Study evaluates capability of emergency medical services to care for stroke patients

Sept. 5, 2013
What happens in the back of an ambulance can save a life.
The skills of emergency medical services (EMS) technicians – and how quickly and well they employ best practices – can be critical to a patient’s survival. This is especially true for stroke patients, who benefit significantly when their illness is diagnosed quickly, clot-dissolving medications are delivered in a timely way, and EMS personnel can transport them directly to a specialized stroke center for care. 

Mehul Patel

Mehul Patel

 A UNC study led by Mehul Patel, MSPH, epidemiology doctoral student at the Gillings School of Global Public Health, surveyed 98 of North Carolina’s 100 county-based EMS systems to determine improvements in stroke training and care practices over the last decade.

The study was published online Sept. 5 in the Centers for Disease Control and Prevention’s Preventing Chronic Disease.
Stroke kills more than 130,000 Americans each year, a disproportionate number of whom are North Carolinians.
A 2001 survey of EMS providers in North Carolina found that many systems lacked basic services for stroke. In 2006, state legislation was passed to address stroke care resources in N.C., and by 2010, all N.C. EMS systems were required to use standardized patient care protocols.
Patel and colleagues wanted to know how well the EMS systems complied with the stroke protocol and whether there was variance among counties.

Of the surveyed counties, 95 percent reported that they had provided stroke education and training to EMS personnel within the past two years. Most (96 percent) reported using a validated stroke scale or screening tool to determine the seriousness of the cardiovascular event, and 98 percent reported having a policy to notify hospitals that a stroke patient was in transit.

Among 70 EMS systems surveyed both in 2001 and 2012, significant improvements were observed in education about stroke scales or screening tools (from 61 percent to 93 percent). Major improvements in EMS stroke care, especially in prehospital stroke screening, were made during the decade. The greatest change was an increase in use of validated stroke scale or screening tools (from 23 percent to 96 percent).

However, the researchers found shortcomings in training and overall capacity and found variance between stated policy and actual practice.

Although most systems provided at least two hours of stroke training per year (78 percent), educated personnel at least once each year (69 percent), and covered the basic topics in stroke education (66 percent), only 44 percent demonstrated all of these aspects of training, and 12 percent demonstrated none.

“Personnel education activities should continue to be a focus, especially the content of stroke training sessions,” the authors write.

Only 46 percent reported always communicating the stroke scale or screening results to the destination hospital, despite the fact that 98 percent of the systems had implemented a policy to do so. Previous studies have determined that pre-notification by EMS personnel of a suspected stroke can significantly reduce in-hospital delays and improve treatment.

Although a plan for transporting stroke patients to a specialized stroke center is required in North Carolina, only half of the EMS systems reported always using their plan, and another 12 percent ‘never’ or ‘only sometimes’ used it, suggesting that systems are complying at varying degrees.

The authors conclude that the study offers an example of improvements that can occur after policy changes such as the 2006 legislation in North Carolina. It is important, however, to continue to monitor the capacity of EMS systems to respond to and manage stroke patients. Further study is also needed, they state, to understand how training and protocols translate into actual emergency care received.

“I hope this work emphasizes the importance of EMS in caring for stroke,” Patel said. “EMS personnel are highly trained medical professionals, and EMS systems have policies and plans in place to help ensure recovery from stroke. It’s critical for people to know the stroke warning signs and to call 9-1-1 if they think someone is having a stroke.”

Co-authors from the Gillings School are Kelly Evenson, PhD, research professor of epidemiology; Chirayath Suchindran, PhD, professor of biostatistics; and epidemiology professor Wayne Rosamond, PhD. Other co-authors are Jane Brice, MD, MPH, Gillings School alumna and associate professor of emergency medicine in the UNC School of Medicine, and Kathryn Rose, PhD, an affiliate of SRA International, in Durham, N.C, and adjunct faculty member at the Gillings School.

The study, “Emergency Medical Services Capacity for Prehospital Stroke Care in North Carolina,” is available online.

Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or