Dispatcher Recognition of Stroke Using the National Academy Medical Priority Dispatch System

[Guest guest]

Background and Purpose‹ Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods‹ We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results‹ Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions‹ Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

And as I recall, flipping a coin has a 50% predictive value, does it not?

So much for the accuracy of MPDS...

Bledsoe wrote:

>

>

> Background and Purpose‹ Emergency medical dispatchers play an

> important role

> in optimizing stroke care if they are able to accurately identify calls

> regarding acute cerebrovascular disease. This study was undertaken to

> assess

> the diagnostic accuracy of the current national protocol guiding

> dispatcher

> questioning of 911 callers to identify stroke (QA Guide version 11.1

> of the

> National Academy Medical Priority Dispatch System).

>

> Methods‹ We identified all Los Angeles Fire Department paramedic

> transports

> of patients to University of California Los Angeles Medical Center during

> the 12-month period from January to December 2005 in a prospectively

> maintained database. Dispatcher-assigned Medical Priority Dispatch System

> codes for each of these patient transports were abstracted from the

> paramedic run sheets and compared to final hospital discharge diagnosis.

>

> Results‹ Among 3474 transported patients, 96 (2.8%) had a final

> diagnosis of

> stroke or transient ischemic attack. Dispatchers assigned a code of

> potential stroke to 44.8% of patients with a final discharge diagnosis of

> stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

> 0.41, specificity of 0.96, positive predictive value of 0.45, and negative

> predictive value of 0.95.

>

> Conclusions‹ Dispatcher recognition of stroke calls using the widely

> employed Medical Priority Dispatch System algorithm is suboptimal, with

> failure to identify more than half of stroke patients as likely stroke.

> Revisions to the current national dispatcher structured interview and

> symptom identification algorithm for stroke may facilitate more accurate

> recognition of stroke by emergency medical dispatchers.

>

> Stroke. 2009;40:2027-2030

>

>

[Guest guest]

Hi Folks,

As someone who believes that good use of MPDS is (on the whole) better than

other alternatives that I'm aware of (kind of like 'Democracy isn't perfect,

but it's the best approach I know of'), I was curious what Dr. Clawson's

perspective on the LA study would be. Here is what they sent to STROKE,

where the study was published. Thanks - Todd

Compliance to and Use of Up-to-date National Academies of Medical Dispatch

Medical Priority Dispatch System Protocols in Dispatch Practice and Research

Studies Must Be a Requirement.

Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

(National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

We observed significant omissions and errors in the study's methods/design,

findings, and conclusions of in the recent paper by Buck et al.,1 which we

respectfully wish to point out.

First, the National Academies of Emergency Dispatch (NAED) Medical Priority

Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

used in this study1 is significantly outdated. Three subsequent versions

(v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and v12.0,

valid from 2008 to date) have been issued, each containing significant

clinically predictive modifications in the stroke protocol (Protocol 28).

Utilizing an outdated protocol, is unsafe in a communication center, not the

standard of dispatch practice, and misleads readers about the " current "

effectiveness of the state-of-the-art of an evolving protocol system. In

the MPDS v11.1 protocol's rules at that time, a compliant emergency medical

dispatcher (EMD) selection of the " stroke " chief complaint (CC), was limited

only to cases where the caller used the word " stroke " to describe the

patient's condition. To select a stroke CC if confronted with other

symptoms was non-compliance to protocol back then, and would not be done by

certified EMDs. The automated evaluation process (stroke evaluation and

diagnostic tool) in the current MPDS stroke protocol version 12.02

(available to centers upon request) incorporates the validated Cincinnati

prehospital stroke scale in the final dispatch coding after detailed

identification of stroke possibility in 91l callers - identifying specific

combination of signs and symptoms relevant to stroke.

Second, for a dispatch protocol-based study to be valid, all cases studied

must either be audio-reviewed for protocol compliance, or come from a

NAED-accredited dispatch center that has a documented, proven high protocol

compliance. A minimum of 90%-95% compliance level is required, with monthly

compliance reporting of audited cases. Without verified high compliance, one

cannot study the MPDS protocol because non-compliant cases with subjective

calltaker decisions will skew the findings. We assume that protocol

compliance audit was not part of Buck et al. study,1 since Los Angeles (LA)

Fire Department Communications Center is not NAED-accredited, and protocol

compliance was not reported.

Third, other CC codes that are known to contain stroke patients were not

accounted for in the study. The authors used the LA prehospital stroke

screen method3 which does not identify all strokes despite its reported high

sensitivity and specificity) to identify 1,283 strokes from the initial

database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes records -

which could potentially confound the findings.

It is known that 911 callers may describe stroke victims in any number of

ways, with complaints such as falls, unconscious, not alert, diabetic,

weakness, headache, general illness, etc. The MPDS has been purposefully

designed to capture these symptoms on non-stroke CC determinants and

prioritize cases accordingly- even when the caller doesn't

recognize/describe the patient's condition as stroke. Buck et al.1 only

measures when the dispatcher identified stroke during the very first

question posed in the MPDS protocol " What's the problem, tell me exactly

what happened? " , not when stroke-like symptoms were identified later in the

MPDS. This demonstrates lack of basic understanding of how the MPDS

protocols work, and relate to EMS response and patient treatment.

Surprisingly, the study does not mention when an Emergency Medical Services

(EMS) response would differ to non-stroke patients, and how any difference

in response would change the patient's treatment.

A recently published study4 of the basic protocol's effectiveness (selection

in the case entry section of the stroke CC) in the San Diego EMS dispatch

system was a better scientific evaluation of what the current NAED protocol

and training does, using MPDS protocol version 11.2.

In the future, publications of the Stroke journal's stature should engage

reviewers with the knowledge of the above dispatch-related parameters to

correctly validate that, what is claimed, is what is studied. The NAED has

an Institutional Review Board and Research Council to help review

methodology in this regard.

Disclosures

Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

Priority Dispatch Corp. Olola is the Director of Research and

Biomedical Informatics Division and Greg is a member of the Council of

Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

USA.

References

1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

City, Utah: National Academy of Emergency Medical Dispatch.

3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

stroke in the field. Prospective validation of the Los Angeles prehospital

stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

Jul-Sep;12(3):307-13.

From: texasems-l [mailto:texasems-l ] On

Behalf Of Bledsoe

Sent: Thursday, July 09, 2009 8:31 PM

To: texasems-l ; Paramedicine

Subject: Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Hi Folks,

As someone who believes that good use of MPDS is (on the whole) better than

other alternatives that I'm aware of (kind of like 'Democracy isn't perfect,

but it's the best approach I know of'), I was curious what Dr. Clawson's

perspective on the LA study would be. Here is what they sent to STROKE,

where the study was published. Thanks - Todd

Compliance to and Use of Up-to-date National Academies of Medical Dispatch

Medical Priority Dispatch System Protocols in Dispatch Practice and Research

Studies Must Be a Requirement.

Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

(National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

We observed significant omissions and errors in the study's methods/design,

findings, and conclusions of in the recent paper by Buck et al.,1 which we

respectfully wish to point out.

