HONOLULU—Stroke diagnosis accuracy rates by emergency medical services increased from 71% to 77% during a three-year period in a community hospital setting after implementation of an education program, researchers reported at the 2013 International Stroke Conference.
“Baseline Emergency Medical Services [EMS] stroke diagnostic accuracy for units delivering to our hospital did not significantly change, but we did experience a clinically important level of improvement over the three-year study period,” stated Diane Handler, MSN, RN Stroke Coordinator at the Mercy Medical Center in Cedar Rapids, Iowa, and colleagues. “While our intervention did not demonstrate further improvement, this may indicate a ceiling effect for paramedic stroke diagnostic accuracy above 77% to 79% that should be considered acceptable.”
The researchers evaluated 198 consecutive EMS-diagnosed stroke patients who were admitted to the Mercy Medical Center. An EMS Report Card intervention program was developed to provide feedback on all suspected stroke cases. Report cards were shared with all services, including rural volunteer EMT-based services and community paramedic services. Education was provided based on trends in EMS reports and patient presentation to help improve diagnostic accuracy.
The investigators analyzed 41 EMS diagnosed stroke alerts in 2009, 83 cases in 2010, and 74 cases in 2011. The percentage of stroke mimics decreased during the three-year period, from 29% in 2009, to 26% in 2010, and to 23% in 2011. In 2009, the leading stroke mimic diagnoses were drug reaction and infection; in 2010, the leading stroke mimics were infection and hypoglycemia; and in 2011, the leading stroke mimic was seizure.
In addition, the median door-to-bolus time for t-PA administration was 60.5 minutes in 2009, 50.5 minutes in 2010, and 51 minutes in 2011.
“There was a trend toward increased numbers of t-PA–treated patients by the EMS squad and faster times to treat,” noted Ms. Handler.
The diagnostic accuracy rate in the study approaches the highest such rate recorded in the literature—79% by Wojner-Alexandrov et al in 2005—which resulted from continuous feedback education.
“Accuracy of stroke paramedic diagnosis is important, in that EMS stroke calls drive hospital resources and response systems tied to acute stroke diagnosis and treatment,” said Ms. Handler. “High rates of inaccuracy may exhaust these critical systems. EMS report cards should be considered an important component of stroke center coordination to ensure ongoing improvement and maintenance of important prehospital diagnostic skills.”
—Colby Stong
Editor
Suggested Reading
Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D, et al. Houston paramedic and emergency stroke treatment and outcomes study (HoPSTO). Stroke. 2005;36(7):1512-1518.