Ian Mosley

Stroke Symptoms and the Decision to Call for an Ambulance

Background and Purpose— Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. Methods— For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. Results— One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as “stroke.” Factors independently associated with a call within 1 hour were: speech problems (P=0.009), caller family history of stroke (P=0.017), and the patient was not alone at symptom onset (P=0.018). Conclusions— Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment.

The Impact of Ambulance Practice on Acute Stroke Care

Background and Purpose— Few patients with acute stroke are treated with alteplase, often due to significant prehospital delays after symptom onset. The aims of this study were to: (1) identify factors associated with rapid first medical assessment in the emergency department after a call for ambulance assistance, and (2) determine the impact of ambulance practice on times from the ambulance call to first medical assessment in the emergency department. Methods— During a 6-month period in 2004, all ambulance-transported patients with stroke or transient ischemic attack arriving from a geographically defined region in Melbourne, Australia (population 383 000) to one of 3 hospital emergency departments were assessed prospectively. Ambulance records including the tape recording of the call for ambulance assistance and hospital medical records, were analyzed. Results— One hundred ninety-eight patients were included in the study. One hundred eighty-seven ambulance patient care records were complete and available for analysis. Factors associated with first medical assessment in the emergency department <60 minutes from the ambulance call and <10 minutes from hospital arrival were: Glasgow Coma Scale <13 (P<0.001 and P=0.021) and hospital prenotification (P=0.04 and P<0.001). Paramedic stroke recognition and hospital prenotification were associated with shorter times from the ambulance call to first medical assessment (P=0.001 and P<0.001). Conclusions— Paramedic stroke recognition and hospital prenotification are associated with shorter prehospital times from the ambulance call to hospital arrival and in-hospital times from hospital arrival to first medical assessment. This highlights the importance of including ambulance practice in comprehensive care pathways that span the whole process of stroke care.

Stroke Public Awareness Campaigns Have Increased Ambulance Dispatches for Stroke in Melbourne, Australia

Background and Purpose— Launch of the National Stroke Foundation stroke awareness campaigns has occurred annually during Stroke Week (September) since 2004. From 2006, the campaign used FAST (Face, Arm, Speech, Time) with calling an ambulance added in 2007. The aim of this study was to explore the impact of these campaigns on ambulance dispatches for stroke (Medical Priority Dispatch Card 28) in Melbourne, Australia. Methods— A cross-sectional study examining the monthly proportions of ambulance dispatches for stroke between August 1999 and 2010 was conducted. The proportions of dispatches for stroke were used due to increases in the population and in ambulance dispatches over the study period. These proportions were statistically compared for the month before Stroke Week (August) and the month after Stroke Week (October) for each year and seasonal variation was examined. Results— Between 1999 and 2009, the annual proportion of dispatches for stroke increased from 2.1% (n=4327) to 2.95% (n=9918). When stroke dispatches in August were compared with those in October, a significant increase in October was only detected since the call an ambulance message was added to FAST: 2007 (2.62% to 3.00%, P=0.006), 2008 (2.62% to 3.05%, P=0.003), and 2009 (2.70% to 3.09%, P=0.007). From 2005, the peak season for stroke dispatches shifted from winter to spring. Conclusions— Ambulance dispatches for stroke significantly increased after the National Stroke Foundation campaigns began, particularly in years receiving greater funding and featuring the FAST symptoms and the message to call an ambulance. Monitoring ambulance use appears to be an effective measure of campaign penetration.

Acute Childhood Arterial Ischemic and Hemorrhagic Stroke in the Emergency Department

