PRACTICE GUIDELINES
The effect of Cincinnati Prehospital Stroke Scale on telephone triage of stroke patients: evidence-based practice in emergency medical services Javad Malekzadeh MS, a,b Hojjat Shafaee MS, c,d Hamidreza Behnam MS e,f and Amir Mirhaghi PhD a,b a Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, bDepartment of Medical-Surgical Nursing, School of Nursing and Midwifery, Chahrrah-e-Doktorha, Mashhad, Razavi Khorasan, cCritical Care Nursing, Emergency Medical Communication Center, Mashhad University of Medical Sciences, dEmergency Medical Communication Center, Mashhad University of Medical Sciences, Kaghani Blv, Rezashahr, eDepartment of Neonatal and Pediatrics Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, and fDepartment of Neonatal and Pediatrics Nursing, School of Nursing and Midwifery, Chahrrah-e-Doktorha, Mashhad, Razavi Khorasan, Iran
ABSTRACT Background: The emergency medical service is designed to recognize and transfer critically ill patients. Evidencebased practice has rarely been emphasized in the emergency medical service field, especially in the dispatch center. Aims: To identify the effect of the Cincinnati Prehospital Stroke Scale (CPSS) on telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center and to compare CPSS with the National Guidelines for Telephone Triage Tool (NGTT). Methods: A quasi-empirical study was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS. Two hundred and forty-six patients were randomly allocated to the CPSS intervention group (n ¼ 121) and the NGTT control group (n ¼ 125). True triage, triage error and odds ratio were statistically reported. Results: The mean age of the patients was 70.9 12.7 years. Of all the cases, 77.7 and 65.6% of patients in the intervention and the control groups, respectively, were accurately triaged. Under-triage cases were 10.7 and 13.6% of the patients in the intervention and the control groups. Odds ratio was 1.14 (95% confidence interval 0.62–2.07) for the CPSS compared with the NGTT. Conclusion: CPSS is more efficient for use by telephone triage nurses in identifying stroke. The use of CPSS assists nurses by reducing the triage error and supports the evidence-based care. It needs to be developed to cover signs and symptoms of posterior-circulation stroke patients. Key words: CPSS, emergency, prehospital, stroke, telephone, triage Int J Evid Based Healthc 2015; 13:87–92.
Introduction
S
troke is the most prevalent cerebrovascular disease in the world.1 Moreover, stroke is considered to be one of the most important cause of mortality and the main reason for long-term disabilities and morbidity Correspondence: Amir Mirhaghi, PhD, Department of MedicalSurgical Nursing, School of Nursing and Midwifery, Chahrrah-eDoktorha, Mashhad, Razavi Khorasan 9137913199, Iran. E-mail: [email protected] DOI: 10.1097/XEB.0000000000000046
worldwide.2 More than five million people die from stroke each year.3 Some studies have shown the incidence rate of stroke in the Iranian population between 45 and 48 years old is higher than in all the European countries.4 Furthermore, stroke imposes a significant economic cost on the healthcare system.5,6 Prompt recognition and care is crucial7,8 to accelerate rapid and timely thrombolytic therapy in hospitals.9 Although different protocols for telephone triage of stroke have been developed to promote early recognition of stroke patients, previous studies have
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
87
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al.
demonstrated that only 31–52% of stroke calls are being accurately recognized by telephone triage nurses,10 so the efficiency of these protocols is questionable.11–13 Some telephone triage protocols mainly evaluate slurred speech and altered state of consciousness, and do not focus on the loss of movement, whereas this sign often appears in 55–65% of the stroke patients.14 The Cincinnati Prehospital Stroke Scale (CPSS) is an abridged version of the National Institutes of Health Stroke Scale (NIHSS).15 It takes 30–90 s to perform CPSS by nurses in the dispatch center; therefore, it does not significantly interfere with other telephone requests for the emergency service.16 It is simple, brief and easy to follow by people who are not healthcare professionals, so it seems to be an appropriate tool for recognition of stroke symptoms through telephone triage.17 CPSS assesses three major clinical signs including face droop, arm drift and speech clarity in patients.1 However, CPSS has only been used at emergency medical dispatch centers in developed countries, and has not been reported in developing countries.18 Several studies have been conducted on hospital triage,19 whereas only a few have focused on the prehospital telephone triage, so there is in (insufficient) evidence to support the efficiency of telephone triage, especially in patients with stroke.1 In addition, more rigorous methodological research is needed to support the evidence-based practice of CPSS in emergency medical services (EMS) because previous studies have been performed only with a descriptive cross-sectional design. Error in telephone triage must be reduced in order to improve the accurate identification of stroke patients and to rapidly provide treatment and care for them. Several studies have demonstrated that appropriate triage assignment to stroke patients decreases mortality and optimizes resource utilization, as a result of which both under-triage and over-triage should be minimized.20 Therefore, the aim of the present study was to identify the effect of CPSS on the telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center.
