Utstein recommendation for emergency stroke care

Governance and legal considerations supporting prehospital emergency care in low and middle-income countries—For the Special Series on Prehospital Care in LMICs

Objectives For underserved rural communities with limited geographical access to comprehensive stroke centers, emergency medical services (EMS) play a crucial role in timely, high-quality acute stroke care. This qualitative study aimed to understand rural EMS perspectives on barriers and facilitators to optimal acute stroke care in rural communities. Methods Qualitative, individual semi-structured interviews were conducted with rural EMS professionals. Ten EMS agencies in North Carolina were contacted for participation in virtual 45–60 minute interviews and interested agency professionals self-selected into the study. Covered topics included stroke training and education; stroke care experience and expertise; clinical and sociodemographic patient characteristics; EMS workflows; and system- and patient-level interactions and outcomes. Recorded interviews were transcribed and then coded using an inductive and deductive, iterative approach by two independent reviewers in MAXQDA software. Facilitators and barriers to optimal acute stroke care were derived from thematic analysis. Results Twelve EMS professionals from 4 rural EMS agencies and 1 mixed urban-rural agency were interviewed. Participants worked in clinical (6 Paramedics, 1 EMT) and leadership (2 chiefs, 1 supervisor, 1 field training officer, 1 quality assurance manager) roles for a mean of 4 years (range 1–11 years). Commonly noted facilitators of high-quality stroke care were comprehensive stroke assessment and destination decision protocols, as well as bidirectional communication between EMS and hospital staff. Identified barriers included patient and bystander delays in calling 9-1-1, long transport distances to stroke centers, and limited EMS staffing. EMS professionals noted challenges interacting with nursing home staff and hospital clinicians during patient transfer. Interviewees also discussed the importance of educating the public about stroke signs and symptoms and community engagement. Conclusions Within rural populations, EMS professionals determined that public education and community engagement are high-priority needs. Professionals also noted EMS’ opportunities to enhance rural stroke care through consistent bidirectional communication and improved prehospital protocols. Future research is needed to further explore these themes in rural EMS agencies outside of North Carolina.

Background Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. Methods MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. Results We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. Conclusion We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.

Despite high injury mortality rates, Cameroon currently lacks a formal prehospital care system. In other sub-Saharan African low and middle-income countries, Lay First Responder (LFR) programs have trained non-medical professionals with high work-related exposure to injury in principles of basic trauma care. To develop a context-appropriate LFR program in Cameroon, we used trauma registry data to understand current layperson bystander involvement in prehospital care and explore associations between current non-formally trained bystander-provided prehospital care and clinical outcomes. The Cameroon Trauma Registry (CTR) is a longitudinal, prospective, multisite trauma registry cohort capturing data on injured patients presenting to four hospitals in Cameroon. We assessed prevalence and patterns of prehospital scene care among all patients enrolled the CTR in 2020. Associations between scene care, clinical status at presentation, and outcomes were tested using univariate and multivariate logistic regression. Injury severity was measured using the abbreviated injury score. Data were analyzed using Stata17. Of 2212 injured patients, 455 (21%) received prehospital care (PC) and 1699 (77%) did not receive care (NPC). Over 90% (424) of prehospital care was provided by persons without formal medical training. PC patients were more severely injured (p<0.001), had markers of increased socioeconomic status (p = 0.01), and longer transport distances (p<0.001) compared to NPC patients. Despite increased severity of injury, patients who received PC were more likely to present with a palpable pulse (OR = 6.2, p = 0.02). Multivariate logistic regression adjusted for injury severity, socioeconomic status and travel distance found PC to be associated with reduced emergency department mortality (OR = 0.14, p<0.0001). Although prehospital injury care in Cameroon is rarely performed and is provided almost entirely by persons without formal medical training, prehospital intervention is associated with increased early survival after injury. Implementation of LFR training to strengthen the frequency and quality of prehospital care has considerable potential to improve trauma survival.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