STUDY OBJECTIVE Little is known about the presenting features of acute ischemic and hemorrhagic stroke in children presenting to the emergency department (ED). Yet, initial clinical assessment is a key step in the management pathway of stroke. We describe the presentation in the ED of children with confirmed acute ischemic and hemorrhagic stroke subtypes. METHODS We conducted a retrospective descriptive case series of consecutive patients aged 1 month to younger than 18 years and presenting to a single-center tertiary ED with radiologically confirmed acute ischemic stroke or hemorrhagic stroke during a 5-year period. Patients were identified by medical record search with International Classification of Diseases, 10th Revision codes for hemorrhagic stroke and through the hospital stroke registry for acute ischemic stroke. Signs, symptoms, and initial management were described. RESULTS Fifty patients with acute ischemic stroke and 31 with hemorrhagic stroke were identified. Mean age was 8.7 years (SD 5.2), and 51% were male. Fifty-six percent were previously healthy. Median time from onset of symptoms to ED presentation was 21 hours (interquartile range 6 to 48 hours) for acute ischemic stroke and 12 hours (interquartile range 4 to 72 hours) for hemorrhagic stroke. Acute ischemic stroke presented with symptoms of focal limb weakness (64%; 95% confidence interval [CI] 49% to 77%), facial weakness (60%; 95% CI 45% to 73%), and speech disturbance (46%; 95% CI 31% to 60%). Few patients with acute ischemic stroke presented with vomiting and altered mental status. Most patients with acute ischemic stroke had a Glasgow Coma Scale (GCS) score of 14 or greater (86%; 95% CI 73% to 94%) and presented with at least 1 focal neurologic sign (88%; 95% CI 73% to 98%). Hemorrhagic stroke presented with headache (73%; 95% CI 54% to 87%), vomiting (58%; 95% CI 40% to 75%), and altered mental status (48%; 95% CI 30% to 67%). GCS score in hemorrhagic stroke was less than 14 in 38% and less than 8 in 19% (95% CI 7% to 37%). Less than one third of patients had focal limb weakness, facial weakness, or slurred speech. Nineteen percent of patients with hemorrhagic stroke were intubated in the ED and admitted to the ICU. None of the acute ischemic stroke patients were intubated in the ED, and 4% were admitted to the ICU. CONCLUSION Diagnosis of stroke in children with acute ischemic stroke and hemorrhagic stroke was delayed. Acute ischemic stroke presented mainly with focal findings; hemorrhagic stroke, with headache, vomiting, and mental status change.

Australian Public’s Awareness of Stroke Warning Signs Improves After National Multimedia Campaigns

Background and Purpose— The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia. Methods— A total of 12 439 surveys were performed across 6 states during 6 years on random state–weighted samples of Australians ≥40 years old. Results— Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 (P<0.001), as did the unprompted recall of ≥2 most common stroke warning signs 20% to 53% (P<0.001). Awareness of stroke advertising was independently associated with recalling ≥2 common signs (adjusted odds ratio=1.88, 95% confidence interval [1.74–2.04]; P<0.001). Awareness was not greater in respondents with previous stroke or risk factors, except atrial fibrillation. Conclusions— The Australian public’s awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.

Establishment of an effective acute stroke telemedicine program for Australia: protocol for the Victorian Stroke Telemedicine project

Rationale Urgent treatment of acute stroke in rural Australia is problematic partly because of limited access to medical specialists. Utilization of telemedicine could improve delivery of acute stroke treatments in rural communities. Aim The study aims to demonstrate enhanced clinical decision making for use of thrombolysis within 4·5 h of ischemic stroke symptom onset in a rural setting using a telemedicine specialist support model. Design A formative program evaluation research design was used. The Victorian Stroke Telemedicine program was developed and will be evaluated over five stages to ensure successful implementation. The phases include: (a) preimplementation phase to establish the Victorian Stroke Telemedicine program including the clinical pathway, data collection tools, and technology processes; (b) pilot clinical application phase to test the pathway in up to 10 patients; (c) modification phase to refine the program; (d) full clinical implementation phase where the program is maintained for one-year; and (e) a sustainability phase to assess project outcomes over five-years. Qualitative (clinician interviews) and quantitative data (patient, clinician, costs, and technology processes) are collected in each phase. Study outcomes The primary outcome is to achieve a minimum 10% absolute increase in eligible patients treated with thrombolysis. Secondary outcomes are utilization of the telestroke pathway and improvements in processes of stroke care (e.g., time to brain scan). We will report door to telemedicine consultation time, length of telemedicine consultation, clinical utility and acceptability from the perspective of clinicians, and 90-day patient outcomes. Summary This research will provide evidence for an effective telestroke program for use in regional Australian hospitals.

Can the FAST and ROSIER adult stroke recognition tools be applied to confirmed childhood arterial ischemic stroke

