Houston Paramedic and Emergency Stroke Treatment and Outcomes Study

Houston Paramedic and Emergency Stroke Treatment and Outcomes Study
(HoPSTO)
Anne W. Wojner-Alexandrov, Andrei V. Alexandrov, Diana Rodriguez, David Persse
and James C. Grotta
Stroke 2005;36;1512-1518; originally published online Jun 16, 2005;
DOI: 10.1161/01.STR.0000170700.45340.39
Stroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514
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Houston Paramedic and Emergency Stroke Treatment and
Outcomes Study (HoPSTO)
Anne W. Wojner-Alexandrov, PhD; Andrei V. Alexandrov, MD; Diana Rodriguez;
David Persse, MD; James C. Grotta, MD
Background and Purpose—Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid
transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital
performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines.
Methods—Pre-intervention and active-intervention phases with parallel data measurement points were used. The study
involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and
patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected
acute-stroke patients admitted by Houston Fire Department–Emergency Medical Services. A multilevel educational
intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-
performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study.
Results—Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating
hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department—Emergency
Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase
(P 0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of
symptom onset increased from 58% to 62% (P 0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post–
tissue plasminogen activator hemorrhage (3.7%) reported.
Conclusions—A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and
increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window.
Stroke center development supports safe thrombolytic practice in community settings. (Stroke. 2005;36:1512-1518.)
Key Words: community health services
education
paramedics
stroke, acute
thrombolytic therapy
StrokerepresentsasignificantmedicalproblemintheUnited Commission on Accreditation of Health Care Organizations
States, with annual estimates of new cases approximating
launched a certification program for Primary Stroke Centers
700 000, of which 160 000 result in death.1,2 As the leading
supported by the BAC and ASA guidelines.8 It is expected
cause of adult disability, stroke produces significant burden for
that formal stroke center recognition will consolidate re-
individuals and communities, carrying lifetime costs averaging
sources such as diagnostic capabilities and personnel trained
$90 000 per patient for ischemic stroke, $124 000 per patient for
to assess and implement evidenced-based practices, as well as
intracranial hemorrhage, and $225 000 per patient in the case of
make evident to the public the location of centers able to
subarachnoid hemorrhage.3
support the needs of stroke victims.
In 1997, a national consensus conference identified the
Developing cooperation among competing hospitals to facil-
need to establish designated stroke centers where patients
itate stroke center development is complex, and effecting im-
with suspected stroke could receive emergent, comprehensive
provement in public recognition of stroke warning signs has
care.4 The Brain Attack Coalition5 (BAC) furthered this
been shown to be difficult, yet essential.9–11 Similarly, facilitat-
recommendation with a framework for stroke center devel-
ing change in paramedic prehospital care and transport practices
opment adopted by the American Stroke Association (ASA),
is challenging, although these factors have been identified as
along with published performance indicators for stroke cen-
significant contributors to timely emergency department (ED)
ters to support program development and ongoing practice
arrival,12,13 ultimately effecting thrombolysis candidacy. In this
improvement.6 The set of ASA guidelines Get with the
study, we sought to develop citywide stroke centers and improve
Guidelines—Stroke7 was recently developed to promote
prehospital paramedic performance to increase the number of
stroke center development, and, most recently, the Joint
patients receiving acute stroke treatment.
Received November 30, 2004; final revision received March 4, 2005; accepted April 21, 2005.
From the University of Texas–Houston, Stroke Program (A.W.W.-A., A.V.A., J.C.G.), Department of Neurology, Houston Tex; and the Houston Fire
Department Emergency Medical Services (D.A., D.P.), Houston, Tex.
Correspondence to Anne W. Wojner-Alexandrov, Stroke Program, Dept of Neurology, University of Texas–Houston Health Science Center, 6431
Fannin, MSB 7.044, Houston, TX 77030. E-mail: anne.wojner@health-outcomes-institute.com
© 2005 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000170700.45340.39
1512
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TABLE 1.
