Why aren't you testing these much earlier ideas out? Incompetently don't know about them? Your NIHSS has no objectivity.
Hats off to Helmet of Hope - stroke diagnosis in 30 seconds; February 2017
New Device Quickly Assesses Brain Bleeding in Head Injuries - 5-10 minutes April 2017
Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial
- et al.
Published:September, 2023DOI:https://doi.org/10.1016/S1474-4422(23)00237-5
Summary
Background
Timely treatment of acute stroke depends on early identification and triage. Improved
methods for recognition of stroke in the prehospital setting are needed. We aimed
to assess whether use of the National Institutes of Health Stroke Scale (NIHSS) by
paramedics in the ambulance could improve communication with the hospital, augment
triage, and enhance diagnostic accuracy of acute stroke.
Methods
The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge,
single-blind, cluster-randomised controlled trial. Patients with suspected acute stroke,
who were evaluated by paramedics from five ambulance stations in Oslo, Norway, were
eligible for inclusion. The five ambulance stations (defined as clusters) all initially
managed patients according to a standard stroke protocol (control group), with randomised
sequential crossover of each station to the intervention group. The intervention consisted
of supervised training on NIHSS scoring, a mobile application to aid scoring, and
standardised communication with stroke physicians. Random allocation was done via
a simple lottery draw by administrators at Oslo University Hospital, who were independent
of the research team. Allocation concealment was not possible due to the nature of
the intervention. The primary outcome was the positive predictive value (PPV) for
prehospital identification of patients with a final discharge diagnosis of acute stroke,
analysed by intention to treat. Prespecified secondary safety outcomes were median
prehospital on-scene time and median door-to-needle time. This trial is registered
with ClinicalTrials.gov, NCT04137874, and is completed.
Findings
Between June 3, 2019, and July 1, 2021, 935 patients were evaluated by paramedics
for suspected acute stroke. 134 patients met exclusion criteria or did not consent
to participate. The primary analysis included 447 patients in the intervention group
and 354 in the control group. There was no difference in PPV for prehospital identification
of patients with a final discharge diagnosis of acute stroke between the intervention
group (48·1%, 95% CI 43·4–52·8) and control group (45·8%, 40·5–51·1), with an estimated
percentage points difference between groups of 2·3 (95% CI –4·6 to 9·3; p=0·51). Median
prehospital on-scene time increased by 5 min in the intervention group (29 min [IQR
23–36] vs 24 min [19–31]; p<0·0001), whereas median door-to-needle time was similar between
groups (26 min [21–36] vs 27 min [20–36]; p=0·90). No prehospital deaths were reported in either group.
Interpretation
The intervention did not improve diagnostic accuracy in patients with suspected stroke.
A general increase in prehospital time during the pandemic and the identification
of smaller strokes that require more deliberation are possible explanations for the
increased on-scene time. The ParaNASPP model is to be implemented in Norway from 2023,
and will provide real-life data for further research.
Funding
Norwegian Air Ambulance Foundation and Oslo University Hospital.
No comments:
Post a Comment