BackgroundStroke recognition tools have been shown to improve diagnostic accuracy in adults. Development of a similar tool in children is needed to reduce lag time to diagnosis. A critical first step is to determine whether adult stoke scales can be applied in childhood stroke.Our objective was to assess the applicability of adult stroke scales in childhood arterial ischemic stroke (AIS)MethodsChildren aged 1 month to < 18 years with radiologically confirmed acute AIS who presented to a tertiary emergency department (ED) (2003 to 2008) were identified retrospectively. Signs, symptoms, risk factors and initial management were extracted. Two adult stroke recognition tools; ROSIER (Recognition of Stroke in the Emergency Room) and FAST (Face Arm Speech Test) scales were applied retrospectively to all patients to determine test sensitivity.Results47 children with AIS were identified. 34 had anterior, 12 had posterior and 1 child had anterior and posterior circulation infarcts. Median age was 9 years and 51% were male. Median time from symptom onset to ED presentation was 21 hours but one third of children presented within 6 hours. The most common presenting stroke symptoms were arm (63%), face (62%), leg weakness (57%), speech disturbance (46%) and headache (46%). The most common signs were arm (61%), face (70%) or leg weakness (57%) and dysarthria (34%). 36 (78%) of children had at least one positive variable on FAST and 38 (81%) had a positive score of ≥1 on the ROSIER scale. Positive scores were less likely in children with posterior circulation stroke.ConclusionThe presenting features of pediatric stroke appear similar to adult strokes. Two adult stroke recognition tools have fair to good sensitivity in radiologically confirmed childhood AIS but require further development and modification. Specificity of the tools also needs to be determined in a prospective cohort of children with stroke and non-stroke brain attacks.

What is Stroke Symptom Knowledge

Background No commonly agreed definition exists for ‘stroke symptom knowledge’ among members of the general public. Recalling at least one correct stroke symptom has been used in the past. However, this criterion was not associated with rapid presentation to hospital. Rapid presentation is vital in order to provide effective acute stroke treatment. Aims and/or hypothesis We sought to identify a base level of community stroke symptom knowledge associated with stroke recognition when symptoms occur, an immediate ambulance call, and ‘stroke recognition and immediately calling an ambulance’ as a single sequence of events. Methods For six-months in 2004–2005, we identified all patients with stroke living in a defined region of Melbourne and who were transported by ambulance to one of the three hospitals. The person who called the ambulance (caller) was interviewed. Results One hundred ninety-eight patients were identified and 150 callers interviewed. Symptoms reported most frequently were limb weakness (67%), speech problems (57%), and facial weakness (24%). Reporting at least two of the symptoms – facial weakness, limb weakness, or speech problems (62% of callers) – was associated with stroke recognition (P = 0.004), immediately calling an ambulance (P = 0.065), and both ‘stroke recognition and immediately calling an ambulance’ (P = 0.053). Conclusions Knowing at least two of the symptoms – facial weakness, limb weakness, and speech problems – appears to be an appropriate indicator of stroke symptom knowledge as it is associated with stroke recognition and appropriate action. Recognizing stroke symptoms and immediately calling an ambulance increase the potential to reduce prehospital time delays and improve eligibility of acute stroke patients for rapid treatment.

Is telemedicine helping or hindering the delivery of stroke thrombolysis in rural areas? A qualitative analysis.

Fast diagnosis and delivery of treatment to patients experiencing acute stroke can reduce subsequent disability. While telemedicine can improve rural community access to specialists and facilitate timely diagnosis and treatment decisions, it is not widely used for stroke in Australia.

Parental Care–Seeking Behavior and Prehospital Timelines of Care in Childhood Arterial Ischemic Stroke

Background and Purpose— Taking appropriate action in the prehospital setting is important for rapid stroke diagnosis in adults. Data are lacking for children. We aimed to describe parental care–seeking behavior and prehospital timelines of care in childhood arterial ischemic stroke. Methods— A structured questionnaire was developed, using value-focused event-driven conceptual modeling techniques, to interview parents of children presenting to the emergency department with arterial ischemic stroke from 2008 to 2014. Results— Twenty-five parents (median age 41 years, interquartile range 36–45) were interviewed. Twenty-four children were awake, and 1 child was asleep at stroke onset; 23 had sudden onset symptoms. Location at stroke onset included home (72%), school (8%), or other setting (20%). Carergivers present included parent (76%), another child (8%), teacher (4%), or alone (8%). Eighty-four percent of parents thought symptoms were serious, and 83% thought immediate action was required, but only 48% considered the possibility of stroke. Initial actions included calling an ambulance (36%), wait and see (24%), calling a general practitioner (16%) or family member (8%), and driving to the emergency department or family physician (both 8%). Median time from onset to emergency department arrival was 76 minutes (interquartile range 53–187), being shorter for ambulance-transported patients. Conclusions— Stroke recognition and care-seeking behavior are suboptimal, with less than half the parents considering stroke or calling an ambulance. Initiatives are required to educate parents about appropriate actions to facilitate time-critical interventions.