Emergency medical services (EMS) fellowships are growing in significance within the United States prehospital health care system. While fellowships represent a cornerstone of EMS subspecialty education, an individual learner's experiences are limited by local resources and practices. California EMS fellowships have developed an innovative method for expanding fellows' educational experiences outside their immediate programs. Each month, fellows, fellowship directors, and local EMS medical directors from throughout the state participate in a video conference. This meeting is divided into four distinct components: book chapter presentation, board-style question review, call review, and an EMS literature review. The two-volume text Emergency Medical Services: Clinical Practice and Systems Oversight has been categorized into 12 modules, one for each month of the fellowship. Every meeting, one fellow prepares a didactic presentation summarizing the highlights from that month's chapters. Fellows each create five multiple-choice questions and answers, based on the section reading. Questions are assessed by the group, both for informational content and for appropriate formatting. After completion, these questions are submitted for future review for the EMS fellowship in-service examination. Based on that month's module topics, a call is chosen and reviewed. Regional protocol and practice differences from different systems are discussed. The online medical oversight provided and the prehospital provider performance are evaluated by the group. Fellows not assigned to present a call or didactic segment each choose one paper focusing on a subject relevant to the module or call. Strengths of the study design, analysis, outcomes, and relevance to EMS practice are discussed. Fellows and experienced EMS attendings are exposed to different protocol and system approaches in an interactive and accessible format. This partnership expands educational opportunities for fellows and promotes collaboration across EMS systems.

Introduction: Trauma-related deaths are rising in low- and middle-income countries (LMICs) like Nepal, where pre-hospital care systems are limited. Community health responders (CHRs) could reduce the time to post-injury care in rural settings. This pilot study evaluates the feasibility and impact of a CHR-based trauma program in rural Nepal. Methods: A quasi-experimental study first adapted a trauma curriculum for CHRs in Achham, Nepal, using global guidelines from the World Health Organization and the American College of Surgeons, using a modified Delphi process. The final program included three components: a two-day skills training, a pictorial guidebook for reference, and a one day refresher after three months. Two municipalities in Achham were assigned to intervention or control, with only the intervention group’ CHRs receiving the training. Outcomes measured included CHRs’ knowledge and confidence assessed over six months, and patient-based pre-hospital care process indicators. Care process indicators were assessed at the hospital emergency department. Changes in knowledge over time were analyzed using repeated measures ANOVA. Bivariate analysis was performed to assess differences in pre-hospital trauma care indicators by study group. Results: The intervention group showed a significant increase in knowledge and confidence immediately post-course and sustained over six months. There was no significant difference in mean patient age (26.5 years versus 22.1) and trauma mechanism (p = 0.14) across the two groups. The most common mechanism was falls (n=165, 77.5%). Intervention municipalities had higher rates of pre-hospital care provision, including fracture immobilization (51.4% versus 17.1%, p &lt; .001) and cervical collar use, compared to controls. Conclusion: This study adapted and implemented a contextual trauma training program for CHRs in rural Nepal. Results show early feasibility and appropriateness in this context. The program leverages existing community networks and offers a potential approach in LMICs to bridge the existing critical gaps in rural pre-hospital trauma care that require further investigation.

Background Guidelines recommend to establish a regional reperfusion strategy to maximize the efficiency of care for patients diagnosed with ST-elevation myocardial infarction (STEMI). In Addition, the recently developed mobile cloud-based 12-lead electrocardiogram (ECG) transmission system enables the transmission of prehospital ECGs at a low cost. Medical staff can use electronic devices to access and review ECGs from anywhere. However, the effectiveness of the prehospital mobile cloud ECG system has not yet been clearly established. Objective This single-center study aims to evaluate the impact of the prehospital mobile cloud ECG system on reducing Door-to-Balloon Time (DTBT), myocardial damage, and mid-term all-cause mortality in patients with STEMI. Methods In June 2018, eight prehospital Mobile Cloud ECG Transmission systems were integrated into the regional Emergency Medical Service (EMS) in our region. This study examined and compared Door-to-Catheterization Laboratory Time (DTCT), DTBT, Onset-to-Reperfusion Time (OTRT), peak creatine kinase-MB (CK-MB) levels, and one-year mortality rates of STEMI patients in the five years before and after introducing the prehospital mobile cloud ECG system. From June 2013 to May 2023, our institute received a total of 426 STEMI patients via ambulances from these two EMS departments. After excluding 23 patients with OTRT exceeding 24 hours and 76 patients who were transferred without the system post-introduction, 327 consecutive STEMI patients who underwent emergency percutaneous coronary intervention (PCI) were included in the study. The patients were divided into two groups: 169 patients before the prehospital mobile cloud ECG system introduction and 158 patients after that. Results There were no significant differences in age, gender, past medical history, and Killip Class IV between the two groups, except for the proportion of left main trunk (LMT) lesions, which was significantly higher in the ECG group. Significant reductions were observed in both DTCT and DTBT in the group after introduction, with differences noted as (DTCT: 42 min vs. 26 min; p &amp;lt; 0. 001, and DTBT: 74 min vs. 56 min; p &amp;lt; 0.001, respectively). However, the OTRT did not show a significant difference. Peak creatine kinase-MB (CK-MB) levels did not differ between the two groups, and Kaplan-Meier analysis revealed no significant difference in one-year mortality between them. Multivariate Cox regression analysis, which included variables such as age, peak CK-MB levels, Killip Class IV, LMT lesions, OTRT and the prehospital mobile cloud ECG transmission system usage, revealed that only Killip Class IV was significantly associated with one-year mortality (hazard ratio of 2.82 and a 95% confidence interval of 1.61-4.94; p=0.0003). Conclusion The prehospital mobile cloud ECG transmission system significantly reduced DTBT, but did not lead to a reduction in myocardial damage or an improvement in mid-term prognosis.Effect of the ECG Transmission SystemKaplan-Meier analysis