First, the National Academies of Emergency Dispatch (NAED) Medical Priority

Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

used in this study1 is significantly outdated. Three subsequent versions

(v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and v12.0,

valid from 2008 to date) have been issued, each containing significant

clinically predictive modifications in the stroke protocol (Protocol 28).

Utilizing an outdated protocol, is unsafe in a communication center, not the

standard of dispatch practice, and misleads readers about the " current "

effectiveness of the state-of-the-art of an evolving protocol system. In

the MPDS v11.1 protocol's rules at that time, a compliant emergency medical

dispatcher (EMD) selection of the " stroke " chief complaint (CC), was limited

only to cases where the caller used the word " stroke " to describe the

patient's condition. To select a stroke CC if confronted with other

symptoms was non-compliance to protocol back then, and would not be done by

certified EMDs. The automated evaluation process (stroke evaluation and

diagnostic tool) in the current MPDS stroke protocol version 12.02

(available to centers upon request) incorporates the validated Cincinnati

prehospital stroke scale in the final dispatch coding after detailed

identification of stroke possibility in 91l callers - identifying specific

combination of signs and symptoms relevant to stroke.

Second, for a dispatch protocol-based study to be valid, all cases studied

must either be audio-reviewed for protocol compliance, or come from a

NAED-accredited dispatch center that has a documented, proven high protocol

compliance. A minimum of 90%-95% compliance level is required, with monthly

compliance reporting of audited cases. Without verified high compliance, one

cannot study the MPDS protocol because non-compliant cases with subjective

calltaker decisions will skew the findings. We assume that protocol

compliance audit was not part of Buck et al. study,1 since Los Angeles (LA)

Fire Department Communications Center is not NAED-accredited, and protocol

compliance was not reported.

Third, other CC codes that are known to contain stroke patients were not

accounted for in the study. The authors used the LA prehospital stroke

screen method3 which does not identify all strokes despite its reported high

sensitivity and specificity) to identify 1,283 strokes from the initial

database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes records -

which could potentially confound the findings.

It is known that 911 callers may describe stroke victims in any number of

ways, with complaints such as falls, unconscious, not alert, diabetic,

weakness, headache, general illness, etc. The MPDS has been purposefully

designed to capture these symptoms on non-stroke CC determinants and

prioritize cases accordingly- even when the caller doesn't

recognize/describe the patient's condition as stroke. Buck et al.1 only

measures when the dispatcher identified stroke during the very first

question posed in the MPDS protocol " What's the problem, tell me exactly

what happened? " , not when stroke-like symptoms were identified later in the

MPDS. This demonstrates lack of basic understanding of how the MPDS

protocols work, and relate to EMS response and patient treatment.

Surprisingly, the study does not mention when an Emergency Medical Services

(EMS) response would differ to non-stroke patients, and how any difference

in response would change the patient's treatment.

A recently published study4 of the basic protocol's effectiveness (selection

in the case entry section of the stroke CC) in the San Diego EMS dispatch

system was a better scientific evaluation of what the current NAED protocol

and training does, using MPDS protocol version 11.2.

In the future, publications of the Stroke journal's stature should engage

reviewers with the knowledge of the above dispatch-related parameters to

correctly validate that, what is claimed, is what is studied. The NAED has

an Institutional Review Board and Research Council to help review

methodology in this regard.

Disclosures

Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

Priority Dispatch Corp. Olola is the Director of Research and

Biomedical Informatics Division and Greg is a member of the Council of

Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

USA.

References

1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

City, Utah: National Academy of Emergency Medical Dispatch.

3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

stroke in the field. Prospective validation of the Los Angeles prehospital

stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

Jul-Sep;12(3):307-13.

From: texasems-l [mailto:texasems-l ] On

Behalf Of Bledsoe

Sent: Thursday, July 09, 2009 8:31 PM

To: texasems-l ; Paramedicine

Subject: Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Hi Folks,

As someone who believes that good use of MPDS is (on the whole) better than

other alternatives that I'm aware of (kind of like 'Democracy isn't perfect,

but it's the best approach I know of'), I was curious what Dr. Clawson's

perspective on the LA study would be. Here is what they sent to STROKE,

where the study was published. Thanks - Todd

Compliance to and Use of Up-to-date National Academies of Medical Dispatch

Medical Priority Dispatch System Protocols in Dispatch Practice and Research

Studies Must Be a Requirement.

Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

(National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

We observed significant omissions and errors in the study's methods/design,

findings, and conclusions of in the recent paper by Buck et al.,1 which we

respectfully wish to point out.

First, the National Academies of Emergency Dispatch (NAED) Medical Priority

Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

used in this study1 is significantly outdated. Three subsequent versions

(v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and v12.0,

valid from 2008 to date) have been issued, each containing significant

clinically predictive modifications in the stroke protocol (Protocol 28).

Utilizing an outdated protocol, is unsafe in a communication center, not the

standard of dispatch practice, and misleads readers about the " current "

effectiveness of the state-of-the-art of an evolving protocol system. In

the MPDS v11.1 protocol's rules at that time, a compliant emergency medical

dispatcher (EMD) selection of the " stroke " chief complaint (CC), was limited

only to cases where the caller used the word " stroke " to describe the

patient's condition. To select a stroke CC if confronted with other

symptoms was non-compliance to protocol back then, and would not be done by

certified EMDs. The automated evaluation process (stroke evaluation and

diagnostic tool) in the current MPDS stroke protocol version 12.02

(available to centers upon request) incorporates the validated Cincinnati

prehospital stroke scale in the final dispatch coding after detailed

identification of stroke possibility in 91l callers - identifying specific

combination of signs and symptoms relevant to stroke.

Second, for a dispatch protocol-based study to be valid, all cases studied

must either be audio-reviewed for protocol compliance, or come from a

NAED-accredited dispatch center that has a documented, proven high protocol

compliance. A minimum of 90%-95% compliance level is required, with monthly

compliance reporting of audited cases. Without verified high compliance, one

cannot study the MPDS protocol because non-compliant cases with subjective

calltaker decisions will skew the findings. We assume that protocol

compliance audit was not part of Buck et al. study,1 since Los Angeles (LA)

Fire Department Communications Center is not NAED-accredited, and protocol

compliance was not reported.

Third, other CC codes that are known to contain stroke patients were not

accounted for in the study. The authors used the LA prehospital stroke

screen method3 which does not identify all strokes despite its reported high

sensitivity and specificity) to identify 1,283 strokes from the initial

database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes records -

which could potentially confound the findings.

It is known that 911 callers may describe stroke victims in any number of

ways, with complaints such as falls, unconscious, not alert, diabetic,

weakness, headache, general illness, etc. The MPDS has been purposefully

designed to capture these symptoms on non-stroke CC determinants and

prioritize cases accordingly- even when the caller doesn't

recognize/describe the patient's condition as stroke. Buck et al.1 only

measures when the dispatcher identified stroke during the very first

question posed in the MPDS protocol " What's the problem, tell me exactly

what happened? " , not when stroke-like symptoms were identified later in the

MPDS. This demonstrates lack of basic understanding of how the MPDS

protocols work, and relate to EMS response and patient treatment.

