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Factors Associated with Unrecognized Acute Ischemic Stroke Among EMS-Transported Patients

Author: Alyssa M. Green, BA, NREMT-P | |

Associate Authors:

Introduction and Background

Limited data exists regarding EMS recognition for acute ischemic stroke. Understanding factors associated with EMS stroke recognition in patients diagnosed with acute ischemic stroke is critical for improving patient outcomes.

Objective

Our objective was to identify factors related to EMS recognizing stroke in patients diagnosed with acute ischemic stroke.

Methods

This retrospective analysis used the 2019 ESO Data Collaborative public use research dataset to analyze linked prehospital and hospital records. Patients diagnosed with acute ischemic stroke were identified by hospital ICD-10 code. We excluded patients with decreased level of consciousness, cardiac arrest, non-9-1-1 encounters and patients without hospital diagnoses. EMS stroke recognition was identified using primary impression, secondary impression, protocol used, stroke alert and/or documented stroke screen. Univariable logistic regression models were used to analyze the relationship between patient/encounter characteristics and EMS stroke recognition. Odds ratios (OR) and 95% confidence intervals (95%CI) are reported.

Results

We analyzed 5939 records for EMS-transported patients diagnosed with acute ischemic stroke. Median patient age was 72 years (IQR: 62,82). Male patients made up 49% of the cohort. Injury was noted in 7% (N = 428) of patients. EMS recognized stroke in 61% (N = 3,623) of patients.
There was a three-fold increase in odds of stroke recognition when responding emergent (OR: 3.51, 95% CI: 2.93-4.23). Patients with an injury had 71% lower odds of EMS recognizing stroke (OR: 0.29, 95% CI: 0.24-0.36).
Odds of stroke recognition were 13% lower for female patients compared to males (OR: 0.87, 95% CI: 0.78-0.97). Additionally, odds of EMS stroke recognition were 25% lower for Hispanic patients (OR: 0.75, 95% CI: 0.61-0.94) and 21% lower for Black patients (OR: 0.79, 95% CI: 0.7-0.9) compared to White patients.

Conclusions

Stroke was unrecognized in the prehospital setting for more than 1 in 3 patients diagnosed with ischemic stroke. Stroke recognition was lower when an injury was present, suggesting a possible target for performance improvement initiatives. Disparate prehospital stroke recognition was observed for female, Hispanic, and Black patients, which warrant further investigation. Limitations include convenience samples, potential missing documentation of stroke recognition, and timing of the diagnosis.