Characteristics of Hospital Study Sites
tation of infusion. Final discharge diagnoses were collected to
determine paramedic diagnostic accuracy. Patients transported to
Hospital
Location
Type
Size (n)
Hospital 1 by HFD that were not diagnosed by paramedics with
stroke were screened during the last 3 months of the pre- and
Hospital 1,
Urban; TMC
University-affiliated hospital
750
active-intervention phases to determine final ED diagnoses for use in
stroke center
sensitivity and specificity calculations. Two data collectors were
Hospital 2
Urban; TMC
Community hospital
920
used, with one assuming entry of all data into a project registry; a
Hospital 3
Suburban
Community hospital
485
10% random sample of project registry cases was used monthly to
determine inter- and intrarater reliability, consistently revealing
Hospital 4
Suburban
Community hospital
290
100% agreement. Data were entered and analyzed using SPSS
Hospital 5,
Urban; TMC
University-affiliated hospital
1000
(Version 11; SPSS); dichotomous variables were analyzed for
stroke center
differences by
2, whereas continuous variables were analyzed for
differences by Student t test for independent samples or 1-way
Hospital 6
Suburban
Community hospital
250
ANOVA.
TMC indicates Texas Medical Center.
Results
Subjects and Methods
A total of 446 suspected stroke patients (on average 74
The research goal of the study was to determine whether parallel
patients per month) were transported by HFD paramedics to
programs of paramedic, hospital, and community education im-
one of the 6 hospitals during the 6-month pre-intervention
proved stroke care in Houston. The study was approved by the
Committee for Protection of Human Subjects at all sites and the
period, representing 59.8% of the total cases of HFD-EMS
Houston Fire Department (HFD) and took place from September
diagnosed stroke patients transported within the city of
1999 to March 2001.
Houston during this period. During the active-intervention
Houston, Tex, is a multiethnic city of approximately 5 million.
phase, 1072 suspected stroke patients (on average 89 patients
Data from operating year 1998 indicated that HFD paramedics
per month) were transported by HFD-EMS to the same
transported a total of 2382 suspected stroke patients;
75% of these
cases were transported to 1 of 9 Houston hospitals, 4 of which are
hospitals, accounting for 68.7% of stroke cases transported in
centrally located in the Texas Medical Center, whereas the remaining
Houston (P 0.001). Overall, 852 (56%) patients were fe-
5 hospitals are located within the greater Houston community. All 9
male, the mean age was 69 years (SD 30; median 71), and
top-admitting hospitals were approached to participate in the study,
ethnicity was 2% Asian, 14% Hispanic, 40% black, and 44%
and 6 hospitals agreed to participate in the project. Of the 3 hospitals
white; these characteristics were similar in both study phases
declining participation, rationale included lack of administrative and
medical professional incentive because of low stroke reimbursement
(P not significant [NS]).
and disinterest in thrombolysis (2 centers) and no ability to assign a
staff person to assume the role of hospital study coordinator/stroke
Symptom Onset to Emergency Department Arrival
registrar because of nurse staffing shortage (1 center).
During the pre-intervention period, time from suspected
Characteristics describing the 6 participating hospitals are present-
stroke onset to arrival at a study hospital was documented in
ed in Table 1. Hospital 1 had served as a stroke center since 1988,
359 (80.5%) cases from patient and/or witness interview by
and Hospital 5 became a stroke center in 1997. The remaining
participating facilities were community hospitals, none of which had
the ED medical team; in this sample, time from onset of
been designated as a stroke center at the time of baseline data
symptoms to arrival in a study site ED ranged from 14 to
collection; 3 of these community hospitals had access to stroke
4320 minutes, with an interquartile range of 177 minutes
fellowship-trained members of the stroke team from Hospital 1 to
(mean 226 minutes; SD 347; median 95 minutes). In the
assist with emergency patient assessment and treatment.
active-intervention phase, time from suspected stroke onset to
The study was designed with two phases:
arrival at a study site was documented by the ED medical
1. The pre-intervention phase involved the collection of baseline
team in 680 cases (63%) and ranged from 10 to 20 160
paramedic, hospital, and patient data from September 1999 to
minutes, with an interquartile range of 156 minutes
February 2000.
