Open AccessPotential accuracy of prehospital NIHSS‐based triage for selection of candidates for acute endovascular stroke therapy
Author(s) -
Klingman Jeffrey G.,
Alexander Janet G.,
Vinson David R.,
Klingman Lauren E.,
NguyenHuynh Mai N.
Publication year - 2021
Publication title -
journal of the american college of emergency physicians open
Language(s) - English
Resource type - Journals
ISSN - 2688-1152
DOI - 10.1002/emp2.12441
Subject(s) - medicine , triage , stroke (engine) , acute stroke , emergency medicine , referral , psychological intervention , emergency medical services , medical emergency , emergency department , family medicine , mechanical engineering , psychiatry , engineering
Abstract Objective Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)‐capable center is controversial. We sought to estimate the accuracy of field‐based identification of potential EST candidates in a hypothetical best‐of‐all‐worlds situation. Methods In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. Results Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. Conclusions Even if field‐based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST‐capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door‐to‐needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST‐capable centers.