Methods A quasi-empirical design was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS, which receives more than 5000 emergency calls daily. Following approval from the university’s ethics committee, informed consent was obtained from each of the telephone triage nurses participating in the study. The need for obtaining informed consent from callers and patients was waived due to the time-critical nature of 88
their circumstances, so all the calls received ambulance services. The content validity of the translated instrument was assessed by 10 experts who had experience in the neurologic emergency and emergency triage. Original CPSS and translated versions were reviewed to work out if the translated version could accurately measure the acuity of stroke patients. A Likert-type scale was used to determine the relevance. Each expert rated the items as follows: 1, not relevant; 2, somewhat relevant; 3, quite relevant and 4, highly relevant. Items that were irrelevant were scored with a 1 and 2, and items that were quite relevant were scored with a 3 and 4. Only items scoring 3 and 4 were considered relevant and thus were used to calculate the actual content validity index (CVI). It was possible to comment for each item if required. Using an inter-rater reliability method, the reliability of the instrument was assessed to compare researchers’ measurements in the pilot study. A random sample of 15 calls was piloted to assess the reliability between caller and another individual who was present at the scene. In addition, inter-rater reliability between two telephone triage nurses was assessed. Telephone triage nurses were divided into two groups including the intervention and the control group. Each group received calls randomly. In the intervention group, CPSS was used to prioritize the patients. The National Guidelines for Telephone Triage (NGTT) has been routinely used at the Emergency Medical Dispatch, so NGTT was used in the control group. NGTT has been a routine protocol to triage patients by telephone triage nurses in the medical dispatch center. It is a questionbased protocol which includes most signs and symptoms of stroke patients and relevant comorbidity factors, except for loss of movement questions. Researchers also upgraded the triage software according to CPSS for the intervention group in the medical dispatch center. All incoming emergency calls were recorded in a secured computerized database. Nurses in the intervention group had been trained to use CPSS. All calls had been examined to evaluate how accurately nurses performed each protocol until all the nurses had successfully utilized protocols during telephone triage conversations. During the study, nurses asked the callers basic questions including their chief complaint and demographic information in both the control and the intervention groups. After initially detecting the patients’ condition, the suspected stroke patients were examined on the basis of their own protocols. Finally, triage nurses identified patients as either positive or negative in terms of stroke. All decisions including ‘expected’ triage
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
PRACTICE GUIDELINES decisions, ‘over triage’ decisions and ‘under triage’ decisions were recorded onto the databases. In the CPSS, ‘no evidence of stroke’ is defined by a score of 0, score 1 represents the presence of ‘few evidence of stroke’, score 2 indicates ‘strong evidence of stroke’ and a score of at least 3 signifies ‘explicit evidence of stroke’. Patients were diagnosed as ‘stroke’ (score of 2) or ‘nonstroke’ (score of 0 or 1). Inclusion criteria were as follows: callers and patients must be aged over 18 years and calls must be placed by the patients’ direct caregivers. Adults have different causes of stroke as compared with pediatric patients (who are aged 18 years and below), and it is assumed that patients’ direct caregivers are more familiar with patients, so it is expected they will have effective communication with the patients. Exclusion criteria were patients with life-threatening conditions such as impaired consciousness and respiratory impairments, or medical requests which were cancelled by the callers. Life-threatening conditions need life support directions in order to save the patients’ life. To monitor outcomes, researchers attended the hospitals to find out the final patient diagnosis. Final diagnosis of stroke documented in patients’ medical records was used as the gold standard to assess the accuracy of the nurses’ decisions in identifying stroke patients through telephone triage. ‘True triage’ cases involved patients whose symptoms were correctly diagnosed as stroke or nonstroke on the basis of final diagnosis. Descriptive and inferential statistics were used. Fisher’s exact test, independent-sample t test, intraclass correlation coefficients and Cohen kappa statistics (k) were employed to analyze the data. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois, USA, and Release 16.0.2).
Results Content validity index of the translated version was 0.98. Callers’ reliability was 0.97. In addition, inter-rater reliability between two telephone triage nurses was high (k ¼ 0.93). Two hundred and forty-six patients were randomly allocated to each group: 121 in the intervention group and 125 in the control group. The mean age of the sample group was 70.9 12.7 years. There was no significant difference in terms of confounding variables between the two groups (Table 1). Of all cases, 77.7% of patients in the intervention group and 65.6% of patients in the control group were accurately triaged. Under-triage cases were 10.7% of the patients in the intervention group and 13.6% of the patients in the control group. Also, over-triage cases were 11.6 and 20.8% of cases, respectively (Fig. 1). Odds ratio (OR) was 1.14 [95% confidence interval (CI) 0.62– 2.07] for the CPSS compared with the NGTT. Of all patients in the intervention group, 57.1% had ischemic stroke, 16.1% had transit ischemic attack and 1.8% had hemorrhagic stroke diagnosis. In the control group, 41.7% had ischemic stroke, 11.7% had transit ischemic attack and 3.3% had hemorrhagic stroke diagnosis (Table 2). Error analysis of nurses’ decisions showed that all occasions of under-triage were missed in spite of the fact that callers reported stroke in 25% of the cases (Table 3).
Discussion Telephone triage nurses in the intervention group were found to recognize stroke patients 12% more accurately as compared with those in the control group. The rate of under-triage and over-triage decisions in the control group was 3 and 9% greater than that of the intervention group, respectively. In the light of the finding, it is argued that the use of CPSS at EMS is likely to improve the accuracy of
Table 1. Distribution of patients’ age and sex, and nurses’ experience Patients’ age (mean SD) Male patients (%) Female patients (%) Nurses’ experience (years old) Emergency calls (%) Calls duration (min) Response timea (min) Operation timeb (min)
Intervention
Control
Total
71.5 12.6 58 (48) 63 (52) 3.5 1.2 47185 (53.47) 1.85 0.28 18.2 5.8 43.9 10.8
70.4 12.9 55 (44) 70 (56) 3.7 1.4 41059 (46.52) 1.63 0.04 17.2 5.9 41.7 11.8
70.9 12.7 113 (46) 113 (54) 3.6 1.3 88244 (100) 1.73 0.16 17.7 5.7 42.9 11.3
There is significant difference between the two groups. a The period between when a (115) emergency call is recorded by the emergency medical dispatch center and the time when the first ambulance arrives at the scene. b The period between when a (115) emergency call is recorded by the emergency medical dispatch center and the time when the first ambulance resource arrives at the hospital.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
89
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al.
