Paramedic Response to Acute Stroke/Tia: A Population-based Study of Current Practice and Outcomes
Tunnage, Bronwyn Kaye
One or more files will be made publicly available from 2019-12-15.
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Stroke is a major cause of death and disability. Recent changes in the treatment and care of stroke and transient ischaemic attack (TIA) patients have improved survival and quality of life. However, these therapies are strictly time-dependent, with improved outcomes for early-arriving patients, while late-arriving patients are excluded from some forms of treatment. The overarching aim of this thesis is to explore the paramedic care of acute stroke/TIA patients, through an investigation of the utilisation of the emergency medical services (EMS) as the first medical contact, current EMS practice and patient-focused outcomes. This population-based study links clinical and operational data from the EMS, with patient data from hospital medical records, to explore whether there is a relationship between paramedic care and patient outcomes in acute stroke/TIA. The observational study adopts a quantitative approach and includes records from 2,524 stroke/TIA cases. Sixty-four percent of patients in this study, had their first medical contact with a paramedic rather than with a primary care doctor or Emergency Department staff. Four factors were associated with initial contact with an EMS paramedic: increasing patient age, the presence of signs at onset that were recognisable with a FAST test, a final diagnosis of intracerebral haemorrhage compared to TIA and other sub-classifications compared to lacunar circulation infarct. Paramedics recognised 70 percent of stroke/TIA cases. Six factors were associated with non-recognition of stroke/TIA by paramedics. These factors were: a dispatch code other than stroke, absence of a patient or familial history of stroke/TIA, severity described as minor compared to more severe presentations, absence of a documented FAST assessment, a final diagnosis of intracerebral haemorrhage or ischaemic stroke compared to TIA and a classification of posterior compared to lacunar circulation infarction. Among ischaemic stroke patients, first medical contact with an EMS paramedic was associated with a shorter onset-to-door delay compared to initial contact with a primary care doctor. Thrombolysis rates were higher among ischaemic stroke patients when the paramedic recognised the event. Mortality was higher, and functional independence and quality of life scores were lower among EMS patients than those using other prehospital pathways. These poorer patient outcomes were associated with greater dependency prior to stroke onset or a more severe stroke among this group of patients. However, despite greater severity at baseline in the EMS group, there was no difference between the two groups in the proportion who improved to achieve independent functioning at 28 days. This study identifies a need for increased public awareness of the importance of contacting the EMS in cases of suspected stroke/TIA and of the risk of stroke among younger age groups. Paramedics need to be educated about atypical stroke symptoms and the necessity of screening a wider range of patients in order to improve recognition of stroke/TIA cases. The importance of arriving at a stroke centre as early as possible to maximise the benefits of treatment, rather than within four hours, should be emphasised. Finally, paramedicine as a nascent healthcare profession, should be actively engaged in research collaborations that support evidence-based practice. Files will be made publicly available from 2019-12-15