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Objective: Strokes are a leading cause of morbidity and mortality in the United States, especially in the "stroke belt" of the southeast. Up to 65% of stroke patients access care by calling 9-1-1. The primary objective of this study is to measure the accuracy of emergency medical dispatchers (EMD) and paramedics, in the prehospital identification of stroke., Methods: The study was based at Grady Emergency Medical Services, which is Atlanta, Georgia's public emergency medical services (EMS) provider. A retrospective analysis of all medically related 9-1-1 calls to Grady EMS classified as "stroke" between January 1, 2012, and December 31, 2012 was performed. A database was created using deterministic linkage between records from Grady EMS, Grady Hospital Emergency Department (ED), and the Grady Hospital Stroke Registry. Patients excluded were less than 18 years of age, had previous or concurrent head injuries, were transferred from another inpatient facility, and/or had incomplete patient records in any one of the three databases. Descriptive analysis, linear regression, and logistic multivariable regression were performed to discover the accuracy of stroke identification and contributory prehospital factors., Results: A total of 548 patients were included: 475 were transported with EMS impression of stroke and 73 with an impression other than stroke. The median age was 59 years, 87.4% were black, and 52.6% were female. Paramedics adhered to all seven elements of the Grady EMS stroke protocol in 76.4% (n = 363) of suspected stroke cases. Sensitivity and positive predictive value for paramedic stroke identification was 76.2% and 49.3%, respectively, and for EMD, was 48.9% and 24%, respectively. Identification of hemorrhagic strokes had a relatively lower sensitivity. Paramedics were more likely to positively identify strokes when the Cincinnati Prehospital Stroke Scale (CPSS) screen was positive, or when classified by EMD as stroke. Paramedics were less likely to identify stroke in female patients. Paramedics' diagnostic accuracy was similar regardless of their adherence to the EMS stroke care protocol., Conclusions: EMD and EMS personnel in a large city in the Southeastern United States, with high stroke prevalence, had a relatively high sensitivity in identifying acute stroke patients. Paramedic accuracy was augmented by positive CPSS screening and by EMD recognition of stroke.

Introduction: Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients., Methods: Multistage probabilistic matching, using a fine-grained record integration and linkage software program and combinations of key variables, was used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared., Results: Average age of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03-1.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry., Conclusion: Hospital discharge data can be linked with death data to assess the impact of clinical-level or community-level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome.

Background: This paper summarizes the experiences of the Paul Coverdell National Acute Stroke Registry first four prototype registries in Georgia (GA), Massachusetts (MA), Michigan (MI), and Ohio (OH), and includes information on their sampling design, case ascertainment, and data collection methods, as well as some key findings., Methods: Using a combination of different sampling methods, each prototype obtained a representative statewide sample of hospitals. Acute stroke admissions were identified through prospective (MA, MI) or retrospective (GA, OH) methods. A common set of case definitions and data elements were used by each registry. Weighted site-specific frequencies and 95% confidence intervals were generated for each outcome. A summary estimate, representing a weighted average of the four site-specific estimates, was also calculated., Results: Of the total 6867 admissions, 1487 (21.6%) were from the GA registry, 1206 (17.6%) from MA, 2566 (37.4%) from MI, and 1608 (23.4%) from the OH prototype. Just less than 60% of admissions were ischemic strokes (site-specific estimates ranged from 52% to 70%), with transient ischemic attack (18.5%) and intracerebral hemorrhage (8.8%) making up most of the remainder. Twenty-one percent of patients admitted were younger than 60 years of age, and 55.3% were women. The proportion of black subjects varied from 7.1% (MI) to 30.6% (GA). Twenty-three percent of admissions arrived at the emergency department within 3 hours of onset. Overall 4.5% of ischemic stroke admissions were treated with recombinant tissue plasminogen activator; site-specific treatment rates were 3.0% (GA), 3.2% (OH), 3.4% (MI), and 8.5% (MA). Only a small minority of treated patients (range, 10.8% [OH] to 19.6% [MI]) received recombinant tissue plasminogen activator within the recommended 1 hour door-to-needle time. A minority of eligible subjects were screened for dysphagia (45.4%), underwent lipid testing (33.6%), or received smoking-cessation counseling (21.4%). In contrast, compliance with antithrombotic treatments at discharge was high (91.5%)., Conclusions: A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the healthcare systems level, are needed to improve acute stroke care in the United States.

Background and Purpose: The Paul Coverdell National Acute Stroke Registry is being developed to improve the quality of acute stroke care. This article describes key features of acute stroke care from 4 prototype registries in Georgia (Ga), Massachusetts (Mass), Michigan (Mich), and Ohio., Methods: Each prototype developed its own sampling scheme to obtain a representative sample of hospitals. Acute stroke admissions were identified using prospective (Mass, Mich) or retrospective (Ga, Ohio) methods. All prototypes used a common set of case definitions and data elements. Weighted site-specific frequencies were generated for each outcome., Results: A total of 6867 admissions from 98 hospitals were included; the majority were ischemic strokes (range, 52% to 70%) with transient ischemic attack and intracerebral hemorrhage comprising the bulk of the remainder. Between 19% and 26% of admissions were younger than age 60 years, and between 52% and 58% were female. Black subjects varied from 7.1% (Mich) to 30.6% (Ga). Between 20% and 25% of admissions arrived at the emergency department within 3 hours of onset. Treatment with recombinant tissue plasminogen activator (rtPA) was administered to between 3.0% (Ga) and 8.5% (Mass) of ischemic stroke admissions. Of 118 subjects treated with intravenous rtPA, <20% received it within 60 minutes of arrival. Compliance with secondary prevention practices was poorest for smoking cessation counseling and best for antithrombotics., Conclusions: A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the health care systems level, are needed to improve acute stroke care in the United States.

Background: To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke., Methods: Adults in Georgia were studied with a random digit dial telephone survey., Results: Answering an unaided question, 39% of 602 respondents named > or =1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family., Conclusions: Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.