To compare outcomes between stroke patients managed on the stroke unit, on general wards with stroke team support or at home by specialist domiciliary team and to derive prognostic variables that will identify patients most suitable for management by each strategy. To describe organisational aspects of individual strategies of stroke care and to evaluate cost-effectiveness of each strategy and its acceptability to patients, carers and professionals. Prospective single-blind randomised controlled trial undertaken in patients recruited from a community-based stroke register. Suburban district in south-east England. Patients with disabling stroke who could be supported at home. The stroke unit gave 24-hour care provided by specialist multidisciplinary team based on clear guidelines for acute care, prevention of complications, rehabilitation and secondary prevention. The stroke team provided management on general wards with specialist team support. The team undertook stroke assessments and advised ward-based nursing and therapy staff on acute care, secondary prevention and rehabilitation aspects. Domiciliary care involved management at home under the supervision of a GP and stroke specialist with support from specialist team and community services. Support was provided for a maximum of 3 months. The primary measure was death or institutionalisation at 1 year. Secondary measures were dependence, functional abilities, mood, quality of life, resource use, length of hospital stay, and patient, carer and professional satisfaction. Of the 457 patients randomised, 152 patients were allocated to the stroke unit; 152 patients to stroke team and 153 patients to domiciliary stroke care (average age 76 years, 48% women). The groups were well matched for baseline characteristics, stroke type and severity, level of impairment and initial disability. Fifty-one (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality and institutionalisation at 1 year were lower on stroke unit compared with stroke team or domiciliary care. Significantly fewer patients on the stroke unit died compared with those managed by the stroke team. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team or domiciliary care. These differences were present at 3 and 6 months after stroke. Stroke survivors managed on the stroke unit showed greater improvement on basic activities of daily living compared with other strategies. Achievement of higher levels of function was not influenced by strategy of care. Quality of life at 3 months was significantly better in stroke unit and domiciliary care patients. There was greater dissatisfaction with care on general wards compared with stroke unit or domiciliary care. Poor outcome with domiciliary care and on general wards was associated with Barthel Index <5, incontinence and, on general wards, age over 75 years. The total costs of stroke per patient over the 12-month period were pound 11,450 for stroke unit, pound 9527 for stroke team and pound 6840 for home care. However, the mean costs per day alive for the stroke unit were significantly less than those for the specialist stroke team patients, but no different from domiciliary care patients. Costs for the domiciliary group were significantly less than for those managed by the specialist stroke team on general wards. Stroke units were found to be more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation and dependence after stroke. A role for specialist domiciliary services for acute stroke is not supported by this study. Management of patients with strokes on general medical wards, even with specialist team input, is not supported by this study. The stroke unit intervention was less costly per patient day alive and more effective than the stroke team intervention. The stroke unit was more effective and of equivalent cost when compared to home care. Hence, the stroke unit is a more cost-effective intervention than either stroke team or home care. Further research is needed to understand processes contributing to the reduction in mortality on stroke units and to determine the generalisability of these results and the factors that will influence the implementation of the findings of this study in clinical practice.

