Response to Letter by Bray and Bladin
We thank Ms Bray and Dr Bladin for their comments and agree with their general points. Audit and feedback can improve performance, but the effect is usually modest.1 Although we did not provide the specific type of feedback they describe, regular performance evaluations are part of the standard educational and quality improvement programs provided to the Emergency Medical Services personnel included in our study. The patients were taken to a medical center with a rapid response stroke team that continuously monitors performance, so in our case, the issue of transporting patients expeditiously only to have treatment delayed or deferred does not apply.
We also found that the sensitivity of the Cincinnati Prehospital Stroke Scale, the subject of our study, could be improved by the addition of several items at a cost of reduced specificity. Specificity is particularly important if the results are used to aid in ambulance routing or diversion. Given the importance of rapid stroke patient identification and transport,2 additional studies carried out in the field similar to those described in our report and by Ms Bray and Dr Bladin are needed.
Acker JE III, Pancioli AM, Crocco TJ, Eckstein MK, Jauch EC, Larrabee H, Meltzer NM, Mergendahl WC, Munn JW, Prentiss SM, Sand C, Saver JL, Eigel B, Gilpin BR, Schoeberl M, Solis P, Bailey JR, Horton KB, Stranne SK; American Heart Association; American Stroke Association Expert Panel on Emergency Medical Services Systems, Stroke Council. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke. 2007; 38: 3097–3115.