Surprisingly, the study does not mention when an Emergency Medical Services

(EMS) response would differ to non-stroke patients, and how any difference

in response would change the patient's treatment.

A recently published study4 of the basic protocol's effectiveness (selection

in the case entry section of the stroke CC) in the San Diego EMS dispatch

system was a better scientific evaluation of what the current NAED protocol

and training does, using MPDS protocol version 11.2.

In the future, publications of the Stroke journal's stature should engage

reviewers with the knowledge of the above dispatch-related parameters to

correctly validate that, what is claimed, is what is studied. The NAED has

an Institutional Review Board and Research Council to help review

methodology in this regard.

Disclosures

Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

Priority Dispatch Corp. Olola is the Director of Research and

Biomedical Informatics Division and Greg is a member of the Council of

Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

USA.

References

1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

City, Utah: National Academy of Emergency Medical Dispatch.

3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

stroke in the field. Prospective validation of the Los Angeles prehospital

stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

Jul-Sep;12(3):307-13.

From: texasems-l [mailto:texasems-l ] On

Behalf Of Bledsoe

Sent: Thursday, July 09, 2009 8:31 PM

To: texasems-l ; Paramedicine

Subject: Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Using outdated dispatch protocols - shame on them. Whether that actually

skews the study remains to be seen. Stroke symptoms have been the same

for as long as people have been having strokes. One wonders why dispatch

protocols v11.1, v11.2, and v11.3 didn't accurately screen for those

symptoms, yet 12.0 does. Perhaps it's the Windows Vista of dispatch

protocols, and those Luddites in Los Angeles need to abandon their old,

stable Windows 98 platform and get with the new program.

Anyone got old copies of v11.1 and v12.0 that they can post here for a

comparison? It would be interesting to see what has changed, other than

the price tag.

As far as translating the rest of the response: " You haven't paid for

our proprietary merit badge, therefore you aren't doing it right. "

Of course, if my sarcasm hasn't openly proclaimed my bias thus far, I'll

go ahead and state it here: I regard MPDS as something a little more

accurate than a Ouija board, but not quite as accurate as a coin flip.

Todd Stout wrote:

>

>

> Hi Folks,

>

> As someone who believes that good use of MPDS is (on the whole) better

> than

> other alternatives that I'm aware of (kind of like 'Democracy isn't

> perfect,

> but it's the best approach I know of'), I was curious what Dr. Clawson's

> perspective on the LA study would be. Here is what they sent to STROKE,

> where the study was published. Thanks - Todd

>

> Compliance to and Use of Up-to-date National Academies of Medical Dispatch

> Medical Priority Dispatch System Protocols in Dispatch Practice and

> Research

> Studies Must Be a Requirement.

>

> Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

>

> (National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

>

> We observed significant omissions and errors in the study's

> methods/design,

> findings, and conclusions of in the recent paper by Buck et al.,1 which we

> respectfully wish to point out.

>

> First, the National Academies of Emergency Dispatch (NAED) Medical

> Priority

> Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

> used in this study1 is significantly outdated. Three subsequent versions

> (v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and

> v12.0,

> valid from 2008 to date) have been issued, each containing significant

> clinically predictive modifications in the stroke protocol (Protocol 28).

> Utilizing an outdated protocol, is unsafe in a communication center,

> not the

> standard of dispatch practice, and misleads readers about the " current "

> effectiveness of the state-of-the-art of an evolving protocol system. In

> the MPDS v11.1 protocol's rules at that time, a compliant emergency

> medical

> dispatcher (EMD) selection of the " stroke " chief complaint (CC), was

> limited

> only to cases where the caller used the word " stroke " to describe the

> patient's condition. To select a stroke CC if confronted with other

> symptoms was non-compliance to protocol back then, and would not be

> done by

> certified EMDs. The automated evaluation process (stroke evaluation and

> diagnostic tool) in the current MPDS stroke protocol version 12.02

> (available to centers upon request) incorporates the validated Cincinnati

> prehospital stroke scale in the final dispatch coding after detailed

> identification of stroke possibility in 91l callers - identifying specific

> combination of signs and symptoms relevant to stroke.

>

> Second, for a dispatch protocol-based study to be valid, all cases studied

> must either be audio-reviewed for protocol compliance, or come from a

> NAED-accredited dispatch center that has a documented, proven high

> protocol

> compliance. A minimum of 90%-95% compliance level is required, with

> monthly

> compliance reporting of audited cases. Without verified high

> compliance, one

> cannot study the MPDS protocol because non-compliant cases with subjective

> calltaker decisions will skew the findings. We assume that protocol

> compliance audit was not part of Buck et al. study,1 since Los Angeles

> (LA)

> Fire Department Communications Center is not NAED-accredited, and protocol

> compliance was not reported.

>

> Third, other CC codes that are known to contain stroke patients were not

> accounted for in the study. The authors used the LA prehospital stroke

> screen method3 which does not identify all strokes despite its

> reported high

> sensitivity and specificity) to identify 1,283 strokes from the initial

> database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes

> records -

> which could potentially confound the findings.

>

> It is known that 911 callers may describe stroke victims in any number of

> ways, with complaints such as falls, unconscious, not alert, diabetic,

> weakness, headache, general illness, etc. The MPDS has been purposefully

> designed to capture these symptoms on non-stroke CC determinants and

> prioritize cases accordingly- even when the caller doesn't

> recognize/describe the patient's condition as stroke. Buck et al.1 only

> measures when the dispatcher identified stroke during the very first

> question posed in the MPDS protocol " What's the problem, tell me exactly

> what happened? " , not when stroke-like symptoms were identified later

> in the

> MPDS. This demonstrates lack of basic understanding of how the MPDS

> protocols work, and relate to EMS response and patient treatment.

>

> Surprisingly, the study does not mention when an Emergency Medical

> Services

> (EMS) response would differ to non-stroke patients, and how any difference

> in response would change the patient's treatment.

>

> A recently published study4 of the basic protocol's effectiveness

> (selection

> in the case entry section of the stroke CC) in the San Diego EMS dispatch

> system was a better scientific evaluation of what the current NAED

> protocol

> and training does, using MPDS protocol version 11.2.

>

> In the future, publications of the Stroke journal's stature should engage

> reviewers with the knowledge of the above dispatch-related parameters to

> correctly validate that, what is claimed, is what is studied. The NAED has

> an Institutional Review Board and Research Council to help review

> methodology in this regard.

>

> Disclosures

>

> Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

> Priority Dispatch Corp. Olola is the Director of Research and

> Biomedical Informatics Division and Greg is a member of the

> Council of

> Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

> USA.

>

> References

>

> 1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

> D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

> Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

>

> 2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

> Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

> City, Utah: National Academy of Emergency Medical Dispatch.

>

> 3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

> stroke in the field. Prospective validation of the Los Angeles prehospital

> stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

>

> 4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

> Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

> dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

> Jul-Sep;12(3):307-13.