ABSTRACTObjectives: Patients presenting with ST-elevation myocardial infarction (STEMI) benefit from rapid cardiac reperfusion therapy. Emergency medical service (EMS) agencies can improve patient outcomes by calling STEMI alerts to the receiving facility. The aim of this study was to evaluate the use of pre-hospital activation systems for suspected ST-elevation myocardial infarctions (STEMI) throughout Colorado.Methods: A cross sectional, survey design was utilized to collect all data from EMS agencies in Colorado. A univariable logistic regression model was used to identify factors predictive of an agency reporting that they utilize a STEMI activation protocol.Results: 84.5% [95% CI: 78.3 to 90.7%] of agencies included indicate that they utilize a STEMI activation protocol. Based on the logistic regression analysis, the number of EMT employees was significantly associated with whether or not an agency indicates that they utilize a STEMI activation protocol. For every 10% increase in the number of EMTs employed by an EMS agency, there was a 3.0 [95% CI: 1.5 to 6.0, p = 0.0012] fold increase in the odds of the agency indicating they utilize a STEMI activation protocol.Conclusions: Our study provides evidence that larger agencies are more likely to utilize a STEMI activation protocol. In areas without a STEMI system of care, improvements in smaller agencies that cover more ground (with longer transport times) should be the focus for protocol implementation. Based on the current prevalence of such training, competency based training in reading ST-elevations on ECG should be considered by EMS agencies.

This study aimed to compare emergency medical services (EMS) and police utilization trends, epidemiology, and emergency department (ED) outcomes between pediatric patients with mental or behavioral health (MBH) emergencies and those with non-MBH concerns transported to a large children's hospital system. This was a retrospective cohort study of patients aged 5 to 18 years transported via EMS and police to two EDs affiliated with a children's hospital from January 2012 through December 2020. Data were abstracted from electronic hospital records. Encounters for MBH emergencies were identified using diagnostic codes and chief complaints. Trends of EMS and police transports of patients with MBH emergencies were examined. Patient demographics and ED outcomes were compared between children presenting with MBH emergencies and those with non-MBH concerns. During the 9-year study period, out of 40,663 transports to the EDs, 36,137 (89%) arrived via EMS, and 4,526 (11%) arrived via police. A total of 10,250 (28.4%) EMS transports were for MBH emergencies. The volume of patients transported by EMS for MBH emergencies increased by 1.4% per year ( P < 0.01) with no significant change in total EMS patient volumes. Patients with MBH emergencies transported by EMS were more likely to be older, female, of White race, and publicly insured; require restraint in the ED; and be admitted ( P < 0.001). Of police transports, 4153 (91.8%) were for MBH emergencies, with no statistical change in the proportion of police transports that were for MBH emergencies. Police-transported MBH patients compared to non-MBH police-transported patients were more likely to be younger, female, and of White race ( P < 0.001); 8.7% required mechanical/physical restraints in ED, 6.7% required pharmacologic restraint medications in ED, and 53% were admitted. The proportion of pediatric transports for MBH emergencies by EMS is rising and comprises the majority of police transports. Distinct from non-MBH pediatric patients transported, MBH patients necessitate significant ED resources, including ED-administered restraints and admission, highlighting their unique burden on the prehospital and ED systems.

Creating an ideal system of care to address the care forpatients with ST-elevation myocardial infarction (STEMI) iscomplex from both the system’s and patient/family’s perspec-tives. In general, this care is unlike most other hospital care.It typically involves very fast and complex decision makingand, often, sudden transportation to another facility forpercutaneous coronary intervention (PCI). All of this occurswith a potentially critically ill patient and at a time when thefamily is often not immediately available. In this report, weaddress key perspectives from the patient and public point ofview of the current system of care for STEMI patients andhighlight the barriers and gaps that must be addressed by anideal system of care (Table 1).

Background: Large vessel occlusion (LVO) strokes are among the most severe forms of ischemic stroke, requiring rapid identification and transfer to thrombectomy-capable centers for optimal outcomes. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score, derived from the NIH Stroke Scale, has shown promise in identifying LVOs. However, most prior studies assessed FAST-ED retrospectively or in hospital settings. This study evaluates the real-time use of FAST-ED by emergency medical services (EMS) personnel in San Diego County and its effectiveness in predicting LVOs during prehospital care. Methods: This observational study analyzed data collected from January 1 to June 30, 2024, involving EMS-transported patients with suspected stroke across San Diego County. Following standardized training, EMS providers calculated the FAST-ED score during field assessment for patients meeting stroke protocol criteria. Data from seven receiving stroke centers were collected, including FAST-ED scores, clinical outcomes, and confirmed LVO status via imaging. These data were de-identified and analyzed by the local EMS authority to evaluate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the FAST-ED score in identifying LVOs. Results: Among patients assessed, the FAST-ED score demonstrated a high NPV, supporting its utility in effectively ruling out LVOs in the field. While higher FAST-ED thresholds (≥6) were associated with improved PPV, lower score thresholds yielded more false positives, which could lead to overtriage to comprehensive stroke centers. Nonetheless, the tool provided EMS personnel with a standardized, rapid method to assess stroke severity and support early triage decisions in a geographically diverse region with variable access to thrombectomy-capable centers. Conclusions: Implementation of the FAST-ED score by EMS providers in the prehospital setting offers valuable support in identifying and ruling out LVOs, particularly in regions like San Diego County with complex transport logistics. While the tool enhances early stroke severity assessment, its moderate PPV suggests it should be integrated with other clinical findings or triage protocols rather than used as a sole determinant for transport destination. Continued refinement, including regional threshold adjustments and integration with EMS technologies, may enhance its effectiveness and optimize prehospital stroke triage systems.