100 Intervention Control
Frequency
80 60 40 20 0 True
Error
Over-triage
Under-triage
Accuracy
Figure 1. Accuracy of nurses’ telephone triage of stroke patients. Error contains both over-triage and under-triage data.
telephone triage decisions to recognize stroke patients promptly. The patients who received CPSS were recognized 1.14 times more accurately than the patients who received NGTT. On the basis of these results, the researcher would recommend that all patients who are suspected with stroke should receive CPSS. The NGTT does not place enough emphasis on the motor signs of stroke. Nurses focused mainly on some stroke signs and symptoms (i.e. abnormal speech and impaired consciousness) when using NGTT to identify stroke patients, whereas these clinical features happen in 55–65% of stroke patients14; therefore, using NGTT contributes to the poor recognition of the stroke symptoms. It shows the significance of motor sign of stroke. In general, 80–90% of all stroke patients experience motor
Table 2. Final diagnosis of patients who were recognized as stroke by nurses in telephone triage
Ischemic stroke Transit ischemic attack Hemorrhagic stroke Stress Sepsis Tumor Heart attack Hypoglycemia Uremia Renal failure Other Total a
Intervention (%)
Control (%)
Total (%)
32 (57.1) 9 (16.1)
25 (41.7) 7 (11.7)
57 (49.1) 16 (13.8)
1 (1.8) 3 (5.4) 1 (1.8) 2 (3.6) 1 (1.8) 1 (1.8) 1 (1.8) 1 (1.8) 4 (7.2) 56 (100)
2 (3.3) 3 (5.0) 3 (5.0) 2 (3.3) 2 (3.3) 2 (3.3) 2 (3.3) 2 (3.3) 10 (16.5) 60 (100)
3 (2.6) 6 (5.2) 4 (3.4) 4 (3.4) 3 (2.6) 3 (2.6) 3 (2.6) 3 (2.6) 14 (12.0) 116 (100)
signs of stroke.14 The accurate recognition of stroke symptoms by telephone triage nurses significantly influences the quality of patient care in terms of transfer time and also provides the highest level of care for patients.21,22 Patients who were under-triaged as nonstroke in medical dispatch centers have been labeled as those with ‘weakness due to tiredness’ at the end of the telephone triage interview in both the study groups (Table 3). One possible explanation for the finding that nurses in the intervention group were not easily able to identify patients with stroke may be due to the CPSS structure. The CPSS identifies anterior-circulation stroke better than posterior-circulation stroke, while 70% of stroke is anterior-circulation stroke.17 Posterior-circulation stroke is hard to diagnose because it usually shows signs and symptoms similar to vertigo, weakness, ataxia, nausea, vomiting and visual impairment.23 It could also be responsible for significant delays to the treatment and care. The analysis of the telephone triage interviews of under-triage cases revealed that 26.7% of callers had mentioned the word ‘stroke’ in their conversations, and this was more common in the control group. This finding is consistent with that of Rosamond et al.24 who reported only 31% of nurses were able to recognize stroke even though they had been told both the exact word of stroke and the description of stroke symptoms. This finding implies that there was neglect or considerable opposition to the callers’ subjective interpretations of a suspected stroke condition. In addition, speech impairment and limb numbness had been mainly reported by callers.
Table 3. Distribution of reported complaints of under-triaged patients Complaints
Intervention (%)
Control (%)
Total (%)
Stroke Unable to walk Crashed Unable to talk Weakness Dyspnea Lethargy Hypoglycemia Numbness Hypertension Altered mental state Vertigo Chill Nausea and vomiting Total
3 (23.1) 2 (15.4) 0 (0) 0 (0) 2 (15.4) 2 (15.4) 2 (15.4) 0 (0) 1 (7.7) 0 (0) 0 (0) 1 (7.7) 1 (1.8) 1 (7.7) 13 (100)
5 (29.4) 2 (11.8) 3 (17.6) 2 (11.8) 0 (0) 0 (0) 0 (0) 1 (5.9) 0 (0) 1 (5.9) 1 (5.9) 0 (0.0) 0 (0.0) 0 (0) 17 (100)
8 (26.7) 4 (13.4) 3 (10.0) 2 (6.7) 2 (6.7) 2 (6.7) 2 (6.7) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3) 1 (0.9) 1 (3.3) 30 (100)
There is significant difference between the two groups.
90
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
PRACTICE GUIDELINES Patients who had been over-triaged were diagnosed as having tumor, hypoglycemia, heart attack, sepsis, uremia, stress and pneumonia when discharged from the hospital. This result confirms the earlier findings of Buck et al.14 who investigated over-triage patients’ final diagnosis, which included cardiopulmonary disorders, vertigo, syncope, altered level of conscience, hypotension and malignancy. Generally, some disorders such as tumor, vertigo, headache, dysphasia,25 and hypoglycemia, hyperglycemia and convulsion26 are similar to the signs and symptoms of stroke. However, the medical dispatch center was the only place that received the emergency calls. Multicenter study could enhance the generalizability of these findings. Further studies are also recommended to revise CPSS to cover posterior-circulation stoke signs and symptoms.
3.
4.
5.
6.
