Fast track — ArticlesThe Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument
Introduction
The benefits of early assessment and hyperacute treatment of stroke patients with thrombolysis within the first 3 h is well known.1, 2 Additional reasons to achieve rapid early diagnosis of suspected stroke in the emergency room (ER) are to facilitate early transfer of stroke patients to organised acute stroke care, and to initiate appropriate treatment for events that mimic stroke, such as seizure, acute confusional states due to sepsis, syncope, and hypoglycaemia. The efficacy of treatment with thrombolysis is highly time dependent, which increases the importance of a prompt diagnosis. Since patients commonly first present to the ER, ER physicians have a critical and potentially expanding role at the forefront of stroke management. One of the challenges in this setting lies in expediting rapid triage while achieving good diagnostic accuracy.3, 4, 5 Delayed early assessment and ineffective triage may deny timely administration of thrombolytic therapy in up to two-thirds of patients.6 Diagnostic accuracy of ER physicians varies from 22% to 96%.7, 8, 9, 10, 11 In the study that reported a very high diagnostic accuracy,11 all referrals had received prior CT brain scanning in a large urban teaching hospital in which a comprehensive stroke intervention programme was in place. The differentiation of common stroke mimics presenting to the ER can be a challenge to physicians who do not specialise in stroke care.12
Substantial progress has been made with the development of stroke diagnostic tools for ambulance paramedics. Rapid assessment and triage by paramedics has achieved a consistent diagnostic accuracy of between 80% and 95%, with stroke assessment instruments such as the Cincinnati Pre-hospital Stroke Scale (CPSS) and the Los Angeles Pre-hospital Stroke Screen (LAPSS) in the USA, and the Face Arm Speech Test (FAST) in the UK.7, 13, 14, 15 In the light of this experience, we hypothesised that the development of a similar stroke recognition instrument for the ER would be a means of increasing diagnostic accuracy and improving rapid triage of stroke patients. In the UK, clinical assessment and brain imaging of patients admitted with suspected acute stroke to the ER is often delayed.16 Therefore, our aim was to develop and validate a simple and practical clinical stroke recognition instrument for ER physicians.
Section snippets
Methods
This study was divided into two phases. First, a development phase, in which data were prospectively collected over a 1-year period for the purpose of designing the Recognition of Stroke in the Emergency Room (ROSIER) scale. Second, a prospective validation phase, during which independent validation of the ER physicians' use of ROSIER was undertaken over a 9-month period. The study was reviewed by the Newcastle Joint Ethics committee who decided that written informed consent was not required
Results
343 patients were assessed between Aug 1, 2001, and July 31, 2002, with similar numbers of stroke and non-stroke cases (table 1). Age and sex were similar between stroke and non-stroke cases. The median time from admission to assessment by the research neurologist (95% of cases) and senior physicians of the stroke team was 300 mins (IQR 150–480). The most common stroke mimics were seizure, syncope, and sepsis, which together composed 56% of the total non-stroke cases (table 1). Prevalence and
Discussion
The ROSIER scale is a clinical diagnostic stroke scale that is simple, sensitive, specific, and suitable for use in the ER. The early distinction between stroke and non-stroke is becoming more important with the increasing use of thrombolytic therapy. Whereas developments in stroke imaging, such as diffusion-weighted MRI, may be able to exclude stroke mimics, assessment of a patient with suspected stroke usually starts with a non-specialist clinical assessment and often ends with an expert
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