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Abstract |
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• Objectives To measure the performance of paramedics and emergency departments providing care for patients with suspected acute stroke.
• Methods Two stroke centers and 4 other hospitals where most patients with acute stroke in Houston, Tex, are admitted participated. Hospital and paramedic performance data were collected prospectively on 446 patients with suspected acute stroke transported by paramedics between September 1999 and February 2000.
• Results Paramedics had a sensitivity of 66%, specificity of 98%, and overall accuracy of 72% in diagnosing stroke. For patients with suspected stroke, 58.5% arrived in the emergency department within 120 minutes of symptom onset; in confirmed cases, that percentage was 67%. Mean total transport time was 42.2 minutes and was significantly longer (P < .001) to inner-city hospitals (44 minutes) than to suburban, community-based centers (39 minutes). Door to computed tomography times were significantly (P < .001) shorter for the 2 stroke centers than the other hospitals. Overall thrombolysis treatment rate among patients with confirmed ischemic stroke was 7.4% (range, 0–19.4%); treatment rates at the 2 stroke centers were 5.9% and 19.4%.
• Conclusions More than half of patients with suspected stroke arrive at hospitals while thrombolytic treatment is still feasible. Although the current rate for thrombolytic treatment in Houston exceeds the national rate, performance of paramedics and hospitals in treating acute stroke can be improved by increasing efficiency and standardizing medical practices.
As part of a study funded by the ASA, we sought to understand the baseline performance characteristics of prehospital paramedics and emergency departments caring for patients admitted with suspected acute stroke. These data were used to support (1) development of an intervention currently under way to establish emergency stroke centers and (2) a citywide paramedic educational program to improve management of acute stroke in Houston, Tex.
Within the prehospital care sector, communities may experience a number of impediments to organizing a training program to improve local paramedics’ response to patients with suspected stroke. Paramedic services may be decentralized and scattered around a city or region and are often provided by competing ambulance companies, making organization of paramedic training and orchestration of regional communication systems between paramedics and stroke centers difficult. Furthermore, today’s healthcare system fosters competition between stroke care providers and hospitals, and the system lacks regional organization by program capability into stroke centers. This climate creates uncertainty in the community at large as to which hospital and paramedic service can provide the best stroke care.
| Patients with suspected stroke should have computed tomography within 30 minutes of arrival at the emergency department.
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The ASA has established performance indicators for stroke centers that include completion and interpretation of an unenhanced computed tomography (CT) scan of the brain within 30 minutes of arrival in the emergency department and in patients receiving thrombolytic therapy, a maximum of 60 minutes from arrival in the emergency department to the start of administration of recombinant tissue plasminogen activator (rtPA).3 National performance statistics for these indicators have not been reported yet, although a uniform data set for quality measurement is being constructed.
At a consensus conference of the National Institute of Neurological Disorders and Stroke (NINDS) in 1997, the need to establish designated stroke centers where patients with suspected stroke could receive emergent, comprehensive care was identified.4 The Brain Attack Coalition5 further discussed this recommendation, as did the ASA, which published standards of care for self-designated stroke centers in 2000.3 As has been the case since the creation of regional trauma centers by the American College of Surgeons, it is expected that the creation of stroke centers will consolidate diagnostic capabilities and personnel trained to assess patients and implement state-of-the-science therapy for acute stroke.
Once established, it is projected that stroke centers practicing in accordance with the ASA standards will increase stroke awareness among the community and healthcare professionals and simplify paramedics’ decision making about destinations, thereby stimulating more rapid transport of stroke patients. However, current problems with the development of stroke centers include the lack of formally designated accreditation authorities and processes, regional assessments of capacity/population needs, a uniform database to support a stroke registry system, and a system to support ongoing quality monitoring for stroke centers.