Emergency medical service (EMS) systems are public services that provide quick response, transportation as well as appropriate emergency medical care to the emergent patient. For EMS, every second is critical. Unfortunately, current EMS systems have many challenges: lack effective communication between EMS providers and hospital professionals, less attention on care quality and limited resources of medical equipment and personnel. Motivated by this, in this paper, we explore the use of wearable sensing, smart mobile device as well as video technology to propose STREMS: an efficient smart real-time prehospital communication system for EMS. Specifically, we first introduce a cost-effective wearable physiological sensing solution to support multi-dimensional telemetry monitoring for an ambulance operating at as Basic Life Support, a type of EMS service level without sophisticated medical equipment or paramedics. Then we propose to build a cloud-based real-time data sharing platform, enabling automated streaming all gathered prehospital data (e.g., vital signs, EKG and image/short videos about accident scene) to the hospital prior to ambulance arrival, thus giving a more complete figure about the incoming patient. This can significantly decrease the handoff time and improve the efficiency at the hospital. Additionally, a live point to point video communication is proposed to support EMS telemedicine to enhance prehospital care quality through directly video conversation to assist EMS providers in consultation, triage, early medical examination and treatment. We implemented STREMS as an Android mobile app and evaluated its feasibility over the broadband cellular network in the city of Detroit. In a moving context, our results demonstrate STREMS can successfully deliver 100% of emergency data to the hospital in less than 1.5s, on average 0.75s for reporting a new case and 0.05s for health data. As the live video with 1280 × 720 pixel resolution, STREMS only works when the vehicle speed is less than 40MPH.

BackgroundProviding safe care by emergency medical services (EMS) personnel at the stressful scene of an incident is one of the most crucial factors influencing the preservation and enhancement of patient health. However, culture, attitudes, and social norms can influence the provision of care at the scene of an accident. Consequently, evaluating safe care practices at incident scenes is imperative and necessitates a specialized assessment tool. Presently, there is a lack of reliable and valid instruments for measuring safe care practices among EMS personnel. Therefore, this study was designed and conducted to develop and psychometrically evaluate the Emergency Medical Services Safe Care Scale (EMSSCS).MethodsThis investigation employed a mixed-methods design with a sequential exploratory approach, conducted from January 2024 onwards across the southwestern, western, and southeastern regions of Iran. The study was bifurcated into two distinct phases. In the initial phase, a conventional content analysis method was employed to scrutinize the narratives elicited from 41 EMS personnel. In the subsequent phase, the instrument’s validity and reliability were rigorously assessed.ResultsSafe care provided by EMS personnel was defined as the management of the incident scene, efficient clinical skills, and effective interaction aimed at delivering principled and safe patient care. Subsequently, based on the derived conceptual framework, a safe care instrument was designed with 44 items across three dimensions. During the qualitative and quantitative content validity 11 items, and face validity 3 items were deleted. Exploratory and confirmatory validity of this scale was approved in three dimensions: “incident scene management” (12 items), “efficient clinical skills” (10 items), and “effective interaction” (8 items). The scale’s reliability was reported at 0.95 using Cronbach’s alpha method.ConclusionThe Emergency Medical Services Safe Care Scale (EMSSCS), demonstrated acceptable psychometric properties. Consequently, senior managers in pre-hospital emergency services can utilize this instrument to evaluate safe care practices among pre-hospital emergency medical technicians. They can identify the most appropriate strategies, including educational interventions, to enhance safe care provision at incident scenes when necessary.Clinical trial numberNot applicable.