posterior stroke recognition in the prehospital setting...objectives review the benefits of optimal...
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Posterior Stroke Recognition in the Prehospital Setting
Adam Oostema, MD, FACEP
Associate Professor
Emergency Medicine
Michigan State University
College of Human Medicine
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Disclosures
• Michigan’s Ongoing Stroke Registry to Accelerate Improvement in Care (MOSAIC), Michigan Department of Health and Human Services.
• American Heart Association Mentored Clinical and Population Science Award
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Objectives
Review the benefits of optimal prehospital stroke recognition
1
Discuss challenges in posterior stroke recognition
2
Share findings form a pilot controlled before and after study of an educational intervention to improve prehospital stroke recognition
3
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The Value of EMS in Stroke
Systems
• Arrival by EMS versus other mode1
o Arrive earlier
o Receive CT faster
o Receive t-PA more often
• Prenotification among EMS-transported strokes2,3
o Receive CT faster
o Receive t-PA more often
o Receive t-PA faster
1. Ekundayo et al. Circulation: Cardiovascular Quality and Outcomes 2013;6(3): 262-2692. Lin et al. Circulation: Cardiovascular Quality and Outcomes 2012;5(4): 514-5223. Oostema et al. J Stroke Cerebrovasc Dis 2014;23(10): 2773-2779
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Goals of Prehospital Stroke Care
RECOGNIZE STROKE MINIMIZE TRANSPORTATION DELAY
PRENOTIFY RECEIVING HOSPITAL
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EMS Stroke Recognition and Quality Measure Compliance
0
10
20
30
40
50
60
70
80
90
100
Dispatchedhighest priority
Response time ≤ 8 minutes
CPSS On-scene time ≤ 15 minutes
Glucose levelrecorded
LKW documented Hospital pre-notification
Transportedhighest priority
EMS Recognized EMS Unrecognized
Oostema JA, et al. J Stroke CerebrovascDis 2014;23(10): 2773-2779
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EMS Stroke Recognition and ED Stroke Care
DTCT time t-PA
EMS Recognized 34.6 14.9
EMS Unrecognized 84.7 4.4
0
10
20
30
40
50
60
70
80
90
Min
(D
TCT)
or
Pe
rce
nt
(t-P
A)
EMS Recognized EMS Unrecognized
Oostema et al. J Stroke Cerebrovasc Dis 2014;23(10): 2773-2779
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EMS Stroke Recognition
Sensitivity:
Overcalls:
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Cincinnati Prehospital Stroke Scale and EMS Stroke Recognition
CPSS documented
CPSS NOTdocumented
Likelihood of identifying stroke (Sensitivity)
84.7% 30.9%
Likelihood of accurately calling stroke (Positive Predictive Value)
56.2% 30.4%
Oostema JA et al. Stroke 2015;46: 1513-7
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Unrecognized Strokes
Generalized Weakness
23%
Altered Mental Status14%
Dizziness10%
Focal Neurologic Finding10%
Cardiovascular 7%
Diabetic 6%
Other/Not Specified
30%
Oostema JA, et al. Stroke 2015;46(6):1531-7
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5
Clinical Presentation EMS RecognizedN=141
EMS UnrecognizedN=45
P-value
NIHSS 10 (4-19) 4 (1-9) <0.001
Unilateral Weakness 104 (73.8) 22 (48.9) 0.010
Aphasia 55 (39.0) 16 (35.6) 0.678
Dysarthria 69 (48.9) 19 (42.2) 0.432
Visual Disturbance 31 (22.0) 11 (25.6) 0.731
Altered Mental Status 28 (19.9) 8 (18.6) 0.758
Ataxia 18 (12.8) 13 (30.2) 0.011
Headache 18 (12.8) 13 (30.2) 0.230
Vertigo 8 (5.7) 7 (16.3) 0.034
Non-Vertigo Dizziness 8 (5.7) 4 (9.3) 0.445
Vomiting 6 (4.3) 5 (11.6) 0.090
Oostema JA et al. Stroke 2015;46: 1513-7
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Posterior Circulation Ischemic
Stroke
http://commons.wikimedia.org/wiki/File:Cerebral_vascular_territories.jpg
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• Motor deficits
• Sensory deficits
• “Crossed” syndromes
• Homonymous hemianopia
• Ataxia, imbalance, unsteadiness, or disequilibrium
• Vertigo
• Diplopia
• Dysphagia or dysarthria
• Isolated reduced level of consciousness
Merwick BMJ 2014;384:g3175
Clinical Presentation
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Sarraj et al. Int J Stroke. 2015;10:672-678
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The Grand Rapids Area Prehospital Stroke Registry (GRAPHS)
• Registry of EMS Transported Patients who were EITHER:o EMS primary or secondary impression of stroke/TIA, ORo Hospital discharge diagnosis of stroke/TIA
• Kent County Michigano Population 600,000
o EMS System
• 3 Independent EMS agencies (annual transport volume 55,000)
• All ALS medical transport
o Hospitals
• 4 Acute Care Hospitals/3 Health Systems (Over 1500 licensed beds)
• All Certified Primary Stroke Centers
• Funding: American Heart Association Mentored Clinical and Population Science Award (2015-2017)
http://www.mapsopensource.com/images/location-map-of-kent-county-michigan.gif
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Intervention
• Educationo On-line module
o Mandatory for all paramedics
o Presented local performance data
o Highlighted benefits of quality measure compliance
o Underscored screening for stroke in ambiguous presentations
• Assessmento Pre and Post Test
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http://commons.wikimedia.org/wiki/File:Cerebral_vascular_territories.jpg
Anterior
Circulation:
- Weakness
- Numbness
- Difficulty Speaking
- Neglect
Posterior
Circulation:
- Vertigo
- Balance difficulty
- Double Vision
- Loss of Vision
Clinical Symptoms
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Finger-to-Nose Test
• Test for limb ataxia
• Element of the NIH stroke scaleo Limb ataxia present in 30% of EMS unrecognized stroke cases
in our pilot registry
• Reasonable inter-rater reliabilityo Kappa 0.511 to 0.682
• Easy to teach
• Integrates well into existing prehospital stroke scale (CPSS)