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Methods |
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In the year before the start of this study, Houston Fire Department-Emergency Medical Services (HFD-EMS) paramedics transported a total of 2382 stroke patients. Of these patients, almost 75% were transported to 1 of 9 Houston hospitals, 4 centrally located in the Texas Medical Center and 5 located within the greater Houston community. All 9 top-admitting hospitals were approached to participate in this study, and 6 centers signed on for the project. Rationales for declining the invitation to participate included the following:
| If indicated, patients with suspected stroke should have thrombolytic therapy started within 60 minutes of their arrival at the emergency department. |
Table 1
describes the 6 hospitals participating in the study. Hospital 1 has served as a stroke center since 1988 and has developed a close working relationship with HFD-EMS paramedics since participation in the NINDS rtPA study beginning in 1991. Hospital 5 began calling itself a stroke center in 1997. The remaining participating facilities are community hospitals, none of which had been designated as a stroke center at the time of baseline data collection; 3 of these community hospitals have access to fellowship-trained members of the stroke team from hospital 1 to assist with emergency assessment and interventional treatment of patients with acute stroke.
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Hospital data were collected prospectively and were reviewed again when the medical record was closed to measure efficiency and process variables such as time from arrival at the emergency department to completion and interpretation of the CT scan of the brain, and the numbers of patients treated with rtPA, as well as the outcomes attained after thrombolytic therapy. Final discharge diagnoses were collected on all patients whom paramedics suspected of having stroke and who were brought by HFD-EMS to the 6 hospitals. Additionally, all patients transported by HFD-EMS to the emergency department at hospital 1 who did not have stroke diagnosed by the paramedics were screened to determine final diagnoses. Patients’ demographic data, including times from onset of signs and symptoms to arrival at the hospital, also were collected.
A standardized, computer-based paramedic run sheet was used to ascertain data elements related to prehospital care; run sheets for the total sample of suspected stroke cases were submitted by the HFD-EMS to the study coordinator for data entry. Hospital data were collected by a hospital-based nurse coordinator and forwarded to the study coordinator for data entry, after final chart review at patient discharge. Data were entered and analyzed using SPSS software (SPSS Inc, Chicago, Ill).
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Results |
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indicates the number of patients transported to each site. The sample was predominately female (n = 267; 59.9%); the mean age was 69.8 years (SD = 14.9 years; median = 73 years). Racial distribution for the sample was 1.3% Asian, 17.6% Hispanic, 40.5% African American, and 40.5% white. Race was determined by patient self-identification in accordance with hospital admissions procedures.
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Paramedics used the medical telemetry prehospital notification system 71% of the time to assist with the triage of patients with suspected stroke and to alert the stroke team of a pending emergency admission. Telemetry use was highest (81%) for patients transported by paramedics to the stroke center at hospital 1. The lowest rate of telemetry use (44%) was found in cases transported to hospital 6, the smallest facility studied and the only one without access to 24-hour stroke team management (Table 2).
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| Paramedics accurately diagnosed stroke 72% of the time.
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For paramedics, mean time for prehospital treatment and transport was 9.9 minutes (SD = 5.7 minutes; median = 9 minutes) from dispatch to arrival on the scene of a suspected stroke case (Figure 2). The mean time spent on the scene preparing for transport was 16.7 minutes (SD = 7.3 minutes; median = 16 minutes). Mean total time from dispatch to arrival at a hospital study site was 42.2 minutes for the sample (SD = 13.1 minutes; median = 41 minutes). For community-based hospitals outside the Texas Medical Center, the mean time from dispatch to hospital arrival was 39 minutes (SD = 13.1; median = 36.5 minutes), significantly (F1 = 15.553, P < .001) shorter than times for sites within the Texas Medical Center, which had a mean of 44 minutes (SD = 12.5 minutes; median = 42 minutes; Figure 3).
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). In medically confirmed cases of stroke, door to CT times also were significantly better (P < .001) at the 2 stroke study centers than at the other hospitals (Table 3).
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| Two thirds of patients with confirmed stroke arrived at the hospital within 2 hours of the onset of signs and symptoms.
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In medically confirmed cases of ischemic stroke, the overall thrombolysis treatment rate was 7.4%; use of intravenous rtPA differed dramatically by hospital (Table 4). At the stroke center at hospital 1, an rtPA treatment rate of 19.4% was achieved for patients transported by HFD-EMS, whereas 5.9% of such patients were treated with rtPA in the stroke center at hospital 5. The 4 study sites that were not stroke centers had mean rates of rt-PA administration between 4.7% and 14.3%; at 2 sites, rtPA was not administered to any stroke patients transported by HFD-EMS during the study period. Intracranial and/or other systemic hemorrhages were not documented in any patients receiving rtPA at treating centers during the study period.
