Multilevel Educational Program for Emergency Medical Services
To the Editor:
I read with interest Wojner-Alexandrov and colleagues’ article1 in the July issue of Stroke, evaluating a multilevel educational program designed to improve both paramedic and hospital performance, and raise community awareness, regarding acute stroke. The authors are to be applauded for this multidisciplinary approach; in particular, the inclusion of emergency medical services personnel reflects recognition of the key role that events before arrival at the hospital can play in the chain of events needed to provide optimal care for the acute stroke victim.
However, I disagree with their conclusion that this program may decrease the time from the onset of symptoms to arrival at the hospital. For the entire group of patients for whom this interval was documented, there was no statistical difference between the preintervention (mean 226 minutes, median 95 minutes) and the active-intervention phase (mean 358 minutes, median 89 minutes). Even excluding those patients who presented more than 24 hours after symptom onset, there was no improvement in the active-intervention phase (P=0.054). Only when examining the proportion who arrived within 120 minutes of symptom onset was there a clinically small (58% versus 62%) but statistically significant difference between groups.
Perhaps more importantly from my perspective as an emergency medical services medical director, the program found an improvement in the accuracy of paramedic diagnosis of stroke, but apparently at the expense of additional time in the field. The time paramedics spent on scene increased from 16.7 minutes to 18.2 minutes—again a clinically small but statistically significant increase. Perhaps as a result of diversion to more distant hospitals that were participating in the regional stroke system, transport times also increased from 15.6 to 17.9 minutes. Although these differences are small, it is important to minimize delays in the field in order to maximize the chances of completing transport and emergency department workup within the 3-hour window for the small proportion of stroke patients who are eligible for and may benefit from thrombolysis.
Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D, Persse D, Grotta JC. Houston Paramedic and Emergency Stroke Treatment and Outcomes Study (HoPSTO). Stroke. 2005; 36: 1512–1518.