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Original research
Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols
  1. Eleanor L DiBiasio1,
  2. Mahesh V Jayaraman2,3,4,5,
  3. Lori Oliver2,5,
  4. Gino Paolucci2,5,
  5. Michael Clark2,5,
  6. Cristina Watkins2,5,
  7. Karen DeLisi3,5,
  8. Ann Wilks5,
  9. Shadi Yaghi3,5,
  10. Morgan Hemendinger3,
  11. Grayson L Baird2,6,
  12. J Adam Oostema7,
  13. Ryan A McTaggart2,3,4,5
  1. 1Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
  2. 2Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
  3. 3Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
  4. 4Department of Neurosurgery, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
  5. 5Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island, USA
  6. 6Lifespan Biostatistics Core, Rhode Island Hospital, Providence, Rhode Island, USA
  7. 7Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
  1. Correspondence to Dr. Ryan A McTaggart, Departments of Diagnostic Imaging, Neurology, and Neurosurgery Warren Alpert School of Medicine at Brown University Rhode Island Hospital 593 Eddy Street, Room 377 Providence, RI 02903 USA ; ryan.mctaggart{at}lifespan.org

Abstract

Background Following the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs.

Purpose We developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge.

Methods We assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models.

Results Training was provided for 179 EMS providers throughout the state.

Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%–88%, P<0.0001). Each of the 10 questions was individually assessed and all showed significant gains in EMS knowledge after training (P<0.0001).

Conclusions A brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.

  • stroke

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Introduction

Mechanical thrombectomy (MT) with tissue plasminogen activator (tPA) is now the standard of care for appropriately selected patients with acute ischemic stroke due to emergent large vessel occlusion (ELVO)1 and earlier treatment with MT is associated with superior outcomes.2 Minimizing the time to successful revascularization should not only focus on improving intra-hospital efficiency,3 but also on redesigning pre-hospital systems of care to avoid delays associated with interfacility transfers for potential endovascular candidates.4–6 Although a variety of prehospital stroke severity scores have been derived, few have been validated in the field.7 The Los Angeles Motor Scale (LAMS) score has shown very good validity8–10 and was selected for use in our region.11

In 2015, the Rhode Island Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs,11 which are the only hospitals in the area providing 24/7 neurointerventional coverage. To ensure that EMS protocols are implemented successfully, education and training must be provided to those involved in the affected systems of care. We therefore developed a single-session training curriculum to educate EMS personnel on the statewide protocol for stroke, including use of LAMS in correctly triaging patients as CSC-appropriate in the field. To evaluate the effect of our training on EMS learning, we created an assessment tool to measure knowledge before, and knowledge gained after, the training session. The aim of the present study is to measure the effectiveness of a single training session on EMS provider knowledge, and to propose an educational strategy for EMS personnel in the rapidly evolving field of stroke.

Methods

Training

A multidisciplinary focus group consisting of six stroke providers met to develop the training session. All members of the focus group volunteered to participate, and were selected in order to represent a variety of backgrounds in stroke care (nurses, physicians, advanced practice providers [APPs], and first responders). Each member of the group was asked to identify the topics they felt were most important to address during the training. All members of the group then collaboratively decided on the most important topics to address, which were:  describing ischemic stroke and large vessel occlusion; training on how to perform the LAMS score; and how to triage patients to appropriate stroke centers based on LAMS score and time from onset. A 23-slide PowerPoint presentation was developed with input from all focus group members. The PowerPoint also included definitions of terms such as ‘ELVO’ and ‘thrombectomy,’ epidemiologic data on stroke and the burden of disability on its victims, and information on why minimizing time to treatment is essential and what the treatment options are for ELVO patients. The full PowerPoint used in training is available on the Rhode Island Stroke Task force website.12

One-hour training sessions were held at various times and locations throughout the state over a period of 6 months, with one to two providers leading each training session (MDs, APPs, and/or stroke nurses) and also leading a hands-on practical ELVO simulation event. Training sessions were initiated, arranged, and executed by members of the neurovascular center at our CSC. Following the completion of this pilot program, non-sales market development teams (eg, Stryker Neurovascular) collaborated and helped coordinate our education efforts.

Assessment survey construction and distribution

The assessment tool (see Appendix) was constructed by a quantitative psychologist in conjunction with members of the same focus group who contributed to the training PowerPoint. All focus group participants were asked to contribute questions based on the previously developed training PowerPoint. Questions were selected based on their relative relevance to the training curriculum and how well they simulated real-life conditions under which EMS personnel operate. Content validity was established by ensuring that all questions and answers used in the assessment were derived from the slides provided in training sessions.

EMS attendees at training sessions provided informed consent and were given pre- and post-training tests, which were color-coded and linked by a unique but arbitrary number at the top, thus allowing responses to be anonymous yet matched. EMS participants completed the test prior to the training and then after the training. Data was obtained with IRB approval.

Statistical methods

Test scores were compared before and after training using generalized mixed modeling, assuming binomial (overall score (0–10)) and binary (individual question [1/0]) distributions, with sandwich estimation, where pre/post responses were nested within EMS participants. All modeling was conducted using SAS Software 9.4 (SAS Inc., Cary, NC) using the GLIMMIX procedure. Alpha was established a priori at the 0.05 level and 95% confidence intervals were calculated for point estimates.