>

> From: texasems-l

> [mailto:texasems-l

> ] On

> Behalf Of Bledsoe

> Sent: Thursday, July 09, 2009 8:31 PM

> To: texasems-l ;

> Paramedicine

> Subject: Dispatcher Recognition of Stroke Using the National

> Academy Medical Priority Dispatch System

>

> Background and Purpose< Emergency medical dispatchers play an

> important role

> in optimizing stroke care if they are able to accurately identify calls

> regarding acute cerebrovascular disease. This study was undertaken to

> assess

> the diagnostic accuracy of the current national protocol guiding

> dispatcher

> questioning of 911 callers to identify stroke (QA Guide version 11.1

> of the

> National Academy Medical Priority Dispatch System).

>

> Methods< We identified all Los Angeles Fire Department paramedic

> transports

> of patients to University of California Los Angeles Medical Center during

> the 12-month period from January to December 2005 in a prospectively

> maintained database. Dispatcher-assigned Medical Priority Dispatch System

> codes for each of these patient transports were abstracted from the

> paramedic run sheets and compared to final hospital discharge diagnosis.

>

> Results< Among 3474 transported patients, 96 (2.8%) had a final

> diagnosis of

> stroke or transient ischemic attack. Dispatchers assigned a code of

> potential stroke to 44.8% of patients with a final discharge diagnosis of

> stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

> 0.41, specificity of 0.96, positive predictive value of 0.45, and negative

> predictive value of 0.95.

>

> Conclusions< Dispatcher recognition of stroke calls using the widely

> employed Medical Priority Dispatch System algorithm is suboptimal, with

> failure to identify more than half of stroke patients as likely stroke.

> Revisions to the current national dispatcher structured interview and

> symptom identification algorithm for stroke may facilitate more accurate

> recognition of stroke by emergency medical dispatchers.

>

> Stroke. 2009;40:2027-2030

>

>

[Guest guest]

Using outdated dispatch protocols - shame on them. Whether that actually

skews the study remains to be seen. Stroke symptoms have been the same

for as long as people have been having strokes. One wonders why dispatch

protocols v11.1, v11.2, and v11.3 didn't accurately screen for those

symptoms, yet 12.0 does. Perhaps it's the Windows Vista of dispatch

protocols, and those Luddites in Los Angeles need to abandon their old,

stable Windows 98 platform and get with the new program.

Anyone got old copies of v11.1 and v12.0 that they can post here for a

comparison? It would be interesting to see what has changed, other than

the price tag.

As far as translating the rest of the response: " You haven't paid for

our proprietary merit badge, therefore you aren't doing it right. "

Of course, if my sarcasm hasn't openly proclaimed my bias thus far, I'll

go ahead and state it here: I regard MPDS as something a little more

accurate than a Ouija board, but not quite as accurate as a coin flip.

Todd Stout wrote:

>

>

> Hi Folks,

>

> As someone who believes that good use of MPDS is (on the whole) better

> than

> other alternatives that I'm aware of (kind of like 'Democracy isn't

> perfect,

> but it's the best approach I know of'), I was curious what Dr. Clawson's

> perspective on the LA study would be. Here is what they sent to STROKE,

> where the study was published. Thanks - Todd

>

> Compliance to and Use of Up-to-date National Academies of Medical Dispatch

> Medical Priority Dispatch System Protocols in Dispatch Practice and

> Research

> Studies Must Be a Requirement.

>

> Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

>

> (National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

>

> We observed significant omissions and errors in the study's

> methods/design,

> findings, and conclusions of in the recent paper by Buck et al.,1 which we

> respectfully wish to point out.

>

> First, the National Academies of Emergency Dispatch (NAED) Medical

> Priority

> Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

> used in this study1 is significantly outdated. Three subsequent versions

> (v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and

> v12.0,

> valid from 2008 to date) have been issued, each containing significant

> clinically predictive modifications in the stroke protocol (Protocol 28).

> Utilizing an outdated protocol, is unsafe in a communication center,

> not the

> standard of dispatch practice, and misleads readers about the " current "

> effectiveness of the state-of-the-art of an evolving protocol system. In

> the MPDS v11.1 protocol's rules at that time, a compliant emergency

> medical

> dispatcher (EMD) selection of the " stroke " chief complaint (CC), was

> limited

> only to cases where the caller used the word " stroke " to describe the

> patient's condition. To select a stroke CC if confronted with other

> symptoms was non-compliance to protocol back then, and would not be

> done by

> certified EMDs. The automated evaluation process (stroke evaluation and

> diagnostic tool) in the current MPDS stroke protocol version 12.02

> (available to centers upon request) incorporates the validated Cincinnati

> prehospital stroke scale in the final dispatch coding after detailed

> identification of stroke possibility in 91l callers - identifying specific

> combination of signs and symptoms relevant to stroke.

>

> Second, for a dispatch protocol-based study to be valid, all cases studied

> must either be audio-reviewed for protocol compliance, or come from a

> NAED-accredited dispatch center that has a documented, proven high

> protocol

> compliance. A minimum of 90%-95% compliance level is required, with

> monthly

> compliance reporting of audited cases. Without verified high

> compliance, one

> cannot study the MPDS protocol because non-compliant cases with subjective

> calltaker decisions will skew the findings. We assume that protocol

> compliance audit was not part of Buck et al. study,1 since Los Angeles

> (LA)

> Fire Department Communications Center is not NAED-accredited, and protocol

> compliance was not reported.

>

> Third, other CC codes that are known to contain stroke patients were not

> accounted for in the study. The authors used the LA prehospital stroke

> screen method3 which does not identify all strokes despite its

> reported high

> sensitivity and specificity) to identify 1,283 strokes from the initial

> database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes

> records -

> which could potentially confound the findings.

>

> It is known that 911 callers may describe stroke victims in any number of

> ways, with complaints such as falls, unconscious, not alert, diabetic,

> weakness, headache, general illness, etc. The MPDS has been purposefully

> designed to capture these symptoms on non-stroke CC determinants and

> prioritize cases accordingly- even when the caller doesn't

> recognize/describe the patient's condition as stroke. Buck et al.1 only

> measures when the dispatcher identified stroke during the very first

> question posed in the MPDS protocol " What's the problem, tell me exactly

> what happened? " , not when stroke-like symptoms were identified later

> in the

> MPDS. This demonstrates lack of basic understanding of how the MPDS

> protocols work, and relate to EMS response and patient treatment.

>

> Surprisingly, the study does not mention when an Emergency Medical

> Services

> (EMS) response would differ to non-stroke patients, and how any difference

> in response would change the patient's treatment.

>

> A recently published study4 of the basic protocol's effectiveness

> (selection

> in the case entry section of the stroke CC) in the San Diego EMS dispatch

> system was a better scientific evaluation of what the current NAED

> protocol

> and training does, using MPDS protocol version 11.2.

>

> In the future, publications of the Stroke journal's stature should engage

> reviewers with the knowledge of the above dispatch-related parameters to

> correctly validate that, what is claimed, is what is studied. The NAED has

> an Institutional Review Board and Research Council to help review

> methodology in this regard.