Conclusion The effects of CPSS on telephone triage of stroke patients can reliably identify anterior-circulation stroke. However, it needs to be further developed because it has less emphasis on posterior-circulation stroke signs and symptoms. So it is necessary for a more efficient stroke screening tool to be developed for use in the EMS. The present study has demonstrated that among the existing screening tools, CPSS is more efficient tool for use by telephone triage nurses in identifying stroke.27 The use of CPSS has higher OR than NGTT, so the ethical issues have been addressed in the belief that the patient would benefit from CPSS. CPSS also assists nurses by reducing the triage error and supports the evidence-based care, so it can efficiently boost morale by ensuring the safety of patients and telephone triage nurses. The CPSS contributes to minimizing the delay in treatment and also improves the patients’ outcomes. Moreover, the use of CPSS decreases the costs of the healthcare system through reducing over-triage errors.
7. 8. 9.
10.
11.
12.
Acknowledgements We acknowledge the telephone triage nurses of the emergency medical dispatch center. There is no conflict of interest.
13.
References
14.
1. Lamb M, Buchanan D, Godfrey CM, et al. The psychosocial spiritual experience of elderly individuals recovering from stroke: a systematic review. Int J Evid Based Healthc 2008; 6: 173–205. 2. Thanoon IA, Abdul-Jabbar HA, Taha DA. Oxidative stress and C-reactive protein in patients with cerebrovascular
15.
accident (ischaemic stroke): the role of Ginkgo biloba extract. Sultan Qaboos Univ Med J 2012; 12: 197–205. You JS, Chung SP, Chung HS, et al. Predictive value of the Cincinnati Prehospital Stroke Scale for identifying thrombolytic candidates in acute ischemic stroke. Am J Emerg Med 2013; 31: 1699–702. Azarpazhooh MR, Etemadi MM, Donnan GA, et al. Excessive incidence of stroke in Iran: evidence from the Mashhad Stroke Incidence Study (MSIS): a populationbased study of stroke in the Middle East. Stroke 2010; 41: e3–10. Crocco TJ, Grotta JC, Jauch EC, et al. EMS management of acute stroke: prehospital triage (resource document to NAEMSP position statement). Prehosp Emerg Care 2007; 11: 313–7. Lloyd-Jones DM, Hong Y, Labarthe D, et al. American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation 2010; 121: 586–613. Tait D. Nursing recognition and response to signs of clinical deterioration. Nurs Manag (Harrow) 2010; 17: 31–5. Brown MM. Brain attack: a new approach to stroke. Clin Med 2002; 2: 60–5. De Luca A, Giorgi Rossi P, Villa GF. Stroke group Italian Society pre hospital emergency Services. The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms. BMC Health Serv Res 2013; 13: 513. Reginella RL1, Crocco T, Tadros A, et al. Predictors of stroke during 9-1-1 calls: opportunities for improving EMS response. Prehosp Emerg Care 2006; 10: 369–73. Studnek JR, Asimos A, Dodds J, Swanson D. Assessing the validity of the Cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care 2013; 17: 348–53. Ramanujam P, Guluma KZ, Castillo EM, et al. Accuracy of stroke recognition by emergency medical dispatchers and paramedics: San Diego experience. Prehosp Emerg Care 2008; 12: 307–13. Evenson KR, Brice JH, Rosamond WD, et al. Statewide survey of 911 communication centers on acute stroke and myocardial infarction. Prehosp Emerg Care 2007; 11: 186–91. Buck BH, Starkman S, Eckstein M, et al. Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke 2009; 40: 2027–30. Govindarajan P, Desouza NT, Pierog J, et al. Feasibility study to assess the use of the Cincinnati stroke scale by emergency medical dispatchers: a pilot study. Emerg Med J 2012; 29: 848–50.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
91
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al. 16. Liferidge AT, Brice JH, Overby BA, Evenson KR. Ability of laypersons to use the Cincinnati Prehospital Stroke Scale. Prehosp Emerg Care 2004; 8: 384–7. 17. Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehosp Emerg Care 2005; 9: 292–6. 18. Kue R, Steck A. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am 2012; 30: 617–35. 19. Mirhaghi A, Roudbari M. A survey of emergency department nurses on hospital triage. Iran J Crit Care Nurs 2010; 3: 165–70. 20. Mirhaghi A, Heydari A, Mazlom R, Hasanzadeh F. Reliability of the emergency severity index meta-analysis. Sultan Qaboos Univ Med J 2015; 15: e71–7. 21. Reeves MJ. Reducing the delay between stroke onset and hospital arrival: is it an achievable goal? J Am Heart Assoc 2012; 1: e002477.
