Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry

Abstract

Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.

Keywords: emergency medical services (EMS); healthcare qualtiy assessment; medical record linkage; prehospital; quality improvement; registries; stroke.

Figure 1. Flow diagram of included patients.

CT indicates computed tomography; DTCT, door‐to‐computed tomography; EMS, emergency medical services; MASR, Michigan Acute Stroke Registry; and MI‐EMSIS, Michigan's EMS Information System.

Figure 2. Percentage of 5707 EMS–transported stroke cases with documented prehospital stroke performance metric compliance with 95% CIs.

A, Overall EMS performance at the patient level. B, Patient‐level EMS performance by agency stroke transport volume. EMS, emergency medical services; LKW, last known well; OST, on‐scene time; and PSS, prehospital stroke scale.