>

> Disclosures

>

> Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

> Priority Dispatch Corp. Olola is the Director of Research and

> Biomedical Informatics Division and Greg is a member of the

> Council of

> Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

> USA.

>

> References

>

> 1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

> D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

> Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

>

> 2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

> Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

> City, Utah: National Academy of Emergency Medical Dispatch.

>

> 3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

> stroke in the field. Prospective validation of the Los Angeles prehospital

> stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

>

> 4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

> Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

> dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

> Jul-Sep;12(3):307-13.

>

> From: texasems-l

> [mailto:texasems-l

> ] On

> Behalf Of Bledsoe

> Sent: Thursday, July 09, 2009 8:31 PM

> To: texasems-l ;

> Paramedicine

> Subject: Dispatcher Recognition of Stroke Using the National

> Academy Medical Priority Dispatch System

>

> Background and Purpose< Emergency medical dispatchers play an

> important role

> in optimizing stroke care if they are able to accurately identify calls

> regarding acute cerebrovascular disease. This study was undertaken to

> assess

> the diagnostic accuracy of the current national protocol guiding

> dispatcher

> questioning of 911 callers to identify stroke (QA Guide version 11.1

> of the

> National Academy Medical Priority Dispatch System).

>

> Methods< We identified all Los Angeles Fire Department paramedic

> transports

> of patients to University of California Los Angeles Medical Center during

> the 12-month period from January to December 2005 in a prospectively

> maintained database. Dispatcher-assigned Medical Priority Dispatch System

> codes for each of these patient transports were abstracted from the

> paramedic run sheets and compared to final hospital discharge diagnosis.

>

> Results< Among 3474 transported patients, 96 (2.8%) had a final

> diagnosis of

> stroke or transient ischemic attack. Dispatchers assigned a code of

> potential stroke to 44.8% of patients with a final discharge diagnosis of

> stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

> 0.41, specificity of 0.96, positive predictive value of 0.45, and negative

> predictive value of 0.95.

>

> Conclusions< Dispatcher recognition of stroke calls using the widely

> employed Medical Priority Dispatch System algorithm is suboptimal, with

> failure to identify more than half of stroke patients as likely stroke.

> Revisions to the current national dispatcher structured interview and

> symptom identification algorithm for stroke may facilitate more accurate

> recognition of stroke by emergency medical dispatchers.

>

> Stroke. 2009;40:2027-2030

>

>

[Guest guest]

Using outdated dispatch protocols - shame on them. Whether that actually

skews the study remains to be seen. Stroke symptoms have been the same

for as long as people have been having strokes. One wonders why dispatch

protocols v11.1, v11.2, and v11.3 didn't accurately screen for those

symptoms, yet 12.0 does. Perhaps it's the Windows Vista of dispatch

protocols, and those Luddites in Los Angeles need to abandon their old,

stable Windows 98 platform and get with the new program.

Anyone got old copies of v11.1 and v12.0 that they can post here for a

comparison? It would be interesting to see what has changed, other than

the price tag.

As far as translating the rest of the response: " You haven't paid for

our proprietary merit badge, therefore you aren't doing it right. "

Of course, if my sarcasm hasn't openly proclaimed my bias thus far, I'll

go ahead and state it here: I regard MPDS as something a little more

accurate than a Ouija board, but not quite as accurate as a coin flip.

Todd Stout wrote:

>

>

> Hi Folks,

>

> As someone who believes that good use of MPDS is (on the whole) better

> than

> other alternatives that I'm aware of (kind of like 'Democracy isn't

> perfect,

> but it's the best approach I know of'), I was curious what Dr. Clawson's

> perspective on the LA study would be. Here is what they sent to STROKE,

> where the study was published. Thanks - Todd

>

> Compliance to and Use of Up-to-date National Academies of Medical Dispatch

> Medical Priority Dispatch System Protocols in Dispatch Practice and

> Research

> Studies Must Be a Requirement.

>

> Jeff J. Clawson, MD; Olola, PhD; Greg , EMD-QI

>

> (National Academies of Emergency Dispatch, Salt Lake City, Utah, USA)

>

> We observed significant omissions and errors in the study's

> methods/design,

> findings, and conclusions of in the recent paper by Buck et al.,1 which we

> respectfully wish to point out.

>

> First, the National Academies of Emergency Dispatch (NAED) Medical

> Priority

> Dispatch System (MPDS) protocol version (v11.1, valid from 2001 to 2004)

> used in this study1 is significantly outdated. Three subsequent versions

> (v11.2, valid from 2004 to 2006; v11.3, valid from 2006 to 2008; and

> v12.0,

> valid from 2008 to date) have been issued, each containing significant

> clinically predictive modifications in the stroke protocol (Protocol 28).

> Utilizing an outdated protocol, is unsafe in a communication center,

> not the

> standard of dispatch practice, and misleads readers about the " current "

> effectiveness of the state-of-the-art of an evolving protocol system. In

> the MPDS v11.1 protocol's rules at that time, a compliant emergency

> medical

> dispatcher (EMD) selection of the " stroke " chief complaint (CC), was

> limited

> only to cases where the caller used the word " stroke " to describe the

> patient's condition. To select a stroke CC if confronted with other

> symptoms was non-compliance to protocol back then, and would not be

> done by

> certified EMDs. The automated evaluation process (stroke evaluation and

> diagnostic tool) in the current MPDS stroke protocol version 12.02

> (available to centers upon request) incorporates the validated Cincinnati

> prehospital stroke scale in the final dispatch coding after detailed

> identification of stroke possibility in 91l callers - identifying specific

> combination of signs and symptoms relevant to stroke.

>

> Second, for a dispatch protocol-based study to be valid, all cases studied

> must either be audio-reviewed for protocol compliance, or come from a

> NAED-accredited dispatch center that has a documented, proven high

> protocol

> compliance. A minimum of 90%-95% compliance level is required, with

> monthly

> compliance reporting of audited cases. Without verified high

> compliance, one

> cannot study the MPDS protocol because non-compliant cases with subjective

> calltaker decisions will skew the findings. We assume that protocol

> compliance audit was not part of Buck et al. study,1 since Los Angeles

> (LA)

> Fire Department Communications Center is not NAED-accredited, and protocol

> compliance was not reported.

>

> Third, other CC codes that are known to contain stroke patients were not

> accounted for in the study. The authors used the LA prehospital stroke

> screen method3 which does not identify all strokes despite its

> reported high

> sensitivity and specificity) to identify 1,283 strokes from the initial

> database (n=3,474) and finally utilizing 25% (871/3474) MPDS codes

> records -

> which could potentially confound the findings.

>

> It is known that 911 callers may describe stroke victims in any number of

> ways, with complaints such as falls, unconscious, not alert, diabetic,

> weakness, headache, general illness, etc. The MPDS has been purposefully

> designed to capture these symptoms on non-stroke CC determinants and

> prioritize cases accordingly- even when the caller doesn't

> recognize/describe the patient's condition as stroke. Buck et al.1 only

> measures when the dispatcher identified stroke during the very first

> question posed in the MPDS protocol " What's the problem, tell me exactly

> what happened? " , not when stroke-like symptoms were identified later

> in the

> MPDS. This demonstrates lack of basic understanding of how the MPDS

> protocols work, and relate to EMS response and patient treatment.