(mean 358; SD 1486; median 89 minutes; P NS). Ex-
2. The active-intervention phase, from March 2000 to March
2001, involved monthly paramedic and hospital education
cluding outliers arriving beyond 24 hours of symptom onset,
based on the BAC and ASA guidelines, including competitive
a decrease in time from symptom onset to arrival in the ED
benchmarking of hospital and paramedic performance; HFD
that approached statistical significance was noted in the
implementation of the LAPSS (Los Angeles Prehospital Stroke
active-intervention phase (mean 180 minutes; t 1.97;
Scale)14 modified by removal of age restrictions; public an-
P 0.054), compared with the pre-intervention phase
nouncement of stroke center designation; multimedia commu-
nity education aimed at identification of stroke warning signs
(mean 214 minutes). Arrival at
120 minutes from symp-
using print, radio, and televised media; and community stroke
tom onset was analyzed for differences because of implica-
screening events coordinated by the Houston Operation Stroke
tions for intravenous tPA treatment; with equal variances
Committee of the ASA.
assumed (Levene test, P 0.09), 210 (58%) pre-intervention
compared with 418 (62%) active-intervention suspected
Pre-intervention and active-intervention data were collected from
paramedic run sheets and hospital charts. Paramedic cases were
stroke patients arrived within 120 minutes (t 3.09; P 0.002;
identified by paramedic diagnosis of stroke documented, and study
mean difference, 6.37; 95% CI 2.3 to 10.4). No differences
variables included time from dispatch to arrival on scene, scene time,
in symptom onset to arrival time by gender, age, or ethnicity
time associated with transport to a study hospital, and time from
were identified.
symptom onset to arrival in the ED. Hospital data were collected
prospectively and reviewed again when the medical record was
Paramedic Diagnostic Accuracy
closed; variables included door to brain computed tomography (CT)
interpretation times and treatment with intravenous tissue plasmin-
Definitive medical diagnosis, determined by neurologist di-
ogen activator (tPA), as identified by physician order and documen-
agnosis of stroke, was verified in 323 (72%) charts during the
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July 2005
Figure 1. Paramedic prehospital treat-
ment and transport times.
pre-intervention phase and 895 (84%) charts in the active-
Emergency Department Arrival to CT
intervention phase. During the pre-intervention phase, para-
Interpretation Time
medic diagnosis of stroke was accurate in 61% (n 198;
During the pre-intervention phase, door to CT interpretation
positive predictive value 0.61) of cases, compared with 79%
times were documented in 261 (59%) cases, of which 180
(n 709; positive predictive value 0.79) accuracy in the
were medically confirmed strokes; in the active-intervention
active-intervention phase. Of the cases misdiagnosed by
phase, 600 (56%) cases had door to CT interpretation times
paramedics as stroke in both phases, the most common
documented, of which 450 were medically confirmed strokes
definitive diagnoses were seizure disorders, altered mental
(Table 3). In both “suspected” and medically confirmed
status, headache, and syncope. Review of 10 564 HFD-EMS
strokes, door to CT times were significantly better in both the
patients transported to Hospital 1 identified 32 (0.3%) cases
pre-intervention and active-intervention phases at the 2 pre-
of stroke that were missed by paramedics during the pre-
existing stroke centers when compared with average com-
intervention phase; in the active-intervention phase, 11 296
bined times for newly established stroke centers. Hospitals 1,
reviewed cases transported to Hospital 1 revealed 39 (0.3%)
2, and 3 tended to improve (P NS) their door to CT
interpretation times, whereas Hospital 5 showed significant
stroke cases missed by HFD-EMS. For patients transferred by
improvement (P 0.045) in times for suspected stroke pa-
HFD-EMS to Hospital 1 during the pre-intervention period,
tients. Hospitals 4 and 6 increased their door to CT interpre-
sensitivity for paramedic diagnosis of stroke was 86% with a
tation times in the active-intervention phase; the increase at
specificity of 99%, compared with 95% sensitivity in the
Hospital 6 coincided with implementation of a new billing
active-intervention phase with a specificity of 98%.
practice by the Neurology section that ensured all stroke CTs
Paramedic Transport Times
were read and billed for by admitting neurologists. No
differences in door to CT interpretation times by gender, age,
Transport time data were available in 445 (99.8%) of pre-
or ethnicity were noted.
