Emergency Medicine Residents' Performance with National Institutes of Health Stroke Scale and Its Impact on Key
Matthew Roces1, Trinidad Alacala-Arcos2, Newton Addo3
1University of California Los Angeles, Department of Emergency Medicine, Los Angeles, California.
Background:
Emergency medicine (EM) physicians commonly use the National Institutes of Health Stroke Scale (NIHSS) to assess acute ischemic strokes in community settings. However, this assessment is often led by neurology residents in academic teaching hospitals. We implemented a quality improvement intervention to improve EM resident comfort with the NIHSS and to assess if EM resident-led NIHSS evaluation prolonged key stroke metrics, such as door-to-CT (DTCT), door-to-needle (DTN), or door-to-groin puncture (DTGP) times, which may affect stroke outcomes.
Methods:
This prospective observational comparison analyzed all patients with acute ischemic strokes at the Zuckerberg San Francisco General Hospital, a Level I trauma center from April 2021-October 2022. We implemented the intervention from April 2022 -October 2022 which included NIHSS certification for all residents and attendings. Both EM and neurology residents recorded NIHSS scores separately for each patient and scores were revealed to each resident during patient care once completed. We then compared stroke metrics between pre- and post-intervention periods.
Results:
There were 247 and 122 strokes included in our analysis, pre- and post-intervention, respectively. Overall, 58% (n=213) of all patients were female, 33% were Asian (n=123), and Cantonese was the second most common language after English (15%, n=54). Mean overall NIHSS scores were similar between EM and neurology residents, 6.6 (IQR = 2, 10) and 6.7 (IQR = 1, 10), (p < 0.001), respectively, with substantial agreement between groups (84.4%, κ = 0.63). Median DTCT times were 25 and 28 minutes (p=0.2), DTN times were 38 and 35 minutes (p=0.7), and DTGP times were 94 and 110 minutes (p=0.1) for pre- and post-intervention groups, respectively.
Conclusion:
The NIHSS is one element of stroke evaluation and management that can impact stroke metrics. Our intervention found that EM resident-led NIHSS assessment did not prolong DTCT, DTN, and DTGP times and met nationally established goals.
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