>

> Surprisingly, the study does not mention when an Emergency Medical

> Services

> (EMS) response would differ to non-stroke patients, and how any difference

> in response would change the patient's treatment.

>

> A recently published study4 of the basic protocol's effectiveness

> (selection

> in the case entry section of the stroke CC) in the San Diego EMS dispatch

> system was a better scientific evaluation of what the current NAED

> protocol

> and training does, using MPDS protocol version 11.2.

>

> In the future, publications of the Stroke journal's stature should engage

> reviewers with the knowledge of the above dispatch-related parameters to

> correctly validate that, what is claimed, is what is studied. The NAED has

> an Institutional Review Board and Research Council to help review

> methodology in this regard.

>

> Disclosures

>

> Jeff J. Clawson is the Medical Director, Council of Standards and CEO,

> Priority Dispatch Corp. Olola is the Director of Research and

> Biomedical Informatics Division and Greg is a member of the

> Council of

> Research, National Academies of Emergency Dispatch, Salt Lake City, Utah

> USA.

>

> References

>

> 1. Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, Colby

> D, Saver JL. Dispatcher Recognition of Stroke Using the National Academy

> Medical Priority Dispatch System. Stroke. 2009 Jun;40(6):2027-2030.

>

> 2. Clawson JJ, Dernocoeur KB, Rose B. Principles of Emergency Medical

> Dispatch: 30 years of protocols (1979-2009) (4th ed.). 2008. Salt Lake

> City, Utah: National Academy of Emergency Medical Dispatch.

>

> 3. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying

> stroke in the field. Prospective validation of the Los Angeles prehospital

> stroke screen (LAPSS). Stroke. 2000 Jan;31(1):71-6.

>

> 4. Ramanujam P, Guluma KZ, Castillo EM, Chacon M, Jensen MB, Patel E,

> Linnick W, Dunford JV. Accuracy of stroke recognition by emergency medical

> dispatchers and paramedics--San Diego experience. Prehosp Emerg Care. 2008

> Jul-Sep;12(3):307-13.

>

> From: texasems-l

> [mailto:texasems-l

> ] On

> Behalf Of Bledsoe

> Sent: Thursday, July 09, 2009 8:31 PM

> To: texasems-l ;

> Paramedicine

> Subject: Dispatcher Recognition of Stroke Using the National

> Academy Medical Priority Dispatch System

>

> Background and Purpose< Emergency medical dispatchers play an

> important role

> in optimizing stroke care if they are able to accurately identify calls

> regarding acute cerebrovascular disease. This study was undertaken to

> assess

> the diagnostic accuracy of the current national protocol guiding

> dispatcher

> questioning of 911 callers to identify stroke (QA Guide version 11.1

> of the

> National Academy Medical Priority Dispatch System).

>

> Methods< We identified all Los Angeles Fire Department paramedic

> transports

> of patients to University of California Los Angeles Medical Center during

> the 12-month period from January to December 2005 in a prospectively

> maintained database. Dispatcher-assigned Medical Priority Dispatch System

> codes for each of these patient transports were abstracted from the

> paramedic run sheets and compared to final hospital discharge diagnosis.

>

> Results< Among 3474 transported patients, 96 (2.8%) had a final

> diagnosis of

> stroke or transient ischemic attack. Dispatchers assigned a code of

> potential stroke to 44.8% of patients with a final discharge diagnosis of

> stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

> 0.41, specificity of 0.96, positive predictive value of 0.45, and negative

> predictive value of 0.95.

>

> Conclusions< Dispatcher recognition of stroke calls using the widely

> employed Medical Priority Dispatch System algorithm is suboptimal, with

> failure to identify more than half of stroke patients as likely stroke.

> Revisions to the current national dispatcher structured interview and

> symptom identification algorithm for stroke may facilitate more accurate

> recognition of stroke by emergency medical dispatchers.

>

> Stroke. 2009;40:2027-2030

>

>

[Guest guest]

OK, I'm confused.

Did the LA study suggest that non-identified stroke calls received a lower

level of response? In other words, not a lights and siren response? Was

there a delay in treatment and transport? Are they suggesting that the

paramedics can't figure out who's having a stroke on scene, and if ONLY

dispatch had told them their patient had a stroke, things would have turned out

differently for the patient?

If so, or if not, did the non-identification by call takers affect patient

care or patient outcomes in any way?

Further, I join in wondering just what magic words and cards the

newest version of Clawson's Dispatch Medicine Show added to so miraculously

change things?

Having taken the course but not drunk the Kool-Aid, I remain most skeptical

that any of this makes a twitter of sense in terms of improvement of

patient outcomes.

Emergency medical dispatch systems are fine, in that they do add some

structure to the call taker's job, but nobody has yet shown me that there is any

difference in patient outcomes as a result of using them.

One thing that Dr. Clawson's system does do if you pay him the money, is

buy his appearance for you in court when you get sued because -gasp- the

system didn't work as advertised. I understand that he's an excellent

courtroom

witness.

If anybody does have studies that prove an improvement in outcomes, please

post it. I would be interested in seeing it.

Gene Gandy

>

>

>

> Here¢®s another one from the UK just published with the same results.

>

> Emerg Med J. 2009 Jun;26(6):442- E

> Is ambulance telephone triage using advanced medical priority dispatch

> protocols able to identify patients with acute stroke correctly?

>

> Deakin CD, Alasaad M, King P, F.

>

> South Central Ambulance Service NHS Trust, North Wing, Southern House,

> Sparrowgrove, Otterbourne, Hants, UK. charlesdeakin@charlesdeakich

>

> BACKGROUND AND PURPOSE: As many as half the patients presenting with

> acute stroke access medical care through the ambulance service. In order

> to

> identify and triage these patients effectively as life-threatening

> emergencies, telephone-based ambulance software must have high sensitivity

> and specificity when using verbal descriptions to identify such patients.

> Software-based clinical coding was compared with the patient's final

> clinical diagnosis for all patients admitted by ambulance to North

> Hampshire

> Hospital (NHH) emergency department (ED) over a 6-month period to

> establish

> the ability of telephone-based triage to identify patients with likely

> stroke accurately. METHODS: All emergency calls to South Central Ambulance

> Service over a 6-month period resulting in a patient being taken to NHH ED

> were reviewed. The classification allocated to the patient by ambulance

> advanced medical priority dispatch software (AMPDS version 11.1) was

> compared with the final clinical diagnosis made by a doctor in the ED.

> RESULTS: 4810 patients were admitted to NHH during the study period. Of

> these, 126 patients were subsequently diagnosed as having had a stroke.

