Matthew Rudd

Stroke and TIA Assessment Training: A New Simulation-Based Approach to Teaching Acute Stroke Assessment

Introduction Patient simulators provide an opportunity for teams to rehearse scenarios where a rapid coordinated response is essential for improving the clinical outcome. Treatment of acute ischemic stroke is time dependent and intravenous thrombolysis must be administered within hours of symptom onset. This requires a complicated assessment process often led in its initial stages by emergency department staff. We describe a new single-day training event that uses simulated scenarios to demonstrate stroke recognition and an intravenous thrombolysis protocol. Methods Stroke and TIA Assessment Training (STAT) uses video and audio clips from real patients in conjunction with a patient simulator to create interactive scenarios for emergency department staff. Results Between May 2009 and April 2011, 779 clinical staff in the United Kingdom attended a STAT course. Data from the first year of STAT showed that learner self-confidence for stroke assessment increased significantly. The use of the simulator was highly valued. Conclusions A patient simulator can be successfully combined with patient video material to demonstrate neurologic features in the context of acute stroke assessment.

Remote specialist assessment for intravenous thrombolysis of acute ischaemic stroke by telephone

Objective To describe the process, efficacy and safety of intravenous thrombolysis for acute ischaemic stroke in an emergency department (ED) setting with remote specialist support through structured telephone consultation. Design Retrospective case series. Setting Three EDs within a single stroke service in northern England. Participants Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010. Outcome measures Combined death and dependency at 90 days (0–2 on the modified Rankin Scale for a good outcome vs 3–6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage. Results 192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone). Conclusion In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

A systematic review of stroke recognition instruments in hospital and prehospital settings

Background We undertook a systematic review of all published stroke identification instruments to describe their performance characteristics when used prospectively in any clinical setting. Methods A search strategy was applied to Medline and Embase for material published prior to 10 August 2015. Two authors independently screened titles, and abstracts as necessary. Data including clinical setting, reported sensitivity, specificity, positive predictive value, negative predictive value were extracted independently by two reviewers. Results 5622 references were screened by title and or abstract. 18 papers and 3 conference abstracts were included after full text review. 7 instruments were identified; Face Arm Speech Test (FAST), Recognition of Stroke in the Emergency Room (ROSIER), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Scale (MASS), Ontario Prehospital Stroke Screening tool (OPSS), Medic Prehospital Assessment for Code Stroke (MedPACS) and Cincinnati Prehospital Stroke Scale (CPSS). Cohorts varied between 50 and 1225 individuals, with 17.5% to 92% subsequently receiving a stroke diagnosis. Sensitivity and specificity for the same instrument varied across clinical settings. Studies varied in terms of quality, scoring 13–31/36 points using modified Standards for the Reporting of Diagnostic accuracy studies checklist. There was considerable variation in the detail reported about patient demographics, characteristics of false-negative patients and service context. Prevalence of instrument detectable stroke varied between cohorts and over time. CPSS and the similar FAST test generally report the highest level of sensitivity, with more complex instruments such as LAPSS reporting higher specificity at the cost of lower detection rates. Conclusions Available data do not allow a strong recommendation to be made about the superiority of a stroke recognition instrument. Choice of instrument depends on intended purpose, and the consequences of a false-negative or false-positive result.

Agreement between ambulance and hospital records for information promoting urgent stroke treatment decisions

Objective Rapid decision-making during acute stroke care can improve outcomes. We wished to assess whether crucial information to facilitate decisions is routinely collected by emergency practitioners before hospital admission. Materials and methods We examined whether ambulance records contained information relevant to a thrombolysis treatment decision for consecutive stroke admissions to three emergency departments in England between 14 May 2012 and 10 June 2013. Results In all, 424 of 544 (78%) records included a paramedic diagnosis of stroke. Twice as many hospital records contained a symptom onset time/last known to be well time, but there was 82% agreement within 1 h when a prehospital time was also recorded. This was more likely for younger patients. Documentation of medication history was infrequent (12%), particularly for anticoagulant status (6%). When compared with hospital documentation, paramedics recorded a history of diabetes for 38/49 (78%), previous stroke 44/69 (64%), hypertension 71/140 (51%) and atrial fibrillation 19/64 (30%). Conclusion In a retrospective cohort of stroke patients admitted by emergency ambulance, standard practice did not consistently result in prehospital documentation of information that could promote rapid treatment decisions. Training emergency practitioners and/or providing clinical protocols could facilitate early stroke treatment decisions, but prehospital information availability is likely to be a limiting factor.