1. Brott et al. Stroke 20(7): 864-870.2. Hansen et al. Acta Neurol Scand 90(3): 145-149.
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https://www.k4health.org/toolkits/measuring-success/types-evaluation-designs
Largest Agency
General Stroke Training + FTN
General Stroke Training
12 Months 9 Months
12 Months 9 Months
2 Smaller Agencies
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Characteristics of 139 EMS Transported Posterior Ischemic Strokes
Control
(n=88)
FTN
(n=51)
Before
(n=74)
After
(n=65)
Median Age (IQR) 76 (64 to 85) 74 (65 to 86) 79 (67 to 87) 73 (63 to 84)
Female 35 (39.8) 23 (45.1) 31 (41.8) 27 (41.5)
Non-White Race 11 (21.6) 14 (15.9) 15 (20.3) 10 (15.4)
Dispatched for Stroke 30 (34.1) 22 (43.1) 24 (32.4) 28 (43.1)
Vomiting 18 (20.5) 8 (15.7) 13 (17.6) 13 (20.0)
Headache 16 (18.2) 5 (9.8) 12 (16.2) 9 (13.9)
Dizziness 22 (25.0)* 5 (9.8)* 12 (16.2) 15 (23.1)
Ataxia 14 (15.9) 5 (9.8) 6 (8.1) 13 (20.0)
Gaze Preference/Nystagmus 4 (4.6) 4 (7.8) 6 (8.1) 2 (3.1)
Vision Change 5 (5.7) 3 (5.9) 5 (6.8) 3 (4.6)
NIHSS (IQR) 5 (2 to 11) 6 (2 to 9) 7 (3 to 13) 3 (1 to 7)
DTCT ≤25 Min 23 (26.4) 12 (23.5) 19 (25.7) 16 (24.6)
t-PA 13 (14.8) 4 (7.8) 8 (10.8) 9 (13.9)
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Primary and secondary outcomes by study group and period
Control (N=88) FTN (N=51)
Before
(n=50)
After
(n=38)p-value
Before
(n=24)
After
(n=27)p-value
EMS Recognition (%) 16 (32.0) 15 (39.5) 0.467 11 (45.8) 20 (74.1) 0.039
Mean DTCT Time (SD) 58 (46) 61 (47) 0.771 62 (43) 41 (22) 0.037
t-PA Delivery (%) 5 (10.0) 8 (21.5) 0.148 3 (12.5) 1 (3.7) 0.244
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EMS posterior stroke
recognition by study quarter
Intervention
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Limitations
Small pilot study Insufficient sample size for multivariable analysis
Single county All ALS EMS system
Reason for Improvement Unclear Effect of education or change in evaluation process?
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Conclusions
A larger study in diverse practice settings is needed to confirm these results and explore
sustainability of these gains
Improved recognition may translate into faster ED stroke evaluations
Educating paramedics in the finger-to-nose exam may improve prehospital posterior
stroke recognition rates
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Value of EMS Recognition
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
DTCT <25 Min t-PA Delivery DTNT <45 Min
EMS Recognized EMS Unrecognized
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Focus Groups
• Interview with paramedics from each agency in Kent County
• Focus group recordings were transcribed and uploaded into Dedoose (Version 6.1.18, Los Angeles, CA) for analysis
• Themes and subthemes that described barriers and facilitators of prehospital stroke care were developed iteratively by 3 investigators using grounded theory methods
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• Interview with paramedics from each agency in Kent County
• Focus group recordings were transcribed and uploaded into Dedoose (Version 6.1.18, Los Angeles, CA) for analysis
• Themes and subthemes that described barriers and facilitators of prehospital stroke care were developed iteratively by 3 investigators using grounded theory methods
Focus Groups
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Proposed Measures
• Stroke-1: Prehospital stroke assessment documented for suspected stroke
• Stroke-2: Blood glucose measurement for suspected stroke
• Stroke-3: Prehospital notification
• Stroke-4: Suspected stroke transported to an ‘acute stroke ready’ hospital
• Stroke-5: Documentation of last known well
• Stroke-7: Time from LKW to arrival at stroke hospital
• Stroke-8: Percentage of ED-diagnosed stroke recognized by EMS
http://www.emscompass.org/ems-compass-measures/
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Why Focus on These Measures?
Recognition
Stroke-1: Prehospital stroke assessment documented for suspected stroke
Stroke-2: Blood glucose measurement for suspected stroke
Stroke-8: Percentage of ED-diagnosed stroke recognized by EMS
Efficiency
Stroke-3: Prehospital notification
Stroke-4: Suspected stroke transported to an ‘acute stroke ready’ hospital
Stroke-5: Documentation of last known well
Stroke-7: Time from LKW to arrival at stroke hospital
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EMS Stroke Care Model
• Stroke Screening
• Glucose Check
In-Hospital Stroke
Response
EMS Stroke Recognition
Patient Outcomes
Hospital Pre-
notification
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Venkat, A et al. Neuroepidemiology 2018;51: 123-27