Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania.
Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania.
West J Emerg Med. 2019 Oct 21;21(2):441-448. doi: 10.5811/westjem.2019.9.43127.
There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol.
We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of "stroke/TIA," "CVA," or "neurological problem" were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score's metrics were evaluated as a surrogate marker for a successful EMS triage protocol.
We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%.
In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.
将大血管闭塞（LVO）中风患者分诊到综合中风中心引起了广泛关注。及时接受介入治疗与改善中风预后相关。准确分诊除了需要使用经过验证的筛选工具外，还需要考虑几个紧急医疗服务（EMS）特定因素。本研究探讨了将改良快速动脉闭塞评估（mRACE）评分纳入现有中风治疗方案。
我们对一家综合中风中心转运的患者的 EMS 和医院病历进行了回顾性分析。纳入符合以下条件的成年患者进行分析：EMS 提供者印象为“中风/TIA”、“CVA”或“神经问题”。EMS 方案要求使用辛辛那提院前中风评分（CPSS）。新方案授权使用 mRACE 评分来识别可直接分诊到综合中风中心的候选者。我们计算了各种中风筛查（CPSS 和 mRACE 检查）对 LVO 中风的检测特异性和敏感性。该评分的指标被评估为成功的 EMS 分诊方案的替代标志物。
我们最终分析了 312 份院前图表。CPSS 评分的敏感性可靠，为 85%。CPSS 对 LVO 的特异性为 73%。对于 mRACE 评分≥5，敏感性为 25%。mRACE 的特异性为 75%。mRACE 评分对 LVO 的阳性预测值估计为 12.50%。
在这项对单一综合中风中心分诊患者的回顾性研究中，增加 LVO 特异性筛选工具并未提高准确性。在院前环境中可靠地分诊 LVO 中风是一项具有挑战性的任务。除了特定中风评分的统计性能外，成功的 EMS 方案还应考虑基于系统的因素，如提供者教育和培训。研究局限性可以为未来的 LVO 分诊方案提供信息。