intervention cases and 1063 (99.2%) of active-intervention
cases (Figure 1). Time from dispatch to arrival on the scene
Treatment with Intravenous tPA
of a suspected stroke case remained unchanged by the
All 198 (pre-intervention) and 709 (active-intervention) med-
intervention; however, the average time paramedics spent on
ically confirmed stroke cases were reviewed for intravenous
the scene preparing for hospital transport significantly in-
tPA administration. In the pre-intervention phase, Hospitals
creased following the intervention (P 0.001), as did total
1, 2, 4, and 5 exhibited tPA treatment rates ranging from 4.7%
time from dispatch to arrival at a hospital study site
to 19.4% of all strokes admitted, whereas Hospitals 3 and 6
(P 0.001). In both the pre-intervention and active-
did not treat any strokes with tPA (Figure 3). In the active-
intervention phases, community-based hospitals located out-
intervention phase, all sites administered tPA with treatment
side the Texas Medical Center averaged significantly shorter
rates ranging from 6.8% to 17.2% of all stroke admissions.
(P 0.001 both phases) total dispatch to hospital arrival times
Hospital 2 achieved a significantly higher rate of tPA treat-
compared with those sites within the Texas Medical Center
ment in the active-intervention phase with treatments increas-
(Table 2). Figure 2 illustrates HFD-EMS patient distribution
ing from 2 (4.7%) to 15 (17.3%; 2 3.9; P 0.047). Hospi-
by hospital and study phase. Hospital 1 received the majority
tals 1 and 4 experienced a reduction in the number of tPA
of cases in both phases.
treatments during the active-intervention phase, whereas all
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TABLE 2.
Total Dispatch to Emergency Department Arrival Times: Community-Based and
Inner-City Hospitals
Mean
Hospital Type
Mean (min)
t
P
Difference
95% CI
Pre-intervention phase
Inner-city hospitals
44 (sd 13; median 42)
Community Hospitals
39 (sd 13; median 37)
3.9
0.001
4.96
2.4–7.5
Active-intervention phase
Inner-city hospitals
47 (sd 15; median 47)
Community hospitals
43 (sd 13; median 42)
4.5
0.001
3.98
2.2–5.7
other centers experienced an increase in tPA treatments. No
onset to hospital arrival, improve paramedic diagnostic capa-
differences in tPA treatment by gender, age, or ethnicity were
bilities, and promote safe administration of intravenous tPA
noted. Intracranial and/or other systemic hemorrhages were
among community hospitals. Conduct of this study within
not documented in any patients receiving tPA during the
Houston was challenged by a preexisting commitment to the
pre-intervention phase. During the active-intervention phase,
treatment of acute stroke demonstrated by 2 academic stroke
Hospital 1 documented 1 post-tPA intracranial hemorrhage (1
centers; this may have contributed to an overall reduction in
of 27 treated patients [3.7%]).
the effect of the intervention, as baseline symptom response
times and treatment rates were already well above the
Discussion
national average.
Our study showed that implementation of the BAC and ASA
Others have shown the need for significant community
Guidelines through paramedic, health professional, and com-
education using multilevel strategies to effect a change in
munity education may decrease time from patients’ symptom
awareness of stroke prevention, risk factors, and warning
Figure 2. Patient distribution by hospital
and study phase. Pre-intervention stroke
for Hospital 6 was n 6. Pre-I indicates
pre-intervention phase; Active, active-
intervention phase; All, all patients trans-
ferred to each hospital by HFD-EMS with
“suspected” stroke; stroke, all medically
confirmed stroke cases.
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TABLE 3.
