The views, opinions and decision-making of UK-based paramedics on the use of pre-hospital 12-lead electrocardiograms in acute stroke patients: a qualitative interview study.

Introduction: A qualitative exploration into the views, opinions and decision-making of paramedics involved in undertaking pre-hospital 12-lead electrocardiograms (PHECGs) for stroke patients was undertaken, in order to gain a deeper understanding of the clinical and occupational context that the paramedics work within, the acceptability of the paramedics in using PHECGs for stroke patients and the consequences and influences of their decision-making. Methods: Data were collected via semi-structured interviews and analysed using the framework method, with the underpinning theoretical framework of cognitive continuum theory. A purposive sample of 14 paramedics was recruited and interviewed. Results: Five themes were generated from the analysis of the interviews: (1) 'time is brain': minimising delays and rapid transport to definitive care; (2) barriers and facilitators to undertaking PHECGs for stroke patients; (3) recognising and gaining cues; (4) maintaining patient dignity, self-protection and fully informed consent; and (5) education, experience and engagement with evidence. Conclusion: The study showed mixed views on the usefulness of PHECGs, but all participants agreed that PHECGs should not cause additional delays. Paramedic decision-making on recording PHECGs relies on intuitive and quasi-rational cognitive modes, and requires a number of clinical, logistical and ethical considerations. The findings suggest careful consideration is needed of the benefits and potential drawbacks of incorporating PHECGs into pre-hospital stroke care.

The pre-hospital 12-lead electrocardiogram is associated with longer delay and worse outcomes in patients presenting to emergency medical services with acute stroke: a linked cohort study.

Objectives: To investigate the association between pre-hospital 12-lead electrocardiogram (PHECG) use in patients presenting to emergency medical services (EMS) with acute stroke, and clinical outcomes and system delays. Methods: Multi-centre linked cohort study. Patients with verified acute stroke admitted to hospital via EMS were identified through routinely collected hospital data and linked to EMS clinical records via EMS unique identifiers. Ordinal and logistic regression analyses were undertaken to analyse the relationship between having a PHECG and modified Rankin Scale (mRS); hospital mortality; pre-hospital time intervals; door-to-scan and door-to-needle times; and rates of thrombolysis. Results: Of 1161 eligible patients admitted between 29 December 2013 and 30 January 2017, PHECG was performed in 558 (48%). PHECG was associated with an increase in mRS (adjusted odds ratio [aOR] 1.30, 95% confidence interval [CI] 1.01-1.66, p = 0.04) and hospital mortality (aOR 1.83, 95% CI 1.26-2.67, p = 0.002). There was no association between PHECG and administration of thrombolytic treatment (aOR 1.06, 95% CI 0.75-1.52, p = 0.73). Patients who had PHECG recorded spent longer under the care of EMS (median 49 vs 43 minutes, p = 0.006). No difference in times to receiving brain scan (median 28 with PHECG vs 29 minutes no PHECG, p = 0.32) or thrombolysis (median 46 vs 48 minutes, p = 0.37) were observed. Conclusion: The PHECG was associated with worse outcomes and longer delays in patients with acute ischaemic stroke.

A pilot study evaluating the use of ABCD2 score in pre-hospital assessment of patients with suspected transient ischaemic attack: experience and lessons learned.

BACKGROUND: Suspected transient ischaemic attack (TIA) is a common presentation to emergency medical services (EMS) in the United Kingdom (UK). Several EMS systems have adopted the ABCD2 score to aid pre-hospital risk stratification and decision-making on patient disposition, such as direct referral to an Emergency Department or specialist TIA clinic. However, the ABCD2 score, developed for hospital use, has not been validated for use in the pre-hospital context of EMS care. METHODS: We conducted a pilot study to assess eligibility criteria, recruitment rates, protocol compliance, consent and follow-up procedures to inform the development of a definitive study to validate the ABCD2 tool in pre-hospital evaluation of patients with suspected TIA. RESULTS: From 1st May-1st September 2013, nine patients with an EMS suspected diagnosis of TIA had the TIA diagnosis later confirmed by a specialist from five participating sites. This recruitment rate is comparable to stroke trials in the EMS setting. Bureaucratic obstacles and duplication of approval processes across participating sites took 13 months to resolve before recruitment commenced. Due to the initial difficulty in recruitment, a substantial amendment was approved to modify inclusion criteria, allowing patients with atrial fibrillation and/or taking anticoagulant therapy to participate in the study. CONCLUSIONS: It is possible to identify, recruit and follow up patients with suspected TIA in the EMS setting. Training large numbers of EMS staff is required as exposure to TIA patients is infrequent. Significant insight was gained into the complexity of NHS research governance mechanisms in the UK. This knowledge will facilitate the planning of a future adequately powered study to validate the ABCD2 tool in a pre-hospital setting.