stroke response and use of tPA for patients with
acute IS.13 These benefits likely stem in part from earlier activation of hospital stroke code processes through prearrival
notification.5 Therefore, accurate prehospital stroke recognition is a critical link in the stroke chain of recovery. Although
prehospital stroke scales are endorsed by national guidelines,17
n=70
Discharge Diagnosis
for EMS False-Positive
IS/TIA
n=177
Generalized weakness
16 (22.9)
Infection
22 (12.4)
10 (14.3)
Seizure
20 (11.3)
7 (10.0)
Syncope/transient
hypotension
18 (10.2)
Dizziness
Focal neurological finding
7 (10.0)
Complex migraine
13 (7.3)
Cardiovascular
5 (7.1)
Hypertensive emergency
7 (4.0)
Diabetic
Other/not specified
4 (5.7)
Bell palsy
6 (3.4)
21 (30.0)
Miscellaneous specific
diagnosis
43 (24.3)
Nonspecific diagnosis
48 (27.1)
EMS indicates emergency medical services; IS, ischemic stroke; and TIA,
transient ischemic attack.
Sources of Funding
This study was supported by a Blue Cross Blue Shield of Michigan
Foundation Investigator Initiated Award.
Disclosures
None.
References
1. Turan TN, Hertzberg V, Weiss P, McClellan W, Presley R, Krompf K,
et al. Clinical characteristics of patients with early hospital arrival after
stroke symptom onset. J Stroke Cerebrovasc Dis. 2005;14:272277. doi:
10.1016/j.jstrokecerebrovasdis.2005.07.002.
2. Gache K, Couralet M, Nitenberg G, Leleu H, Minvielle E. The role of
calling EMS versus using private transportation in improving the management of stroke in France. Prehosp Emerg Care. 2013;17:217222.
doi: 10.3109/10903127.2012.755584.
3. Ekundayo OJ, Saver JL, Fonarow GC, Schwamm LH, Xian Y, Zhao X,
et al. Patterns of emergency medical services use and its association
with timely stroke treatment: findings from Get With the GuidelinesStroke. Circ Cardiovasc Qual Outcomes. 2013;6:262269. doi: 10.1161/
CIRCOUTCOMES.113.000089.
4. Sheppard JP, Mellor RM, Greenfield S, Mant J, Quinn T, Sandler D, et al;
CLAHRC BBC Investigators. The association between prehospital care
and in-hospital treatment decisions in acute stroke: a cohort study. Emerg
Med J. 2015;32:9399. doi: 10.1136/emermed-2013-203026.
5. Lin CB, Peterson ED, Smith EE, Saver JL, Liang L, Xian Y, et al. Emergency
medical service hospital prenotification is associated with improved
evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual
Outcomes. 2012;5:514522. doi: 10.1161/CIRCOUTCOMES.112.965210.
6. Patel MD, Rose KM, OBrien EC, Rosamond WD. Prehospital notification by emergency medical services reduces delays in stroke evaluation:
SUPPLEMENTAL MATERIAL
Supplemental Table I: EMS stroke detection rates among ischemic stroke patients with specific
symptoms and signs
Clinical Characteristic
Unilateral Weakness Complaint
Unilateral Weakness on Exam
Aphasia
Dysarthria
Vision Complaints
Altered Mental Status
Ataxia
Headache
Vertigo
Dizziness (non-vertigo)
Vomiting
Recognized
by EMS
EMS sensitivity
(%)
126
128
71
88
42
36
31
27
15
12
11
104
104
55
69
31
28
18
18
8
8
6
82.5
81.3
77.5
78.4
73.8
77.8
58.1
66.7
53.3
66.7
54.5
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/early/2015/04/28/STROKEAHA.115.008650
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Stroke is online at:
http://stroke.ahajournals.org//subscriptions/