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Discussion |
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Similarly, because of community awareness in Houston, currently almost half of patients with suspected acute stroke arrive within the time window for treatment with rtPA. In fact, in confirmed cases of stroke, 67% of the sample arrive by 120 minutes of onset of signs and symptoms, making a full 60 minutes available for workup and possible treatment with rtPA. This effect may also be related to the increased visibility of the stroke center at hospital 1 in the community since the NINDS rtPA trial and suggests the power of using multimedia community education programs to support public healthcare messages.
Mean prehospital paramedic transport time for patients with suspected stroke was 42.2 minutes; most of this time was incurred at the scene, stabilizing and preparing the patient for transport. This finding may suggest the need for emphasizing a "load and go" practice, especially when paramedics assess that the time of onset of signs and symptoms of stroke may jeopardize a patient’s candidacy for intravenous thrombolytic therapy. The significantly greater time for transport of a patient with suspected acute stroke to inner-city based Texas Medical Center hospitals is most likely the result of traffic congestion, which may further delay treatment efficiency. Thus, more suburban, community-based stroke centers with basic competency in the assessment and treatment of patients with acute stroke (demonstrated by using the ASA standards) are needed.
Our data also suggest that although a desire to provide treatment for acute stroke is important, measures aimed at enhancing internal effectiveness and efficiency are an essential part of living up to the title of "stroke center." Significant differences in door-to-CT times suggest the need for reorganization of internal systems and changes in medical practice philosophy. Similarly, adoption of protocols and changes in practice patterns to accommodate the administration of rtPA to patients with ischemic stroke who meet the inclusion criteria are in order. Although the overall thrombolysis treatment rates for Houston reported in this study are significantly higher than the national mean (which is <3%),5 the dramatic difference in the percentage of cases treated with rtPA at the 6 hospitals supports the need for adoption of the ASA standards to promote uniform assessment and treatment processes across stroke centers. A process that allows hospitals to designate themselves as stroke centers without certification or accreditation may not serve the community well, because differences in performance may vary significantly. The difference in the rates of use of rtPA between the 2 established stroke centers in this study illustrate this point well; although these differences may be accounted for by the sample, they may also represent an inconsistent commitment among medical providers to the level of care specified in the ASA standards.
Establishing a thorough understanding of baseline performance in the prehospital and emergency phases of care of patients with acute stroke promotes identification of opportunities to enhance the services of paramedics and medical providers and the performance of hospital systems. Our findings suggest that in order to improve care of patients with acute stroke in Houston, a significant commitment to change is required, primarily from hospital systems and medical providers. Without such a commitment, the best tactic may be to advocate that both paramedics and members of the community bypass facilities that are not stroke centers.
| The advantages of reperfusion are well documented. Although more than half of the patients with suspected stroke arrived at the hospital in time for thrombolytic therapy, few received it. Clinical guidelines are underused in stroke care.
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ACKNOWLEDGMENT |
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To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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REFERENCES |
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This article has been cited by other articles:
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  D. Summers, A. Leonard, D. Wentworth, J. L. Saver, J. Simpson, J. A. Spilker, N. Hock, E. Miller, P. H. Mitchell, and on behalf of the American Heart Association Counci Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement From the American Heart Association Stroke, August 1, 2009; 40(8): 2911 - 2944. [Full Text] [PDF]
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 Part 9: Adult Stroke Circulation, December 13, 2005; 112(24_suppl): IV-111 - IV-120. [Full Text] [PDF]
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Part 9: Stroke Circulation, November 29, 2005; 112(22_suppl): III-110 - III-104. [Full Text] [PDF]
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B. M. Demaerschalk and T. R. Yip Economic Benefit of Increasing Utilization of Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke in the United States Stroke, November 1, 2005; 36(11): 2500 - 2503. [Abstract] [Full Text] [PDF]
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H. Adams, R. Adams, G. Del Zoppo, and L. B. Goldstein Guidelines for the Early Management of Patients With Ischemic Stroke: 2005 Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association Stroke, April 1, 2005; 36(4): 916 - 923. [Full Text] [PDF]
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