Door to CT Times Among Hospital Study Sites
Pre-intervention (min)
Active Intervention (min)
Suspected Strokes
Confirmed Strokes
Suspected Strokes
Confirmed Strokes
Hospital study sites
Hospital 1, preexisting
41 35 (median 27)
38 29 (median 27)
43 71 (median 21)
36 61 (median 20)
Hospital 2
66 60 (median 55)
66 68 (median 45)
52 43 (median 40)
49 45 (median 36)
Hospital 3
95 82 (median 75)
85 73 (median 75)
75 78 (median 50)
58 47 (median 45)
Hospital 4
73 50 (median 58.5)
56 35 (median 50)
78 85 (median 58)
73 89 (median 54.5)
Hospital 5, preexisting
54 59* (median 37)
34 19 (median 30)
35 24* (median 30;
32 21 (median 28)
t 2.0; P 0.045;
mean difference 18;
95% CI 1.4–35.3)
Hospital 6
58 62 (median 33.5)
42 26 (median 33.5)
68 42 (median 61.5)
62 39 (median 60)
Differences between preexisting and
new stroke centers
Preexisting stroke centers, combined
46 46 (median 31;
44 59 (median 28;
36 26 (median 29;
38 53 (median 26;
t 3.9; P 0.001;
t 5.4; P 0.001;
t 4.0; P 0.001;
t 4.5; P 0.001;
mean difference 27;
mean difference 30;
mean difference 28;
mean difference 26;
95% CI 13–40)
95% CI 19–41)
95% CI 14–42)
95% CI 14–35)
New stroke centers, combined
72 63 (median 55)
74 74 (median 56)
65 60 (median 49)
63 63 (median 50)
*P 0.05.
signs to impact early treatment.9–11 In our study, 62% of
ongoing stroke education. Interestingly, paramedic transport
patients in the active-intervention phase arrived within 2
times for suspected stroke cases were lengthened during the
hours of symptom onset, providing time for evaluation and
active-intervention phase with significant increases measured
treatment within the 3-hour intravenous tPA window. Precise
for the time spent on scene for initial paramedic assessment
measurement of community education impact was not con-
and management. Whereas others have shown a decrease in
ducted, limiting our ability to credit this outcome to the
the time spent on scene following education,15 our findings
educational intervention; additional measurement strategies
may have been associated with use of competitive bench-
should be encouraged in future studies to gauge the impact of
marking that likely fostered a heightened degree of vigilance
education more precisely.
in assessment and diagnosis.
Paramedic accuracy in diagnosing stroke improved to 79%
A significant reduction in transport times associated with
during the active-intervention phase and was likely tied to use
transports to suburban-based stroke centers, as compared with
of the age-modified LAPSS14 instrument combined with
intercity centers, was measured in both phases of the study.
Figure 3. tPA treatment rates by hospital
study site.
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Although others have shown benefit to the use of helicopter
Effecting change in paramedic, community, and practitio-
and ground transport services16–21 to support movement of
ner response to stroke care is challenging because of a
patients to comprehensive stroke centers, dependence on
combination of factors, such as internal hospital and medical
aeromedical transport may increase acute-care costs at a time
staff politics, financial disincentives, chaotic prehospital and
when hospital reimbursement for stroke services is minimal.
emergency care environments, and the complexity of com-
Although improvement in quality-of-life years may offset the
municating with diverse communities. Our findings support
increased cost of helicopter transport,22,23 hospital reimburse-
that of others, suggesting that a combination of interventions
ment currently does not offer incentive pay for improved
are necessary to improve stroke care. Lastly, increasing rates
patient outcomes recognized within the post-acute healthcare
of expensive acute stroke treatment are not supported by
sector. Additionally, transport-time differences in our study
current hospital reimbursement, and stroke center develop-
were most likely the result of traffic congestion, making
ment may be stifled by lack of financial incentives, as seen in
dependence on intercity ground transportation an unrealistic
our study. Similar to the experience heralded by cardiologists
option. We suggest, instead, expansion of the number of
for improved reimbursement for acute myocardial infarction,
suburban stroke centers to ensure diagnostic and treatment
improved pay for aggressive treatment of stroke must occur
efficiency at the point of stroke occurrence in the community.
to ensure commitment to standard of care.
According to the BAC5 and ASA6 guidelines, stroke center
hospitals must be able to complete a CT scan within 25
Acknowledgments
minutes of ED admission and have it read by a physician
This work was supported by a grant from the American Stroke
within 20 minutes of scan completion. Significant differences
Association, Division of the American Heart Association.
in door to CT interpretation times between preexisting stroke
centers and newly designated centers were noted in both the
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