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. 2023 Sep;54(9):2279-2285.
doi: 10.1161/STROKEAHA.123.042644. Epub 2023 Jul 19.

Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

Luuk Dekker #  1 , Jasper D Daems #  2   3 , Martijne H C Duvekot  2   4 , T Truc My Nguyen  1 , Esmee Venema  3   5 , Adriaan C G M van Es  6 , Anouk D Rozeman  4 , Walid Moudrous  7 , Kirsten R I S Dorresteijn  8 , Jan-Hein J Hensen  9 , Jan Bosch  10 , Erik W van Zwet  11 , Els L L M de Schryver  12 , Loet M H Kloos  13 , Karlijn F de Laat  14 , Leo A M Aerden  15 , Ido R van den Wijngaard  1 , Diederik W J Dippel  2 , Henk Kerkhoff  4 , Marieke J H Wermer  1   16 , Bob Roozenbeek #  2 , Nyika D Kruyt #  1 ; LPSS and PRESTO Investigators
Collaborators, Affiliations

Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

Luuk Dekker et al. Stroke. 2023 Sep.

Abstract

Background: It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians.

Methods: We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference.

Results: We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%).

Conclusions: The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.

Keywords: cerebrovascular disorders; hemorrhagic stroke; ischemic stroke; paramedics; thrombectomy; transient ischemic attack; triage.

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Conflict of interest statement

Disclosures Dr Kruyt reported receiving grant HA20 15.01.02 from the Dutch Brain Foundation, grant 3.240 from the Dutch Innovation Funds, and grant LSHM16041 from Health~Holland during the conduct of the study. Dr Roozenbeek reported funding from the Dutch Heart Foundation and the Netherlands Organization for Health Research and Development (ZonMw) during the conduct of this study, paid to the institution. Dr Wermer reported receiving Clinical Established Investigator grant 2016T086 from the Dutch Heart Foundation and VIDI grant 9171337 from the Netherlands Organization for Health Research and Development (ZonMw) during the conduct of the original LPSS study (Leiden Prehospital Stroke Study). Dr Dippel reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, the Netherlands Organization for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and unrestricted grants from Penumbra Inc, Stryker, Medtronic, Thrombolytic Science, LLC, and Cerenovus for research, all paid to institution outside the submitted work. Dr van den Wijngaard reports compensation from Philips and Medtronic for consultant services, and stock holdings in Neurophyxia BV. The other authors report no conflicts.

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