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Background: Cincinnati Pre-hospital Stroke Scale (CPSS) and Los Angeles Pre-hospital Stroke Scale (LAPSS) are widely used by emergency medical services (EMS) to screen potential ischemic stroke patients. We performed a population based state-wide study to evaluate the accuracy of CPSS and LAPSS in identifying stroke cases and investigate their impact on ischemic stroke treatment. Methods: A statewide EMS database was created by linking South Carolina’s statewide Emergency Department (ED) and hospital discharge records for the calendar years 2010-2012. The EMS data were obtained from the Division of EMS and Trauma at Department of Health Environmental Control and linked to hospitalization records at Office of Research and Statistics. Results from the EMS use of CPSS and LAPSS were compared with hospital discharge diagnoses for stroke. For both scales, we calculated Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV). Additionally we evaluated the impact of identification of stroke during EMS transportation by CPSS/LAPSS on treatment of ischemic stroke with intravenous tissue plasminogen activator (IV-tPA). Results: Of all the EMS transported cases between January 2010 and December 2012, use of CPSS or LAPSS was recorded for 101,442 cases. Among the cases where the use of CPSS/LAPSS stroke scale was recorded, 6,757 cases had a diagnosis of ischemic stroke on hospital discharge records. CPSS demonstrated sensitivity of 59%, and specificity of 96%. Sensitivity and specificity for LAPSS were 26% and 84%, respectively. PPV and NPV for CPSS were 45% and 98%, and for LAPSS were 27% and 83%, respectively. Rates of IV-tPA administration were approximately five times higher for those correctly identified by CPSS (18.3% for true positive vs. 3.5% for false negative, P Conclusion: Early identification of potential stroke cases using CPSS/LAPSS can have a significant impact on treatment of ischemic stroke with IV-tPA. We report a modest accuracy of CPSS and LAPSS in correctly identifying stroke cases in the field, with CPSS leading to a better rate of IV-tPA use compared with LAPSS.

Background and Objective: South Carolina is located in the “buckle” of the stoke belt. Use of the emergency medical services (EMS), intravenous tissue plasminogen activator (IV t-PA) in acute stroke and its correlates, including outcomes have not been trended over time. To study the annual trends in the above acute stroke care parameters we linked the EMS database with the statewide hospital discharge records stored at South Carolina Department of Health and Environmental Control (SC DHEC). Methods: The ongoing statewide EMS database linkage with the hospital discharge records stored at SC DHEC, allow us to track EMS and acute stroke thrombolysis in real-time. Patients with a discharge diagnosis of ischemic stroke were included in the analysis. Patients transported via EMS were compared with patients not transported by EMS. Variables considered included patient demographics, stroke center status of the hospital, telemedicine usage and treatment with IV t-PA for the calendar years of 2010-2012. Results: In the calendar years of 2010-2012, 10,377; 10,532 and 10,900 hospitalized patients in SC were assigned a primary discharge diagnosis of ischemic stroke respectively. Of these, the number of patients transported by EMS that received IV t-PA (7.1%, 9.5% and 10.2%, in the years 2010-12; χ2 trend =15.3, p < 0.0001) shows a significant increasing linear trend over the number of patients that were not transported by EMS that received IV t-PA (2.5%, 3.6% and 3.7%, in the years 2010-12). Over the three years, patients that are treated with IV t-PA were more likely to be discharged home (39%, 42% and 49% in the years 2010-12 ) and less likely to be discharged to a healthcare institution or expire (61%, 58% and 51% in the years 2010-12; χ2 trend=9.3, p =0.002). Conclusion: Transportation by EMS increased the likelihood of receiving IV t-PA. Over three years, IV t-PA usage led to better outcome including increasing discharge to home, decreasing discharge to healthcare institution and death. The real-time data linkage methodology may allow us in future to test the impact of statewide interventions geared to promote the usage of EMS and IV t-PA.

Background: Emergency medical services (EMS) transportation of a potential stroke patient may provide a means of reducing evaluation and treatment times and improve fibrinolytic treatment rates; yet, state-level data have not been linked to diagnosis at discharge and clinical outcomes. Objectives: To link the South Carolina (SC) statewide EMS database with hospital discharge diagnosis and evaluate the impact of EMS transportation in improving identification and treatment of acute stroke. Methods: A retrospective analysis was conducted of the statewide EMS database linked with statewide hospital discharge records stored at SC Department of Health and Environmental Control, for the calendar year 2010. Patients with a discharge diagnosis of stroke were included in the analysis. Patients transported via EMS were compared with patients not transported by EMS. Variables considered included patient demographics, transportation time, location/ type of destination hospital and treatment with intravenous tissue plasminogen activator (tPA). Results: In the year 2010, 18,962 hospitalized patients in SC were assigned a primary discharge diagnosis of stroke. Of these, 36% (6,824) were transported via EMS. The average time from 911 call to hospital arrival was 44.6 minutes. Time from 911 calls to EMS on scene was on average of 1.2 minutes longer for patients residing in rural areas than those in urban areas. About 48% of all stroke cases were treated in primary stroke centers (PSCs) and 4.3% of all ischemic cases received thrombolytic therapy. EMS identification of stroke signs and symptoms was associated with shorter transfer times and a higher transfer rate to a PSC than cases whose symptoms were not identified as stroke by EMS (50% vs. 43% for all strokes, P Conclusions: EMS identification of stroke signs and symptoms was associated with increased rate of transportation to PSCs and fibrinolytic treatment for ischemic stroke.

Background: South Carolina (SC) is located in the “buckle” of the stroke belt with one of the highest stroke death rates in the country. In 2010, SC had 66 acute care hospitals caring for strokes, nine of which were certified primary stroke centers (PSC). The rate of intravenous tissue plasminogen activator (IV-tPA) use and its correlates have not been investigated in the state. Objectives: To study the rate of IV-tPA use and its correlates using the statewide hospital discharge records stored at SC Department of Health and Environmental Control (DHEC), for the calendar year 2010. Methods: A retrospective analysis was conducted of the statewide hospital discharge records stored at SC DHEC, for the calendar year 2010. Patients with a discharge diagnosis of ischemic stroke were included in the analysis. Variables considered included patient demographics, insurance status, location/type of destination hospital, and treatment with IV-tPA. Results: In the calendar year 2010, 10,377 hospitalized patients in SC were assigned a primary discharge diagnosis of ischemic stroke. Of these, 4.2% (442) were treated with IV-tPA. Those who were treated with IV-tPA were younger (mean age ± standard deviation=66.7 ± 14.4, p=0.002) compared with those who did not receive IV-tPA (68.8±13.6). Patients treated at a PSC (49% of all ischemic stroke patients) were more likely to receive IV-tPA (Odds Ratio or OR 4.0, 95% CI 3.2-5.0).Patients treated in hospitals located in urban counties were more likely to receive IV-tPA compared to those treated in rural counties (OR 1.3, 95% CI 1.1-5.3). On multivariate logistic regression analysis, patients treated at a PSC (Adjusted OR 2.2, 95% CI 1.9-2.5) and those treated in urban counties (Adjusted OR 1.4, 95% CI 1.1-1.8) independently increased the likelihood of receiving IV-tPA. Gender, race and insurance status did not significantly change the likelihood of receiving IV-tPA. Conclusions: Younger stroke patients, treatment in a PSC and hospitals located in an urban county increased the likelihood of receiving IV-tPA. Increasing community awareness of PSCs, their location and designation may increase the rate of IV-tPA use.