Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies
Authors: Dekker Luuk , Daems Jasper D. , Duvekot Martijne H.C. , Nguyen T. Truc My , Venema Esmee , van Es Adriaan C.G.M. , Rozeman Anouk D. , Moudrous Walid , Dorresteijn Kirsten R.I.S. , Hensen Jan-Hein J. , Bosch Jan , van Zwet Erik W. , de Schryver Els L.L.M. , Kloos Loet M.H. , de Laat Karlijn F. , Aerden Leo A.M. , van den Wijngaard Ido R. , Dippel Diederik W.J. , Kerkhoff Henk , Wermer Marieke J.H. , Roozenbeek Bob , Kruyt Nyika D. , Alblas Kees C.L. , Bakker Jeannette , van Belle Eduard , Bevelander Timo , Buijck Bianca , Dofferhoff-Vermeulen Tamara , van Doormaal Pieter Jan , Duijndam Dion , van Eijkelenburg Roeland P.J. , Hoek Amber , Koster Gaia T. , Kuiper Jan Willem , de Leeuw Arnoud M. , Lingsma Hester F. , van der Lugt Aad , Lycklama À Nijeholt Geert , Maasland Lisette , van Moll Bruno J.M. , Mulder Laus J.M.M. , Noordam-Reijm Anja , Oskam Erick , Plaisier Aarnout , van de Wijdeven Ruben M. , Wijnhoud Annemarie D. , Willeboer Merel L. , Woudenberg Mirjam , van der Zon Mandy M.A. , Zwets Egon D. , Zylicz Stas A. 
Published: July 2023

BACKGROUND:
It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians.

METHODS:

We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (r
s
) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference.

RESULTS:

We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (r
s
=0.70 [95% CI, 0.68–0.72]). Concerning individual items, prehospital assessment of arm (r
s
=0.68) and leg (r
s
=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (r
s
=0.31), abnormal speech (r
s
=0.50), and gaze deviation (r
s
=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%).

CONCLUSIONS:
The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.