Article

An educational intervention allows for greater prehospital recognition of acute stroke

Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983 1959

Fig. 2. Prehospital and ED naloxone given per patient.

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  • An educational intervention allows for

    greater Prehospital recognition of acute stroke?,??

    To the Editor:

    We performed a study to determine whether a brief educational in- tervention directed at pre-hospital providers would increase the identi- fication of stroke victims in the pre-hospital setting. The purpose of this IRB approved, before-and-after research project was to determine whether the implementation of Advanced Stroke Life Support Class

    ? There was no external funding for this project.

    ?? The abstract was presented at the national ACEP meeting in Las Vegas, NV, October 2016.

    (ASLS) [1] training for pre-hospital providers would lead to improved

    field identification of stroke.

    In June 2014 we presented a didactic and scenario-based 8 h class teaching the Miami Emergency Neurologic Deficit, (MEND) exam [2] as part of the ASLS class which emphasizes the pre-hospital recognition and management of acute stroke to the 25 full-time and 15 part-time paramedics at a local ambulance service with approximately 16,000,911 calls/year. The receiving hospital is a 900-bed suburban teaching hospital with a yearly census of 80,000 and is a JCAHO approved comprehensive stroke center. The course consists of lectures, hands on instruction, and small group stations, which included standardized patients mimicking specific stroke syndromes. At each station, the participants were required to complete a patient assessment, identify the stroke syndrome (left brain, right brain, brainstem, cerebellum and subarachnoid hemorrhage) and recog- nize candidates for IV tPA. A pre- and post-test was completed on the same day.

    The total number of pre-hospital stroke alerts (PHSA) called by the cohort after taking the course was compared to the stroke alerts called by the same ambulance service in the period prior to the intervention. Period A represented the number of PHSA calls during the 19 months prior to any formal instruction. Period B represented PHSA calls 19 months after the class. For both periods we collected the total num- ber of stroke alerts called, the number of strokes correctly identified and the number of PHSAs incorrectly called by this service. We also collected data on interventions (either IV tPA or EVR) for each period.

    After the educational intervention (Period B) there were a total of 82 PHSA called (4.0 PHSAs/month). In Period A, there were 38 PHSA called (2.0/month). The number of pre-hospital stroke alerts called per total number of 911 calls were as follows: Period A: 38/17477 (0.22%) and in Period B: (82/24,090, 0.34); 911 calls in Period B had

    1.57 times the odds of having a pre-hospital stroke alert called com- pared to Period A (95% CI 1.07-2.30). The absolute number of alerts called doubled in Period B (82 vs. 38) without sacrificing accuracy (see Table 1).

    According to the American Heart Association (AHA), every 40 s a person in the United States suffers from an acute stroke [3]. Current AHA/American Stroke Association guidelines state that the use of IV tPA improves functional outcomes at 3-6 months if given within

    1960 Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983

    Table 1

    Characteristics of pre-hospital stroke alerts Period A versus Period B.

    Period A (N = 38)

    Period B (N = 82)

    p-Value

    Mean age

    75 +- 14.3

    75 +- 15.6

    0.82

    Gender (% female)

    13 (54.2)

    47 (57.3)

    0.78

    True strokes

    30 (79.0)

    57 (69.5)

    0.28

    Non-hemorrhagic strokes/not TIA

    20 (66.7)

    45 (79.0)

    Intracranial hemorrhage

    4 (13.3)

    6 (10.5)

    TIA

    6 (20.0)

    6 (10.5)

    Received IV tPA

    10 (38.0)

    21 (42.0)

    0.77

    Received IV tPA alone

    8 (32.0)

    16 (32.0)

    1.00

    Received EVR

    2 (8.0)

    9 (18.0)

    0.32

    Received EVR alone

    0

    4 (8.0)

    0.29

    Received both IV tPA and EVR

    2 (8.0)

    5 (10.0)

    1.00

    Final diagnosis other than stroke

    8

    25

    0.44

    Seizure

    2

    8

    Hypertensive urgency

    0

    1

    Complex migraine

    2

    3

    Psychogenic

    1

    4

    Brain tumor

    1

    1

    Bell’s palsy

    1

    0

    Syncope

    0

    2

    Encephalopathy

    0

    2

    Other

    1

    4

    4.5 h and recommends its use in patients meeting eligibility criteria [4]. It has been shown that favorable outcomes are inversely related to the time between symptom onset and time of treatment [5-6]. A recent study conducted in San Francisco found that up to 39% of acute stroke patients were not identified as having stroke symptoms, demonstrating missed opportunities for treatment of acute stroke [7].

    Prior to the intervention, the ambulance service studied utilized the Cincinnati Prehospital Stroke Scale , which takes about 30 s to perform and assesses the presence or absence of facial droop, arm drift and slurred speech [8-10]. The MEND exam utilized in this course incorporates the CPSS and elements of the NIHSS; it takes about 3 min to complete and should be performed en-route to the hospital [2,11]. It has been shown to correlate with the NIHSS [12] and use of the CPSS has been shown to increase EMS stroke identification sensitivity and positive predictive value [13]. The results of the pre- and post-test in the current study demonstrate mastery of the material with a dra- matic improvement in scores and were consistent with those in the ini- tial study [11].