> The

> sensitivity of AMPDS software for detecting stroke in this sample was

> 47.62%, specificity was 98.68%, positive predictive value was 0.49 and

> negative predictive value was 0.986. CONCLUSIONS: Fewer than half of all

> patients with acute stroke were identified using telephone triage on the

> initial emergency call to the ambulance service. Less than one quarter

> received the highest priority of ambulance response. This first link in

> the

> chain of survival needs strengthening in order to provide prompt and

> timely

> emergency care for these patients.

>

>

>

> >

> >

> >

> >

> >

> > Please forgive me, I have not read this study. Does it mention in the

> study

> > if there was a difference in treatment and/or a difference in patient

> outcomes

> > either way due to the initial dispatch codes used?

> >

> > McGee, EMT-P

>

>

[Guest guest]

OK, I'm confused.

Did the LA study suggest that non-identified stroke calls received a lower

level of response? In other words, not a lights and siren response? Was

there a delay in treatment and transport? Are they suggesting that the

paramedics can't figure out who's having a stroke on scene, and if ONLY

dispatch had told them their patient had a stroke, things would have turned out

differently for the patient?

If so, or if not, did the non-identification by call takers affect patient

care or patient outcomes in any way?

Further, I join in wondering just what magic words and cards the

newest version of Clawson's Dispatch Medicine Show added to so miraculously

change things?

Having taken the course but not drunk the Kool-Aid, I remain most skeptical

that any of this makes a twitter of sense in terms of improvement of

patient outcomes.

Emergency medical dispatch systems are fine, in that they do add some

structure to the call taker's job, but nobody has yet shown me that there is any

difference in patient outcomes as a result of using them.

One thing that Dr. Clawson's system does do if you pay him the money, is

buy his appearance for you in court when you get sued because -gasp- the

system didn't work as advertised. I understand that he's an excellent

courtroom

witness.

If anybody does have studies that prove an improvement in outcomes, please

post it. I would be interested in seeing it.

Gene Gandy

>

>

>

> Here¢®s another one from the UK just published with the same results.

>

> Emerg Med J. 2009 Jun;26(6):442- E

> Is ambulance telephone triage using advanced medical priority dispatch

> protocols able to identify patients with acute stroke correctly?

>

> Deakin CD, Alasaad M, King P, F.

>

> South Central Ambulance Service NHS Trust, North Wing, Southern House,

> Sparrowgrove, Otterbourne, Hants, UK. charlesdeakin@charlesdeakich

>

> BACKGROUND AND PURPOSE: As many as half the patients presenting with

> acute stroke access medical care through the ambulance service. In order

> to

> identify and triage these patients effectively as life-threatening

> emergencies, telephone-based ambulance software must have high sensitivity

> and specificity when using verbal descriptions to identify such patients.

> Software-based clinical coding was compared with the patient's final

> clinical diagnosis for all patients admitted by ambulance to North

> Hampshire

> Hospital (NHH) emergency department (ED) over a 6-month period to

> establish

> the ability of telephone-based triage to identify patients with likely

> stroke accurately. METHODS: All emergency calls to South Central Ambulance

> Service over a 6-month period resulting in a patient being taken to NHH ED

> were reviewed. The classification allocated to the patient by ambulance

> advanced medical priority dispatch software (AMPDS version 11.1) was

> compared with the final clinical diagnosis made by a doctor in the ED.

> RESULTS: 4810 patients were admitted to NHH during the study period. Of

> these, 126 patients were subsequently diagnosed as having had a stroke.

> The

> sensitivity of AMPDS software for detecting stroke in this sample was

> 47.62%, specificity was 98.68%, positive predictive value was 0.49 and

> negative predictive value was 0.986. CONCLUSIONS: Fewer than half of all

> patients with acute stroke were identified using telephone triage on the

> initial emergency call to the ambulance service. Less than one quarter

> received the highest priority of ambulance response. This first link in

> the

> chain of survival needs strengthening in order to provide prompt and

> timely

> emergency care for these patients.

>

>

>

> >

> >

> >

> >

> >

> > Please forgive me, I have not read this study. Does it mention in the

> study

> > if there was a difference in treatment and/or a difference in patient

> outcomes

> > either way due to the initial dispatch codes used?

> >

> > McGee, EMT-P

>

>

[Guest guest]

OK, I'm confused.

Did the LA study suggest that non-identified stroke calls received a lower

level of response? In other words, not a lights and siren response? Was

there a delay in treatment and transport? Are they suggesting that the

paramedics can't figure out who's having a stroke on scene, and if ONLY

dispatch had told them their patient had a stroke, things would have turned out

differently for the patient?

If so, or if not, did the non-identification by call takers affect patient

care or patient outcomes in any way?

Further, I join in wondering just what magic words and cards the

newest version of Clawson's Dispatch Medicine Show added to so miraculously

change things?

Having taken the course but not drunk the Kool-Aid, I remain most skeptical

that any of this makes a twitter of sense in terms of improvement of

patient outcomes.

Emergency medical dispatch systems are fine, in that they do add some

structure to the call taker's job, but nobody has yet shown me that there is any

difference in patient outcomes as a result of using them.

One thing that Dr. Clawson's system does do if you pay him the money, is

buy his appearance for you in court when you get sued because -gasp- the

system didn't work as advertised. I understand that he's an excellent

courtroom

witness.

If anybody does have studies that prove an improvement in outcomes, please

post it. I would be interested in seeing it.

Gene Gandy

>

>

>

> Here¢®s another one from the UK just published with the same results.

>

> Emerg Med J. 2009 Jun;26(6):442- E

> Is ambulance telephone triage using advanced medical priority dispatch

> protocols able to identify patients with acute stroke correctly?

>

> Deakin CD, Alasaad M, King P, F.

>

> South Central Ambulance Service NHS Trust, North Wing, Southern House,

> Sparrowgrove, Otterbourne, Hants, UK. charlesdeakin@charlesdeakich

>

> BACKGROUND AND PURPOSE: As many as half the patients presenting with

> acute stroke access medical care through the ambulance service. In order

> to

> identify and triage these patients effectively as life-threatening

> emergencies, telephone-based ambulance software must have high sensitivity

> and specificity when using verbal descriptions to identify such patients.

> Software-based clinical coding was compared with the patient's final

> clinical diagnosis for all patients admitted by ambulance to North

> Hampshire

> Hospital (NHH) emergency department (ED) over a 6-month period to

> establish

> the ability of telephone-based triage to identify patients with likely

> stroke accurately. METHODS: All emergency calls to South Central Ambulance

> Service over a 6-month period resulting in a patient being taken to NHH ED

> were reviewed. The classification allocated to the patient by ambulance

> advanced medical priority dispatch software (AMPDS version 11.1) was

> compared with the final clinical diagnosis made by a doctor in the ED.

> RESULTS: 4810 patients were admitted to NHH during the study period. Of

> these, 126 patients were subsequently diagnosed as having had a stroke.

