EMS Agency Characteristics Associated with Documentation of Prehospital Stroke Scale and Blood Glucose Level

Reasons for emergency medical services (EMS) agency-level variation in prehospital stroke care are poorly understood. Our objective was to identify EMS agency characteristics associated with low-, average-, and high performance for documentation of prehospital stroke scale and blood glucose to inform strategies for improving prehospital stroke care.

This was a retrospective evaluation of EMS activations for patients with suspected stroke/transient ischemic attack (TIA) in the 2019 ESO Data Collaborative, a de-identified dataset of ∼8.3 million EMS activations from 1,200+ agencies who voluntarily agree to include their data for research and benchmarking. We included agencies that provided ≥10 9-1-1 responses with a field impression of stroke/TIA excluding basic life support agencies and those only responding to acute care facilities (i.e., freestanding or hospital emergency department). Agencies were categorized by mean rates of stroke scale and blood glucose documentation. Low, average, and high performance were defined as the 1st, 2nd-9th, and 10th deciles, respectively. Multinomial logistic regression models were used to calculate relative risk ratios (RRR) to compare agency characteristics (including patient demographics, agency type, and service type) between the three performance groups.

We analyzed 862 EMS agencies (21.6% fire department-based, 65.1% non-volunteer, 93.6% primarily providing 9-1-1 response). The mean agency-level rates by low-, average- and high-performers were 4.9% (SD 6.1%), 69.0% (SD 26.6%), and 99.6% (SD 0.6%) respectively for stroke scale, and 61.7% (SD 10.6%), 87.6% (SD 6.0%), and 98.7% (SD 1.6%) for blood glucose. There were no significant associations between agency characteristics and rates of stroke scale documentation. For blood glucose, agency characteristics associated with better performance were higher rates of urban encounters and non-volunteer providers (urban: RRR for low performance 0.53, 95% CI 0.33-0.85; non-volunteer: RRR for low performance 0.52, 95% CI 0.32-0.84).

The wide agency-level variation in rates of stroke scale and blood glucose documentation indicates an opportunity to better standardize care. Better understanding strategies of high performers and barriers for low performers is key to designing interventions to ensure all stroke patients receive evidence-based, guideline-concordant prehospital care.