    The current study demonstrates that a brief educational intervention increased the number of stroke patients called to the ED as a pre-hospi- tal stroke alert without sacrificing accuracy, thus increasing the number of patients eligible for acute interventions. It is not clear whether the in- crease in the number of stroke alerts called was partially a result of the Hawthorne effect or whether the confidence gained by successful com- pletion of a course emphasizing identification of stroke syndromes and the possibility of therapeutic intervention was responsible. The fact that the improvement was maintained over a nineteen-month period sug- gests it was the latter.

    In our quite typical EMS system an educational intervention that emphasized early Stroke recognition doubled the rate of prehospital alerts and increased the absolute number of therapeutic interventions. The proportion of patients correctly identified as stroke and the propor- tion of patients receiving intravenous lytic therapy or endovascular re- perfusion remained constant.

    Acknowledgments

    Jennifer Macfarlan MPH for her statistical expertise.

    Center for Research in Medical Education, University of Miami School of Medicine, Miami Florida, developers of the ASLS course.

    Cetronia Ambulance Service, Allentown, PA.

    Tara K. Henry-Morrow, EMT-P Bryan D. Nelson, MBA NR-P

    Erin Conahan, MSN, RN, ACNS-BC, CNRN, SCRN

    Claranne Mathiesen, RN MSN Bernadette Glenn-Porter, BS Matthew T. Niehaus, DO

    Lauren M. Porter, DO Mitchell R. Gesell, DO Gregory T. Monaghan, MD Jeanne L. Jacoby, MD FACEP*

    Lehigh Valley Health Network, 2545 Schoenersville Road, 5th Floor, SouthWing, Bethlehem, PA 18017, United States

    *Corresponding author.

    E-mail address: [email protected] (J.L. Jacoby).

    https://doi.org/10.1016/j.ajem.2017.05.036

    References

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  • LaCombe DM, Gordon DL, Issenberg SB, Vega A, Brocato C, Siegel M, et al. Stroke on the mend. JEMS 2000 Oct;25(10):32-41.
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  • Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guide- lines for the early management of patients with acute ischemic stroke regarding endovascular treatment. Stroke 2015 Oct;46(10):3020-35.
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    The benefits and harms of intravenous thrombolysis with recombinant tissue plas- minogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial, Lancet 2012 Jun;379(9834): 2352-63.
  • Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification of stroke and transient ischemic attack in the field. Prehospital Emerg Care Taylor & Francis 1998 Jan 2;2(3):170-5.
  • Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of- hospital NIH Stroke Scale. Acad Emerg Med 1997 Oct;4(10):986-90.
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  • Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med Elsevier 1999 Apr;33(4):373-8.

    Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E, et al. Accu- racy of stroke recognition by Emergency Medical Dispatchers and paramedics–San Diego experience. Prehospital Emerg Care 2008 Jan 2;12(3): 307-13.

    Correspondence / American Journal of Emergency Medicine 35 (2017) 19561983 1961

    Lee Gordon D, Issenberg SB, Gordon MS, LaCombe D, McGaghie WC, Petrusa ER. Stroke training of Prehospital providers: an example of simulation-enhanced blended learning and evaluation. Med Teach Taylor & Francis 2005 Mar 3; 27(2):114-21.
  • Brotons AA, Motola I, Rivera HF, Soto RE, Schwemmer S, Issenberg SB. Abstract 3468:
  • correlation of the Miami Emergency Neurologic Deficit (MEND) exam performed in the field by paramedics with an abnormal NIHSS and final diagnosis of stroke for pa- tients airlifted from the scene. Stroke 2015;43(Suppl. 1).

    Oostema JA, Konen J, Chassee T, Nasiri M, Reeves MJ. Clinical predictors of accurate prehospital stroke recognition. Stroke 2015;46(6).

    Can we imagine a survival chain also for ischemic stroke?

    I read with great interest the article about the University of Amiens experience in the management of acute stroke [1] and the concept of “door-to-needle” time, so similar to the best known “door-to-balloon” one. During my recent training period in an excellent stroke unit, I’ve directly experienced a quite brand new concept, brought by Mechanical thrombectomy, the “door-to-reperfusion” time. We know from meta- analysis data that for every 9-minute delay in reperfusion, 1 of every 100 treated patients had a worse disability outcome (+ 1 point on MrS scale) [2]. As Emergency Physicians we are called to improve the in-hospital chain, making the CT angiography the pivotal and immedi- ate exam after the basal CT in severe ischemic stroke (NIHSS N 10) [3-4], and maybe, someday, even in mild-to-moderate symptoms [5]. As we learned the Echocardiogram to better assess acute AMI in pre- hospital setting, we may learn pre-hospital transcranial color-coded so- nography [6-7] and early sonotrombolysis [8-9], which have been proved to be effective, timesaving and safe. We have available solid and exciting techniques to fight Stroke disability, structured chain pro- tocols and widespread formation in our Emergency Departments are now strongly needed.