92
22. Caceres JA, Adil MM, Jadhav V, et al. Diagnosis of stroke by emergency medical dispatchers and its impact on the prehospital care of patients. J Stroke Cerebrovasc Dis 2013; 22: e610–4. 23. Emsley HC. Posterior circulation stroke: still a Cinderella disease. Br Med J 2013; 346: f3552. 24. Rosamond WD, Evenson KR, Schroeder EB, et al. Calling emergency medical services for acute stroke: a study of 9-11 tapes. Prehosp Emerg Care 2005; 9: 19–23. 25. Hatzitolios A, Savopoulos C, Ntaios G, et al. Stroke and conditions that mimic it: a protocol secures a safe early recognition. Hippokratia 2008; 12: 98–102. 26. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol 1995; 52: 1119–22. 27. Mingfeng H, Zhixin W, Qihong G, et al. Validation of the use of the ROSIER scale in prehospital assessment of stroke. Ann Indian Acad Neurol 2012; 15: 191–5.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
The effect of Cincinnati Prehospital Stroke Scale on telephone triage of stroke patients: evidence-based practice in emergency medical services Javad Malekzadeh MS, a,b Hojjat Shafaee MS, c,d Hamidreza Behnam MS e,f and Amir Mirhaghi PhD a,b a Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, bDepartment of Medical-Surgical Nursing, School of Nursing and Midwifery, Chahrrah-e-Doktorha, Mashhad, Razavi Khorasan, cCritical Care Nursing, Emergency Medical Communication Center, Mashhad University of Medical Sciences, dEmergency Medical Communication Center, Mashhad University of Medical Sciences, Kaghani Blv, Rezashahr, eDepartment of Neonatal and Pediatrics Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, and fDepartment of Neonatal and Pediatrics Nursing, School of Nursing and Midwifery, Chahrrah-e-Doktorha, Mashhad, Razavi Khorasan, Iran
ABSTRACT Background: The emergency medical service is designed to recognize and transfer critically ill patients. Evidencebased practice has rarely been emphasized in the emergency medical service field, especially in the dispatch center. Aims: To identify the effect of the Cincinnati Prehospital Stroke Scale (CPSS) on telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center and to compare CPSS with the National Guidelines for Telephone Triage Tool (NGTT). Methods: A quasi-empirical study was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS. Two hundred and forty-six patients were randomly allocated to the CPSS intervention group (n ¼ 121) and the NGTT control group (n ¼ 125). True triage, triage error and odds ratio were statistically reported. Results: The mean age of the patients was 70.9 12.7 years. Of all the cases, 77.7 and 65.6% of patients in the intervention and the control groups, respectively, were accurately triaged. Under-triage cases were 10.7 and 13.6% of the patients in the intervention and the control groups. Odds ratio was 1.14 (95% confidence interval 0.62–2.07) for the CPSS compared with the NGTT. Conclusion: CPSS is more efficient for use by telephone triage nurses in identifying stroke. The use of CPSS assists nurses by reducing the triage error and supports the evidence-based care. It needs to be developed to cover signs and symptoms of posterior-circulation stroke patients. Key words: CPSS, emergency, prehospital, stroke, telephone, triage Int J Evid Based Healthc 2015; 13:87–92.
Introduction
S
troke is the most prevalent cerebrovascular disease in the world.1 Moreover, stroke is considered to be one of the most important cause of mortality and the main reason for long-term disabilities and morbidity Correspondence: Amir Mirhaghi, PhD, Department of MedicalSurgical Nursing, School of Nursing and Midwifery, Chahrrah-eDoktorha, Mashhad, Razavi Khorasan 9137913199, Iran. E-mail: [email protected] DOI: 10.1097/XEB.0000000000000046
worldwide.2 More than five million people die from stroke each year.3 Some studies have shown the incidence rate of stroke in the Iranian population between 45 and 48 years old is higher than in all the European countries.4 Furthermore, stroke imposes a significant economic cost on the healthcare system.5,6 Prompt recognition and care is crucial7,8 to accelerate rapid and timely thrombolytic therapy in hospitals.9 Although different protocols for telephone triage of stroke have been developed to promote early recognition of stroke patients, previous studies have
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
87
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al.
demonstrated that only 31–52% of stroke calls are being accurately recognized by telephone triage nurses,10 so the efficiency of these protocols is questionable.11–13 Some telephone triage protocols mainly evaluate slurred speech and altered state of consciousness, and do not focus on the loss of movement, whereas this sign often appears in 55–65% of the stroke patients.14 The Cincinnati Prehospital Stroke Scale (CPSS) is an abridged version of the National Institutes of Health Stroke Scale (NIHSS).15 It takes 30–90 s to perform CPSS by nurses in the dispatch center; therefore, it does not significantly interfere with other telephone requests for the emergency service.16 It is simple, brief and easy to follow by people who are not healthcare professionals, so it seems to be an appropriate tool for recognition of stroke symptoms through telephone triage.17 CPSS assesses three major clinical signs including face droop, arm drift and speech clarity in patients.1 However, CPSS has only been used at emergency medical dispatch centers in developed countries, and has not been reported in developing countries.18 Several studies have been conducted on hospital triage,19 whereas only a few have focused on the prehospital telephone triage, so there is in (insufficient) evidence to support the efficiency of telephone triage, especially in patients with stroke.1 In addition, more rigorous methodological research is needed to support the evidence-based practice of CPSS in emergency medical services (EMS) because previous studies have been performed only with a descriptive cross-sectional design. Error in telephone triage must be reduced in order to improve the accurate identification of stroke patients and to rapidly provide treatment and care for them. Several studies have demonstrated that appropriate triage assignment to stroke patients decreases mortality and optimizes resource utilization, as a result of which both under-triage and over-triage should be minimized.20 Therefore, the aim of the present study was to identify the effect of CPSS on the telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center.