> The

> sensitivity of AMPDS software for detecting stroke in this sample was

> 47.62%, specificity was 98.68%, positive predictive value was 0.49 and

> negative predictive value was 0.986. CONCLUSIONS: Fewer than half of all

> patients with acute stroke were identified using telephone triage on the

> initial emergency call to the ambulance service. Less than one quarter

> received the highest priority of ambulance response. This first link in

> the

> chain of survival needs strengthening in order to provide prompt and

> timely

> emergency care for these patients.

>

>

>

> >

> >

> >

> >

> >

> > Please forgive me, I have not read this study. Does it mention in the

> study

> > if there was a difference in treatment and/or a difference in patient

> outcomes

> > either way due to the initial dispatch codes used?

> >

> > McGee, EMT-P

>

>

[Guest guest]

Please forgive me, I have not read this study. Does it mention in the study if

there was a difference in treatment and/or a difference in patient outcomes

either way due to the initial dispatch codes used?

McGee, EMT-P

----------

Sent from AT&T's Wireless network using Mobile Email

- Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Please forgive me, I have not read this study. Does it mention in the study if

there was a difference in treatment and/or a difference in patient outcomes

either way due to the initial dispatch codes used?

McGee, EMT-P

----------

Sent from AT&T's Wireless network using Mobile Email

- Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Please forgive me, I have not read this study. Does it mention in the study if

there was a difference in treatment and/or a difference in patient outcomes

either way due to the initial dispatch codes used?

McGee, EMT-P

----------

Sent from AT&T's Wireless network using Mobile Email

- Dispatcher Recognition of Stroke Using the National

Academy Medical Priority Dispatch System

Background and Purpose< Emergency medical dispatchers play an important role

in optimizing stroke care if they are able to accurately identify calls

regarding acute cerebrovascular disease. This study was undertaken to assess

the diagnostic accuracy of the current national protocol guiding dispatcher

questioning of 911 callers to identify stroke (QA Guide version 11.1 of the

National Academy Medical Priority Dispatch System).

Methods< We identified all Los Angeles Fire Department paramedic transports

of patients to University of California Los Angeles Medical Center during

the 12-month period from January to December 2005 in a prospectively

maintained database. Dispatcher-assigned Medical Priority Dispatch System

codes for each of these patient transports were abstracted from the

paramedic run sheets and compared to final hospital discharge diagnosis.

Results< Among 3474 transported patients, 96 (2.8%) had a final diagnosis of

stroke or transient ischemic attack. Dispatchers assigned a code of

potential stroke to 44.8% of patients with a final discharge diagnosis of

stroke or TIA. Dispatcher identification of stroke showed a sensitivity of

0.41, specificity of 0.96, positive predictive value of 0.45, and negative

predictive value of 0.95.

Conclusions< Dispatcher recognition of stroke calls using the widely

employed Medical Priority Dispatch System algorithm is suboptimal, with

failure to identify more than half of stroke patients as likely stroke.

Revisions to the current national dispatcher structured interview and

symptom identification algorithm for stroke may facilitate more accurate

recognition of stroke by emergency medical dispatchers.

Stroke. 2009;40:2027-2030

[Guest guest]

Here¹s another one from the UK just published with the same results.

Emerg Med J. 2009 Jun;26(6):442-5.

Is ambulance telephone triage using advanced medical priority dispatch

protocols able to identify patients with acute stroke correctly?

Deakin CD, Alasaad M, King P, F.

South Central Ambulance Service NHS Trust, North Wing, Southern House,

Sparrowgrove, Otterbourne, Hants, UK. charlesdeakin@...

BACKGROUND AND PURPOSE: As many as half the patients presenting with

acute stroke access medical care through the ambulance service. In order to

identify and triage these patients effectively as life-threatening

emergencies, telephone-based ambulance software must have high sensitivity

and specificity when using verbal descriptions to identify such patients.

Software-based clinical coding was compared with the patient's final

clinical diagnosis for all patients admitted by ambulance to North Hampshire

Hospital (NHH) emergency department (ED) over a 6-month period to establish

the ability of telephone-based triage to identify patients with likely

stroke accurately. METHODS: All emergency calls to South Central Ambulance

Service over a 6-month period resulting in a patient being taken to NHH ED

were reviewed. The classification allocated to the patient by ambulance

advanced medical priority dispatch software (AMPDS version 11.1) was

compared with the final clinical diagnosis made by a doctor in the ED.

RESULTS: 4810 patients were admitted to NHH during the study period. Of

these, 126 patients were subsequently diagnosed as having had a stroke. The

sensitivity of AMPDS software for detecting stroke in this sample was

47.62%, specificity was 98.68%, positive predictive value was 0.49 and

negative predictive value was 0.986. CONCLUSIONS: Fewer than half of all

patients with acute stroke were identified using telephone triage on the

initial emergency call to the ambulance service. Less than one quarter

received the highest priority of ambulance response. This first link in the

chain of survival needs strengthening in order to provide prompt and timely

emergency care for these patients.

>

>

>

>

>

> Please forgive me, I have not read this study. Does it mention in the study

> if there was a difference in treatment and/or a difference in patient outcomes

> either way due to the initial dispatch codes used?

>

> McGee, EMT-P

[Guest guest]

Here¹s another one from the UK just published with the same results.

Emerg Med J. 2009 Jun;26(6):442-5.

Is ambulance telephone triage using advanced medical priority dispatch

protocols able to identify patients with acute stroke correctly?

Deakin CD, Alasaad M, King P, F.

South Central Ambulance Service NHS Trust, North Wing, Southern House,

Sparrowgrove, Otterbourne, Hants, UK. charlesdeakin@...

BACKGROUND AND PURPOSE: As many as half the patients presenting with

acute stroke access medical care through the ambulance service. In order to

identify and triage these patients effectively as life-threatening

emergencies, telephone-based ambulance software must have high sensitivity

and specificity when using verbal descriptions to identify such patients.

Software-based clinical coding was compared with the patient's final

clinical diagnosis for all patients admitted by ambulance to North Hampshire

Hospital (NHH) emergency department (ED) over a 6-month period to establish

the ability of telephone-based triage to identify patients with likely

stroke accurately. METHODS: All emergency calls to South Central Ambulance

Service over a 6-month period resulting in a patient being taken to NHH ED

were reviewed. The classification allocated to the patient by ambulance

advanced medical priority dispatch software (AMPDS version 11.1) was

compared with the final clinical diagnosis made by a doctor in the ED.

RESULTS: 4810 patients were admitted to NHH during the study period. Of

these, 126 patients were subsequently diagnosed as having had a stroke. The

sensitivity of AMPDS software for detecting stroke in this sample was

47.62%, specificity was 98.68%, positive predictive value was 0.49 and

negative predictive value was 0.986. CONCLUSIONS: Fewer than half of all

patients with acute stroke were identified using telephone triage on the

initial emergency call to the ambulance service. Less than one quarter

received the highest priority of ambulance response. This first link in the

chain of survival needs strengthening in order to provide prompt and timely

emergency care for these patients.

>

>

>

>

>

> Please forgive me, I have not read this study. Does it mention in the study

> if there was a difference in treatment and/or a difference in patient outcomes

> either way due to the initial dispatch codes used?

>

> McGee, EMT-P