Understanding clinicians' decisions to offer intravenous thrombolytic treatment to patients with acute ischaemic stroke: a protocol for a discrete choice experiment

Background Intravenous thrombolysis is an effective emergency treatment for acute ischaemic stroke for patients meeting specific criteria. Approximately 12% of eligible patients in England, Wales and Northern Ireland received thrombolysis in the first quarter of 2013, yet as many as 15% are eligible to receive treatment. Suboptimal use of thrombolysis may have been largely attributable to structural factors; however, with the widespread implementation of 24/7 hyper acute stroke services, continuing variation is likely to reflect differences in clinical decision-making, in particular the influence of ambiguous areas within the guidelines, licensing criteria and research evidence. Clinicians’ perceptions about thrombolysis may now exert a greater influence on treatment rates than structural/service factors. This research seeks to elucidate factors influencing thrombolysis decision-making by using patient vignettes to identify (1) patient-related and clinician-related factors that may help to explain variation in treatment and (2) associated trade-offs in decision-making based on the interplay of critical factors. Methods/analysis A discrete choice experiment (DCE) will be conducted to better understand how clinicians make decisions about whether or not to offer thrombolysis to patients with acute ischaemic stroke. To inform the design, exploratory work will be undertaken to ensure that (1) all potentially influential factors are considered for inclusion; and (2) to gain insights into the ‘grey areas’ of patient factors. A fractional factorial design will be used to combine levels of patient factors in vignettes, which will be presented to clinicians to allow estimation of the variable effects on decisions to offer thrombolysis. Ethics and dissemination Ethical approval for this study was obtained from the Newcastle University Research Ethics Committee. The results will be disseminated in peer review publications and at national conferences. Findings will be translated into continuing professional development activities and will support implementation of a computerised decision aid for thrombolysis (COMPASS) in acute stroke care.

Study on centralising acute stroke services provides no firm conclusions

The improvement in London and Manchester stroke services is important and has offered real clinical benefits to patients.1 However, several problems with the study of Morris and colleagues (and more broadly) limit the extent of the conclusion that increased centralisation of stroke (and other) services automatically improves clinical outcomes. Comparing services in London and Manchester with those in the …

A novel design process for selection of attributes for inclusion in discrete choice experiments: case study exploring variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke

BackgroundA discrete choice experiment (DCE) is a method used to elicit participants’ preferences and the relative importance of different attributes and levels within a decision-making process. DCEs have become popular in healthcare; however, approaches to identify the attributes/levels influencing a decision of interest and to selection methods for their inclusion in a DCE are under-reported. Our objectives were: to explore the development process used to select/present attributes/levels from the identified range that may be influential; to describe a systematic and rigorous development process for design of a DCE in the context of thrombolytic therapy for acute stroke; and, to discuss the advantages of our five-stage approach to enhance current guidance for developing DCEs.MethodsA five-stage DCE development process was undertaken. Methods employed included literature review, qualitative analysis of interview and ethnographic data, expert panel discussions, a quantitative structured prioritisation (ranking) exercise and pilot testing of the DCE using a ‘think aloud’ approach.ResultsThe five-stage process reported helped to reduce the list of 22 initial patient-related factors to a final set of nine variable factors and six fixed factors for inclusion in a testable DCE using a vignette model of presentation.ConclusionsIn order for the data and conclusions generated by DCEs to be deemed valid, it is crucial that the methods of design and development are documented and reported. This paper has detailed a rigorous and systematic approach to DCE development which may be useful to researchers seeking to establish methods for reducing and prioritising attributes for inclusion in future DCEs.

Letter by Price et al Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We welcome the comments made by Price et al1 and Brandler and Sharma2 and are grateful for the opportunity to respond to their observations. In our study,3 ambulance clinicians had to suspect a stroke before they used the Recognition of Stroke in the Emergency Room (ROSIER). Our clinicians use a range of factors to suspect that a patient is having a stroke including clinical assessments and observations taken on scene, medical history, history of the current event, medications, and the call determinant allocated during triage of the emergency call for help. Our clinicians practice in line with the Joint Royal Colleges Ambulance Liaison Committee’s UK Ambulance Service Clinical Practice Guidelines.4 The average age of patients in our study was indeed relatively young at 65 years; however, this is representative of suspected stroke patients in the area of London where our study was conducted. Our stroke audit figures from last year (2012/13) show that the average age of suspected stroke patients conveyed by our clinicians to the hospital involved in our study was 67 years, which is consistent with the age reported in our article. Information from the 2011 National Census5 confirms that the …