Methods A quasi-empirical design was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS, which receives more than 5000 emergency calls daily. Following approval from the university’s ethics committee, informed consent was obtained from each of the telephone triage nurses participating in the study. The need for obtaining informed consent from callers and patients was waived due to the time-critical nature of 88
their circumstances, so all the calls received ambulance services. The content validity of the translated instrument was assessed by 10 experts who had experience in the neurologic emergency and emergency triage. Original CPSS and translated versions were reviewed to work out if the translated version could accurately measure the acuity of stroke patients. A Likert-type scale was used to determine the relevance. Each expert rated the items as follows: 1, not relevant; 2, somewhat relevant; 3, quite relevant and 4, highly relevant. Items that were irrelevant were scored with a 1 and 2, and items that were quite relevant were scored with a 3 and 4. Only items scoring 3 and 4 were considered relevant and thus were used to calculate the actual content validity index (CVI). It was possible to comment for each item if required. Using an inter-rater reliability method, the reliability of the instrument was assessed to compare researchers’ measurements in the pilot study. A random sample of 15 calls was piloted to assess the reliability between caller and another individual who was present at the scene. In addition, inter-rater reliability between two telephone triage nurses was assessed. Telephone triage nurses were divided into two groups including the intervention and the control group. Each group received calls randomly. In the intervention group, CPSS was used to prioritize the patients. The National Guidelines for Telephone Triage (NGTT) has been routinely used at the Emergency Medical Dispatch, so NGTT was used in the control group. NGTT has been a routine protocol to triage patients by telephone triage nurses in the medical dispatch center. It is a questionbased protocol which includes most signs and symptoms of stroke patients and relevant comorbidity factors, except for loss of movement questions. Researchers also upgraded the triage software according to CPSS for the intervention group in the medical dispatch center. All incoming emergency calls were recorded in a secured computerized database. Nurses in the intervention group had been trained to use CPSS. All calls had been examined to evaluate how accurately nurses performed each protocol until all the nurses had successfully utilized protocols during telephone triage conversations. During the study, nurses asked the callers basic questions including their chief complaint and demographic information in both the control and the intervention groups. After initially detecting the patients’ condition, the suspected stroke patients were examined on the basis of their own protocols. Finally, triage nurses identified patients as either positive or negative in terms of stroke. All decisions including ‘expected’ triage
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
PRACTICE GUIDELINES decisions, ‘over triage’ decisions and ‘under triage’ decisions were recorded onto the databases. In the CPSS, ‘no evidence of stroke’ is defined by a score of 0, score 1 represents the presence of ‘few evidence of stroke’, score 2 indicates ‘strong evidence of stroke’ and a score of at least 3 signifies ‘explicit evidence of stroke’. Patients were diagnosed as ‘stroke’ (score of 2) or ‘nonstroke’ (score of 0 or 1). Inclusion criteria were as follows: callers and patients must be aged over 18 years and calls must be placed by the patients’ direct caregivers. Adults have different causes of stroke as compared with pediatric patients (who are aged 18 years and below), and it is assumed that patients’ direct caregivers are more familiar with patients, so it is expected they will have effective communication with the patients. Exclusion criteria were patients with life-threatening conditions such as impaired consciousness and respiratory impairments, or medical requests which were cancelled by the callers. Life-threatening conditions need life support directions in order to save the patients’ life. To monitor outcomes, researchers attended the hospitals to find out the final patient diagnosis. Final diagnosis of stroke documented in patients’ medical records was used as the gold standard to assess the accuracy of the nurses’ decisions in identifying stroke patients through telephone triage. ‘True triage’ cases involved patients whose symptoms were correctly diagnosed as stroke or nonstroke on the basis of final diagnosis. Descriptive and inferential statistics were used. Fisher’s exact test, independent-sample t test, intraclass correlation coefficients and Cohen kappa statistics (k) were employed to analyze the data. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois, USA, and Release 16.0.2).
Results Content validity index of the translated version was 0.98. Callers’ reliability was 0.97. In addition, inter-rater reliability between two telephone triage nurses was high (k ¼ 0.93). Two hundred and forty-six patients were randomly allocated to each group: 121 in the intervention group and 125 in the control group. The mean age of the sample group was 70.9 12.7 years. There was no significant difference in terms of confounding variables between the two groups (Table 1). Of all cases, 77.7% of patients in the intervention group and 65.6% of patients in the control group were accurately triaged. Under-triage cases were 10.7% of the patients in the intervention group and 13.6% of the patients in the control group. Also, over-triage cases were 11.6 and 20.8% of cases, respectively (Fig. 1). Odds ratio (OR) was 1.14 [95% confidence interval (CI) 0.62– 2.07] for the CPSS compared with the NGTT. Of all patients in the intervention group, 57.1% had ischemic stroke, 16.1% had transit ischemic attack and 1.8% had hemorrhagic stroke diagnosis. In the control group, 41.7% had ischemic stroke, 11.7% had transit ischemic attack and 3.3% had hemorrhagic stroke diagnosis (Table 2). Error analysis of nurses’ decisions showed that all occasions of under-triage were missed in spite of the fact that callers reported stroke in 25% of the cases (Table 3).
Discussion Telephone triage nurses in the intervention group were found to recognize stroke patients 12% more accurately as compared with those in the control group. The rate of under-triage and over-triage decisions in the control group was 3 and 9% greater than that of the intervention group, respectively. In the light of the finding, it is argued that the use of CPSS at EMS is likely to improve the accuracy of
Table 1. Distribution of patients’ age and sex, and nurses’ experience Patients’ age (mean SD) Male patients (%) Female patients (%) Nurses’ experience (years old) Emergency calls (%) Calls duration (min) Response timea (min) Operation timeb (min)
Intervention
Control
Total
71.5 12.6 58 (48) 63 (52) 3.5 1.2 47185 (53.47) 1.85 0.28 18.2 5.8 43.9 10.8
70.4 12.9 55 (44) 70 (56) 3.7 1.4 41059 (46.52) 1.63 0.04 17.2 5.9 41.7 11.8
70.9 12.7 113 (46) 113 (54) 3.6 1.3 88244 (100) 1.73 0.16 17.7 5.7 42.9 11.3
There is significant difference between the two groups. a The period between when a (115) emergency call is recorded by the emergency medical dispatch center and the time when the first ambulance arrives at the scene. b The period between when a (115) emergency call is recorded by the emergency medical dispatch center and the time when the first ambulance resource arrives at the hospital.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
89
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al.
