1. Telephone Triage for Stroke by Ambulance Services in the U.K. Summary and Comment by J. Stephen Bohan, MD, MS, FACP, FACEP Published in Journal Watch Emergency Medicine May 29, 2009Journal Watch Emergency Medicine A structured algorithm used at ambulance call centers in the U.K. performed poorly in identifying stroke patients. CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

2. Covering Deakin CD et al. Is ambulance telephone triage using advanced medical priority dispatch protocols able to identify patients with acute stroke correctly? Emerg Med J 2009 Jun; 26:442. CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

3. Background Ambulance dispatch centers in the U.K. use a software program developed and used in the U.S. that leads call center staff through a structured interview about the patient’s symptoms. At the end of the interview, the patient is assigned a chief complaint and a corresponding ambulance response priority category — A: life threatening, requiring an 8-minute ambulance response time; B: urgent, requiring a 19-minute response time; or C: nonurgent, requiring a 60-minute response time. Call center staff generally have no medical background and receive 20 hours of instruction before beginning dispatch work. CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

4. Background To assess the accuracy of this system for identifying patients with acute stroke, researchers retrospectively compared assigned chief complaints and final emergency department diagnoses for all 4810 patients who were transported to a single hospital in England during a 6-month period. CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

5. The Research Of 126 patients with final ED diagnoses of acute stroke, only 60 were assigned a chief complaint of stroke by the software, whereas 66 patients were assigned another chief complaint, most often collapse (34 patients) or unconscious (16). Conversely, 62 patients who did not have final ED diagnoses of stroke were assigned a chief complaint of stroke by the software. The software was 47.6% sensitive and 98.7% specific for identifying patients with stroke. The authors note that in a prior study, in some instances, call center staff assigned another diagnosis even when patients or families mentioned the word “stroke.” CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

6. Comment Although health system planners seek specificity in the interest of containing costs, individual patients, such as those with acute stroke, depend on sensitivity, lest they miss the often brief window for effective intervention. Whether some combination of software revision and increased staff training would improve sensitivity for recognizing stroke symptoms over the telephone remains to be seen. Until then, this system certainly fails for identifying acute stroke, and one wonders how many other acute conditions would similarly be miscategorized. CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

7. About Journal Watch Journal Watch helps physicians and allied heath professionals save time and stay informed by providing brief, clearly written, clinically focused perspectives on the medical developments that affect practice. Journal Watch is an independent, trustworthy source, from the publishers of the New England Journal of Medicine. These slides were derived from Journal Watch Emergency Medicine.Journal Watch Emergency Medicine The best way to stay informed with Journal Watch, is through our alerts. To sign up, visit the My Alerts page.My Alerts page CopyrightCopyright © 2009. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society