    Aurora Vecchiato, MD Emergency Medicine Residency Program, University of Sassari, Italy Corresponding author at: Viale San Pietro 8, 07100, Sassari, Italy.

    E-mail address: [email protected].

    14 May 2017

    https://doi.org/10.1016/j.ajem.2017.05.056

    References

    1. Puy, et al. Creation of an intensive care unit and organizational changes in an adult emergency department: impact on Acute stroke management. Am J Emerg Med Jan 10, 2017.
    2. Saver, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016;316(12):1279-89.
    3. Delgado Almandoz, et al. Computed tomography angiography of the carotid and cere- bral circulation. Radiol Clin North Am 2000;48(2):265-81.
    4. Sabarudin, et al. Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value. Quant Imaging Med Surg 2014;4(4):282-90.
    5. Pfaff, et al. Mechanical thrombectomy in patients with acute ischemic stroke and lower NIHSS scores: recanalization rates, periprocedural complications, and clinical outcome. Am J Neuroradiol 2016;37(11):2066-71.
    6. Herzberg, et al. Prehospital stroke diagnostics based on Neurological examination and transcranial ultrasound. Crit Ultrasound J 2014;6(1):3.
    7. Schlachetzki, et al. Transcranial ultrasound from diagnosis to early stroke treatment: part 2: prehospital neurosonography in patients with acute stroke: the Regensburg stroke mobile project. Cerebrovasc Dis 2012;33(3):262-71.
    8. Holscher, et al. Prehospital stroke diagnosis and treatment in ambulances and heli- copters-a concept paper. Am J Emerg Med Apr 2013;31(4):743-7.

      Non-compliance in the Emergency Department: Is there a difference between medical and psychiatric patient’s reasons and

      use of the ED?

      Patient non-compliance to medication results in Emergency Depart- ment (ED) visits, and various complications which cost about $8.5 billion annually [1]. Medication non-compliance is reported to be a seri- ous issue with about 50-70% of patients in the United States [2]. Reasons for non-compliance are varied and include medication affordability, lack of time to obtain or refill prescriptions, side effects, and understanding and perception of need of medication [3-5] According to Harmon et al. when physicians are initiating treatment in patients they often do not identify barriers to medication adherence and actively engage patients [2]. This is especially true for patients that have chronic illness with complicated medical regimes [6-9].

      Research has also shown that individual patients have variation and often distinct adherence to different medications [10-13]. This problem increases with patients who are diagnosed with a Mental illness [10]. Compliance has been shown to vary by type of mental ill- ness with depressed patients being three times more likely to be non- compliant with treatment recommendations than are non-depressed patients [12,13]. The question of what, if any, differences there are between medical versus psychiatric non-compliant patients led us to a conduct a study with regard to use of the ED and reasons for non- compliance.

      The study was a random sample of patients who present to the ED for medical or psychiatric illnesses who state that they are non-compli- ant with their medicine. They were given a section of the validated Na- tional Health Access Survey. The survey asked about sources of medical care, drug compliance and reason for non-compliance such as access and cost of health care and medication. A comparison of the results was made between the two non-compliant populations in order to de- termine what the reasons for non-compliance were.

      There were a total of 300 participants in the study, 161 of which were medical and 139 were psychiatric, whose ages varied with 30-39 (15%), 40-49 (23%), and 50-59 (30%). There were more males (56%) than fe- males (44%) and the majority were African American (77%) or Hispanic (15%). They took on average between 2 and 6 medications per day.

      There was no significant difference in the reason both medical and Psychiatric patients gave for being non-compliant with their medica- tions that resulted in their ED visit. Each group cited cost as the number one reason (67%) for not taking their medication as prescribed. They chose non-compliance versus skipping doses due to cost (62%), taking less medicine due to cost (61%), or asking about lower cost medicine from doctor (65%). Both groups stated they had a usual source of med- ical care (82%) and no trouble finding medical providers (76%). This in- dicates there are ways to address the issue of medical non-compliance that require less from the ED and more from the patient’s own PCP or specialist. This could include the exchange of information on such issues as cost, benefits, reasons for regimen, side effects and need for adher- ence between patients and their PCP and specialist.

      There was a difference between medical and psychiatric non- compliant patients in this study. The psychiatric patients were more likely to get admitted (p = 0.00), state they could not afford mental health care (p = 0.01), and felt they could not get care from other places thus used the ED for their psychiatric care (p = 0.02).

      The finding that patients with Psychiatric diagnoses were more likely to be admitted than patients with medical diagnoses, could be due to the more severe Negative outcomes of non-compliance for this patient popu- lation. The need to be admitted (50%) with (8%) of the patients having to be sent to another medical facility means that the potential cost of non- compliance in this population was higher.

      Bor-Seng-Shu, et al. Sonothrombolysis for acute ischemic stroke: a systematic review

      of randomized controlled trials. Neurosurg Focus Jan 2012;32(1):E5.

      ? There is no conflict of interest to report with regard to this study.

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