100 Intervention Control
Frequency
80 60 40 20 0 True
Error
Over-triage
Under-triage
Accuracy
Figure 1. Accuracy of nurses’ telephone triage of stroke patients. Error contains both over-triage and under-triage data.
telephone triage decisions to recognize stroke patients promptly. The patients who received CPSS were recognized 1.14 times more accurately than the patients who received NGTT. On the basis of these results, the researcher would recommend that all patients who are suspected with stroke should receive CPSS. The NGTT does not place enough emphasis on the motor signs of stroke. Nurses focused mainly on some stroke signs and symptoms (i.e. abnormal speech and impaired consciousness) when using NGTT to identify stroke patients, whereas these clinical features happen in 55–65% of stroke patients14; therefore, using NGTT contributes to the poor recognition of the stroke symptoms. It shows the significance of motor sign of stroke. In general, 80–90% of all stroke patients experience motor
Table 2. Final diagnosis of patients who were recognized as stroke by nurses in telephone triage
Ischemic stroke Transit ischemic attack Hemorrhagic stroke Stress Sepsis Tumor Heart attack Hypoglycemia Uremia Renal failure Other Total a
Intervention (%)
Control (%)
Total (%)
32 (57.1) 9 (16.1)
25 (41.7) 7 (11.7)
57 (49.1) 16 (13.8)
1 (1.8) 3 (5.4) 1 (1.8) 2 (3.6) 1 (1.8) 1 (1.8) 1 (1.8) 1 (1.8) 4 (7.2) 56 (100)
2 (3.3) 3 (5.0) 3 (5.0) 2 (3.3) 2 (3.3) 2 (3.3) 2 (3.3) 2 (3.3) 10 (16.5) 60 (100)
3 (2.6) 6 (5.2) 4 (3.4) 4 (3.4) 3 (2.6) 3 (2.6) 3 (2.6) 3 (2.6) 14 (12.0) 116 (100)
signs of stroke.14 The accurate recognition of stroke symptoms by telephone triage nurses significantly influences the quality of patient care in terms of transfer time and also provides the highest level of care for patients.21,22 Patients who were under-triaged as nonstroke in medical dispatch centers have been labeled as those with ‘weakness due to tiredness’ at the end of the telephone triage interview in both the study groups (Table 3). One possible explanation for the finding that nurses in the intervention group were not easily able to identify patients with stroke may be due to the CPSS structure. The CPSS identifies anterior-circulation stroke better than posterior-circulation stroke, while 70% of stroke is anterior-circulation stroke.17 Posterior-circulation stroke is hard to diagnose because it usually shows signs and symptoms similar to vertigo, weakness, ataxia, nausea, vomiting and visual impairment.23 It could also be responsible for significant delays to the treatment and care. The analysis of the telephone triage interviews of under-triage cases revealed that 26.7% of callers had mentioned the word ‘stroke’ in their conversations, and this was more common in the control group. This finding is consistent with that of Rosamond et al.24 who reported only 31% of nurses were able to recognize stroke even though they had been told both the exact word of stroke and the description of stroke symptoms. This finding implies that there was neglect or considerable opposition to the callers’ subjective interpretations of a suspected stroke condition. In addition, speech impairment and limb numbness had been mainly reported by callers.
Table 3. Distribution of reported complaints of under-triaged patients Complaints
Intervention (%)
Control (%)
Total (%)
Stroke Unable to walk Crashed Unable to talk Weakness Dyspnea Lethargy Hypoglycemia Numbness Hypertension Altered mental state Vertigo Chill Nausea and vomiting Total
3 (23.1) 2 (15.4) 0 (0) 0 (0) 2 (15.4) 2 (15.4) 2 (15.4) 0 (0) 1 (7.7) 0 (0) 0 (0) 1 (7.7) 1 (1.8) 1 (7.7) 13 (100)
5 (29.4) 2 (11.8) 3 (17.6) 2 (11.8) 0 (0) 0 (0) 0 (0) 1 (5.9) 0 (0) 1 (5.9) 1 (5.9) 0 (0.0) 0 (0.0) 0 (0) 17 (100)
8 (26.7) 4 (13.4) 3 (10.0) 2 (6.7) 2 (6.7) 2 (6.7) 2 (6.7) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3) 1 (0.9) 1 (3.3) 30 (100)
There is significant difference between the two groups.
90
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
PRACTICE GUIDELINES Patients who had been over-triaged were diagnosed as having tumor, hypoglycemia, heart attack, sepsis, uremia, stress and pneumonia when discharged from the hospital. This result confirms the earlier findings of Buck et al.14 who investigated over-triage patients’ final diagnosis, which included cardiopulmonary disorders, vertigo, syncope, altered level of conscience, hypotension and malignancy. Generally, some disorders such as tumor, vertigo, headache, dysphasia,25 and hypoglycemia, hyperglycemia and convulsion26 are similar to the signs and symptoms of stroke. However, the medical dispatch center was the only place that received the emergency calls. Multicenter study could enhance the generalizability of these findings. Further studies are also recommended to revise CPSS to cover posterior-circulation stoke signs and symptoms.
3.
4.
5.
6.
Conclusion The effects of CPSS on telephone triage of stroke patients can reliably identify anterior-circulation stroke. However, it needs to be further developed because it has less emphasis on posterior-circulation stroke signs and symptoms. So it is necessary for a more efficient stroke screening tool to be developed for use in the EMS. The present study has demonstrated that among the existing screening tools, CPSS is more efficient tool for use by telephone triage nurses in identifying stroke.27 The use of CPSS has higher OR than NGTT, so the ethical issues have been addressed in the belief that the patient would benefit from CPSS. CPSS also assists nurses by reducing the triage error and supports the evidence-based care, so it can efficiently boost morale by ensuring the safety of patients and telephone triage nurses. The CPSS contributes to minimizing the delay in treatment and also improves the patients’ outcomes. Moreover, the use of CPSS decreases the costs of the healthcare system through reducing over-triage errors.