Results

Forty-two training sessions were attended by a total of 179 EMS providers throughout the state, all of whom filled out pretests. All but four individuals filled out post-tests as well, for a sample of 175 pre- and post-training assessments. Following training, the average test score improved from 52.4% (95% CI 49% to 56%) to 85.6% (95% CI 83% to 88%, P<0.0001). The proportion of correct responses to each of the 10 questions showed statistically significant improvement after training (see figure 1, P<0.0001 for all 10 questions).

Figure 1

Percent correct, pre- vs. post-training EMS knowledge.

Before training, all questions were answered correctly less than 75% of the time (figure 1). Pre-training EMS knowledge was highest for recognizing the appropriate content of hospital prenotification (question 5, 74.3% correct before training, 95% CI 66.7% to 80.7%) and the components of LAMS (question 3, 70.9% correct before training, 95% CI 63.0% to 77.7%). After training, all questions were answered correctly greater than 75% of the time with the exception of question 2 (56.8% correct after training, 95% CI 50.4% to 66.3%) regarding morbidity associated with untreated ELVO. The educational intervention was highly successful in achieving knowledge in the key areas of the LAMS elements (question 3, 95.5% correct, 95% CI 90.7% to 97.8%), and LAMS-based triage decisions (questions 4, 9, and 10). Furthermore, more than 85% of trainees correctly triaged ELVO case vignettes following training.

Discussion

The stroke chain of survival must change to accommodate the powerful treatment effect of mechanical thrombectomy for ELVO stroke and varying hospital capability (PSCs vs. CSCs) to treat this disease.1 We developed a single-session training curriculum on the LAMS score (components of LAMS can be seen in Figure 2) and its use to correctly triage patients in the field directly to CSCs s directly to CSCs (recommended pre-notification information for CSCs can be seen in Figure 3) according to our statewide EMS stroke protocol.11 After this educational session, trainees demonstrated significant gains in knowledge of the LAMS score, recall of LAMS-based field triage decision rules, and recognition of candidates for direct CSC transport. Areas with greatest knowledge gains after training included vignettes that asked EMS providers to correctly triage hypothetical patients to the appropriate hospital, items that addressed criteria for direct CSC transport, and questions on the definition of ELVO and components of LAMS.

Figure 2

Los Angeles Motor Scale EMS card – front. 

Figure 3

Los Angeles Motor Scale EMS card – back. 

Given that the efficacy of endovascular therapy is time-dependent2 and there are inherent delays in interfacility transfers,4 5 developing strategies to minimize time-to-treatment is essential. EMS may play a critical role in reducing these delays through direct transport of potential endovascular candidates to endovascular-capable facilities. However, recent studies suggest EMS stroke recognition accuracy is modest at baseline13–16 and compliance with existing protocols is inconsistent.17–19 The low baseline rates of EMS knowledge we observed regarding the use of stroke severity scores to appropriately triage patients were therefore not surprising, and demonstrate the importance of stroke education for EMS personnel.

The move toward stroke severity scales and severity-based field triage protocols represents a substantial departure from current EMS practice and therefore we suspect that thorough education, regarding the protocols is likely to be critical to their success. Indeed, an examination of state-wide EMS trauma destination protocols in North Carolina suggested that their impact was likely hampered by inadequate dissemination.20 Our training sessions served multiple purposes: communicating the evidence-based rationale for changing practice, introduction of the specifics of the new protocol, and providing training in the proper conduct and interpretation of the LAMS score. The degree of improvement in protocol knowledge achieved with a relatively brief educational intervention is encouraging and demonstrates that if key messages are effectively communicated, gains in knowledge can be achieved.

Despite this, several limitations to our study must be acknowledged. First, our training and assessment was based on Rhode Island-specific state protocols. Second, we used the same questions for the pre- and post-training assessments. This may have primed participants to be more attuned to answers for these questions during the training, thereby allowing them to more easily recall correct answers for the post-test. Third, our assessment was administered immediately following training and thus it is not known if short-term knowledge gains will be maintained over time. Most importantly, we do not know if improvements in test scores or stroke protocol knowledge will translate into superior EMS performance.

Summary

We demonstrate the efficacy of a brief EMS educational intervention in improving EMS knowledge of a LAMS-based stroke triage protocol. Future studies should examine the durability of these improvements in knowledge and their impact on adherence to state guidelines and outcomes in stroke care.

References

View Abstract

Footnotes

  • Twitter @mobilestroke4U

  • Contributors ELD helped in conceptualization of the research project, design of the assessment tool, data collection, statistical analysis, and drafted and revised the paper. MVJ was involved in data collection and drafting and revising the paper. LO, CW, MC, GP, and KD contributed to design of the assessment tool, implementation of training sessions, data collection, and drafting and revision of the paper. AW was involved in implementation of training sessions and data collection. SY was involved in drafting and revision of the paper. MH contributed data collection, statistical analysis, and drafting and revision of paper. GLB helped in conceptualization of the research project, design of the assessment tool, led the statistical analysis, and helped draft and revise the paper. JAO was integral to interpretation of the data and critical revision of the work. RAM was involved in conceptualization of the research project, design of the assessment tool, implementation of training sessions, and drafting and revising the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Lifespan - Rhode Island Hospital IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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