Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review.

BACKGROUND: Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives). METHOD: We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool. RESULTS: Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%-28%), nausea/vomiting (n=94; 8%-38%), dizziness (n=86; 23%-27%), changes in mental status (n=51; 8%-25%) and visual disturbance/impairment (n=43; 13%-28%). CONCLUSION: Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.

Temporal Trends in Emergency Medical Services and General Practitioner Use for Acute Stroke After Australian Public Education Campaigns.

Background and Purpose- The Australian Stroke Foundation ran annual paid advertising between 2004 and 2014, using the FAST (Face, Arm, Speech, Time) campaign from 2006 and adding the message to call emergency medical services in 2007. In this study, we examined temporal trends in emergency medical services use and referrals from general practitioners in the Australian state of Victoria to evaluate the impact of these campaigns. Methods- Using data from 33 public emergency departments, contributing to the Victorian Emergency Minimum Dataset, we examined trends in emergency department presentations for 118 000 adults with an emergency diagnosis of stroke or transient ischemic attack between 2003 and 2015. Annual trends were examined using logistic regression using a precampaign period (January 2003 to August 2004) as reference and adjusting for demographic variables. Results- Compared with the precampaign period, significant increases in emergency medical services use were seen annually between 2008 and 2015 (all P<0.001, eg, 2015; adjusted odds ratio, 1.16; 95% CI, 1.10-1.23). In contrast, a decrease was seen in patients presenting via general practitioners across all campaign years (all P<0.001, eg, 2015; adjusted odds ratio, 0.48; 95% CI, 0.44-0.53). Conclusions- Since the Stroke Foundation campaigns began, a greater proportion of stroke and transient ischemic attack patients are presenting to hospital by emergency medical services and appear to be bypassing their general practitioners.

Regions With Low Rates of Bystander Cardiopulmonary Resuscitation (CPR) Have Lower Rates of CPR Training in Victoria, Australia.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) more than doubles the chance of surviving an out-of-hospital cardiac arrest. Recent data have shown considerable regional variation in bystander CPR rates across the Australian state of Victoria. This study aims to determine whether there is associated regional variation in rates of CPR training and willingness to perform CPR in these communities. METHODS AND RESULTS: We categorized each Victorian postcode as either a low or high bystander CPR region using data on adult, bystander-witnessed, out-of-hospital cardiac arrests of presumed cardiac etiology (n=7175) from the Victorian Ambulance Cardiac Arrest Registry. We then surveyed adult Victorians (n=404) and compared CPR training data of the respondents from low and high bystander CPR regions. Of the 404 adults surveyed, 223 (55%) resided in regions with low bystander CPR. Compared with respondents from high bystander CPR regions, respondents residing in regions with low bystander CPR had lower rates of CPR training (62% versus 75%, P=0.009) and lower self-ratings for their overall knowledge of CPR (76% versus 84%, P=0.04). There were no differences between the regions in their reasons for not having undergone CPR training or in their willingness to perform CPR. Rates of survival for bystander-witnessed, out-of-hospital cardiac arrests were significantly lower in low bystander CPR regions (15.7% versus 17.0%, P<0.001). CONCLUSIONS: This study found lower rates of CPR training and lower survival in regions with lower rates of bystander CPR in Victoria, Australia. Targeting these regions with CPR training programs may improve bystander CPR rates and out-of-hospital cardiac arrest outcomes.

Strategic framework improves access to stroke reperfusion across the state of Victoria Australia.

BACKGROUND: In 2010, rapid access to stroke thrombolysis centres was limited in some regional areas in the Australian state of Victoria. These results, and planning for endovascular clot retrieval (ECR), have led to the implementation of strategies by the Victorian Stroke Clinical Network, the Victorian Stroke Telemedicine Program and local health services to improve state-wide access. AIMS: To examine whether access to stroke reperfusion services (thrombolysis and ECR) in regional Victoria have subsequently improved. METHODS: The locations of suspected stroke patients attended by ambulance in 2015 were mapped, and drive times to the nearest reperfusion services were calculated. We then calculated the proportion of cases with transport times within: (i) 60 min to thrombolysis centres; and (ii) 180 min to two ECR centres designated to receive regional patients. Statistical comparisons to existing 2010 data were made. RESULTS: In 2015, Ambulance Victoria attended 16 418 cases of suspected stroke (2.9% of all emergency calls), of whom 4597 (28%) were located in regional Victoria. Compared to 2010, a greater proportion of regional suspected stroke patients in 2015 were located within 60 min of a thrombolysis centre by road (77-95%, P < 0.001). A 3-h road travel time to the two ECR centres is currently possible for 88% of regional patients. CONCLUSION: A strategic and region-specific approach has resulted in improved access by road transport to reperfusion therapies for stroke patients across Victoria.

Australian public's awareness of stroke warning signs improves after national multimedia campaigns.

BACKGROUND AND PURPOSE: The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia. METHODS: A total of 12 439 surveys were performed across 6 states during 6 years on random state-weighted samples of Australians≥40 years old. RESULTS: Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 (P<0.001), as did the unprompted recall of ≥2 most common stroke warning signs 20% to 53% (P<0.001). Awareness of stroke advertising was independently associated with recalling ≥2 common signs (adjusted odds ratio=1.88, 95% confidence interval [1.74-2.04]; P<0.001). Awareness was not greater in respondents with previous stroke or risk factors, except atrial fibrillation. CONCLUSIONS: The Australian public's awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.