7. 8. 9.
10.
11.
12.
Acknowledgements We acknowledge the telephone triage nurses of the emergency medical dispatch center. There is no conflict of interest.
13.
References
14.
1. Lamb M, Buchanan D, Godfrey CM, et al. The psychosocial spiritual experience of elderly individuals recovering from stroke: a systematic review. Int J Evid Based Healthc 2008; 6: 173–205. 2. Thanoon IA, Abdul-Jabbar HA, Taha DA. Oxidative stress and C-reactive protein in patients with cerebrovascular
15.
accident (ischaemic stroke): the role of Ginkgo biloba extract. Sultan Qaboos Univ Med J 2012; 12: 197–205. You JS, Chung SP, Chung HS, et al. Predictive value of the Cincinnati Prehospital Stroke Scale for identifying thrombolytic candidates in acute ischemic stroke. Am J Emerg Med 2013; 31: 1699–702. Azarpazhooh MR, Etemadi MM, Donnan GA, et al. Excessive incidence of stroke in Iran: evidence from the Mashhad Stroke Incidence Study (MSIS): a populationbased study of stroke in the Middle East. Stroke 2010; 41: e3–10. Crocco TJ, Grotta JC, Jauch EC, et al. EMS management of acute stroke: prehospital triage (resource document to NAEMSP position statement). Prehosp Emerg Care 2007; 11: 313–7. Lloyd-Jones DM, Hong Y, Labarthe D, et al. American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation 2010; 121: 586–613. Tait D. Nursing recognition and response to signs of clinical deterioration. Nurs Manag (Harrow) 2010; 17: 31–5. Brown MM. Brain attack: a new approach to stroke. Clin Med 2002; 2: 60–5. De Luca A, Giorgi Rossi P, Villa GF. Stroke group Italian Society pre hospital emergency Services. The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms. BMC Health Serv Res 2013; 13: 513. Reginella RL1, Crocco T, Tadros A, et al. Predictors of stroke during 9-1-1 calls: opportunities for improving EMS response. Prehosp Emerg Care 2006; 10: 369–73. Studnek JR, Asimos A, Dodds J, Swanson D. Assessing the validity of the Cincinnati prehospital stroke scale and the medic prehospital assessment for code stroke in an urban emergency medical services agency. Prehosp Emerg Care 2013; 17: 348–53. Ramanujam P, Guluma KZ, Castillo EM, et al. Accuracy of stroke recognition by emergency medical dispatchers and paramedics: San Diego experience. Prehosp Emerg Care 2008; 12: 307–13. Evenson KR, Brice JH, Rosamond WD, et al. Statewide survey of 911 communication centers on acute stroke and myocardial infarction. Prehosp Emerg Care 2007; 11: 186–91. Buck BH, Starkman S, Eckstein M, et al. Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke 2009; 40: 2027–30. Govindarajan P, Desouza NT, Pierog J, et al. Feasibility study to assess the use of the Cincinnati stroke scale by emergency medical dispatchers: a pilot study. Emerg Med J 2012; 29: 848–50.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
91
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
A Mirhaghi et al. 16. Liferidge AT, Brice JH, Overby BA, Evenson KR. Ability of laypersons to use the Cincinnati Prehospital Stroke Scale. Prehosp Emerg Care 2004; 8: 384–7. 17. Hurwitz AS, Brice JH, Overby BA, Evenson KR. Directed use of the Cincinnati Prehospital Stroke Scale by laypersons. Prehosp Emerg Care 2005; 9: 292–6. 18. Kue R, Steck A. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am 2012; 30: 617–35. 19. Mirhaghi A, Roudbari M. A survey of emergency department nurses on hospital triage. Iran J Crit Care Nurs 2010; 3: 165–70. 20. Mirhaghi A, Heydari A, Mazlom R, Hasanzadeh F. Reliability of the emergency severity index meta-analysis. Sultan Qaboos Univ Med J 2015; 15: e71–7. 21. Reeves MJ. Reducing the delay between stroke onset and hospital arrival: is it an achievable goal? J Am Heart Assoc 2012; 1: e002477.
92
22. Caceres JA, Adil MM, Jadhav V, et al. Diagnosis of stroke by emergency medical dispatchers and its impact on the prehospital care of patients. J Stroke Cerebrovasc Dis 2013; 22: e610–4. 23. Emsley HC. Posterior circulation stroke: still a Cinderella disease. Br Med J 2013; 346: f3552. 24. Rosamond WD, Evenson KR, Schroeder EB, et al. Calling emergency medical services for acute stroke: a study of 9-11 tapes. Prehosp Emerg Care 2005; 9: 19–23. 25. Hatzitolios A, Savopoulos C, Ntaios G, et al. Stroke and conditions that mimic it: a protocol secures a safe early recognition. Hippokratia 2008; 12: 98–102. 26. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol 1995; 52: 1119–22. 27. Mingfeng H, Zhixin W, Qihong G, et al. Validation of the use of the ROSIER scale in prehospital assessment of stroke. Ann Indian Acad Neurol 2012; 15: 191–5.
International Journal of Evidence-Based Healthcare ß 2015 University of Adelaide, Joanna Briggs Institute
©2015 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
