Emergency medical services (EMS) can have a positive impact on the care of acute stroke patients through early identification and expedited transport and thus more timely delivery of treatments, notably thrombolytic therapy (1). With proper education and use of protocols, EMS personnel can screen for stroke in the field, initiate patient evaluation, and transport patients to a specialized stroke center (2–4). However, current levels of EMS education and prehospital care practices for stroke patients are not well characterized and vary by location (5–7).

Improving EMS capabilities to respond to and manage care of acute stroke patients is important because stroke is a major cause of death and disability in the United States (8). In North Carolina, state legislation was passed in 2006 to address the availability of stroke-related resources among hospitals and EMS systems (9). This legislation led to the development and implementation of standardized EMS stroke care practices and policies. By 2010, all EMS systems in North Carolina were required to use a standardized protocol to guide the prehospital care of stroke patients and a written destination plan to facilitate the transport of stroke patients to the most appropriate hospital.

A statewide survey in 2001 of EMS stroke care in North Carolina found EMS education and the use of protocols to be lacking (5). However, in the past 10 years, major national and statewide changes have occurred in the prehospital management and care of stroke patients, including the use of standardized protocols and validated stroke screening tools and the development and use of destination plans (10–12).

The objective of this study was to examine current EMS stroke education and stroke care practices and policies in North Carolina and to evaluate statewide changes since 2001. Given advancements in prehospital stroke care and recent EMS implementation of stroke policies, we hypothesized improvements in EMS stroke care capacity during the past decade.

Our study found that some aspects of EMS stroke care in North Carolina were practiced almost universally, including stroke education, use of validated stroke scales or screening tools, and a policy to notify hospitals in advance of suspected stroke. However, data on other measures of stroke education and prehospital practice and policies suggested room for improvement. Among EMS systems that provided stroke training sessions, almost one-third did not cover the basic stroke educational topics. Of the systems surveyed, 69% educated their personnel on stroke at least annually. This percentage was only moderately greater than the 60% found in a study of EMS agencies in Minnesota in 2006, one of the few published, statewide assessments of EMS stroke care capacity (6).

Although almost all EMS systems in North Carolina used a validated stroke scale or screening tool, fewer than half regularly communicated the results to the destination hospital. This finding is consistent with the finding that only 34% of EMS agencies in Minnesota verbally communicated stroke scale findings (6). Moreover, almost all (98%) systems in North Carolina reported a policy to notify hospitals in advance of suspected stroke patients. There appears to be an inconsistency between policy and compliance. Previous studies observed that prenotification by EMS personnel of a suspected stroke can significantly reduce in-hospital delays and increase treatment rates (18–20). Follow-up to our quantitative work could use qualitative methods or intervention studies to better understand the translation of advance notification policies into EMS communication practices.

Bypassing local community hospitals for specialized stroke centers by EMS is a recommended policy and practice for many stroke systems of care (10). Furthermore, all EMS systems in North Carolina are required to implement a destination plan for stroke. In comparison, only 37% of EMS agencies in Minnesota reported having such a plan (6). Although a plan is required in North Carolina, our survey showed that only about half of EMS systems always used their plan and another 12% never or only sometimes used it, suggesting that even with a statewide policy, local systems are complying at varying degrees. Differences in publicizing legislation and enforcing EMS policies across the state may have had an impact on local compliance, although we did not investigate these differences.

We found room for overall improvement in EMS stroke care capacity: 92% of systems scored less than 10 points of a possible 12. Of the main priority areas, continuous quality improvement was the least frequently addressed; only 13 systems (13%) had examined stroke care performance data in the previous year. A Utah-based study examined the feasibility of using electronic EMS records for monitoring prehospital stroke care and found that only 58% of EMS agencies entered data into an electronic system and that data were often incomplete (21). EMS systems in North Carolina are required to enter standardized data elements electronically, so all systems should have the necessary data for performance feedback (12). Moreover, a statistical analysis report on stroke patient data was recently designed and developed to improve EMS systems (12). Nonetheless, we found few systems generate these reports, and more work is needed to encourage data-driven continuous quality improvement in North Carolina and in other states.

Although low patient volume and rural locations are reported to limit EMS stroke care capacity (7,22–25), our comparisons by patient volume and county population density did not demonstrate strong variation by these characteristics. In fact, our findings show that some systems with low patient volume in rural areas have high stroke care capacity. However, further investigation using a larger sample size is needed to examine the relationship between EMS stroke care capacity and patient volume and county population density.

EMS capacity in North Carolina improved since 2001, especially in education and use of a validated stroke scale or screening tools, such as the Los Angeles Prehospital Stroke Screen or the Cincinnati Prehospital Stroke Screen. Our findings are consistent with those of similar studies. In 2006, 47% of Minnesota EMS agencies reported using the Cincinnati Prehospital Stroke Screen (6), whereas a more recent study (7) found that 80% of EMS agencies in 9 states reported using a stroke scale (although the scale used was not identified). Other significant positive changes were in education on all basic stroke topics, education on thrombolytic therapy, and a policy to notify hospitals in advance. Although we observed positive changes overall, we also found that certain EMS systems underwent negative changes (eg, in basic stroke educational topics). Although a formal policy evaluation was beyond the scope of this study, our findings show that statewide standardization of EMS stroke care was associated with improvements in capacity. Other states and regions that implement similar policies may also undergo significant improvements.

Our study has several limitations. Although our survey questions were not validated, they are similar to those in other surveys and were developed with input from subject matter experts (5,6). Our results were based on self-reports and are subject to inaccurate responses. However, respondents were selected because of their knowledge of their systems; in addition, respondents could work with others in completing the survey. Only 2 of the 100 systems did not respond, and systems that did not participate were well represented by the survey respondents according to service level (ie, basic life support, advanced life support), patient volume, and county population density. Our EMS stroke care capacity score was based on expert opinion and guideline recommendations but has not been independently validated. However, it can be easily replicated in other regions, and we believe it provides a useful summary of overall EMS capacity for stroke. In the absence of guidance in published literature, we chose to weight each priority area equally. We encourage further research to improve on this scoring method. A strength of our study was the direct system-specific comparisons between 2 years of data. Although we compared changes in 70 EMS systems only, these systems serviced about 81% of the 9.5 million residents in North Carolina. This subset of systems was similar to all EMS systems in North Carolina in level of service, patient volume, and county population density.

Our findings demonstrate areas of progress and areas that need improvement if EMS systems are to provide the best care for stroke patients in North Carolina. Education of EMS personnel should continue to be a focus, especially the content of stroke training sessions. Significant progress occurred in the institution of standardized patient care protocols, validated scales and screening tools, destination plans, and advance notification policies. However, the use of destination plans and communication to hospitals of stroke screen results need improvement. Given its large stroke burden and recent statewide actions to advance stroke care, North Carolina was a unique setting for this study. Many of the improvements observed in this study could be explained by statewide efforts to standardize prehospital stroke care and encourage best practices, such as bypassing local hospitals for stroke centers, although secular trends also likely played a role. Although other states may not require standardized protocols and destination plans, this study offers an example of how stroke care capacity can improve after such a policy is put in place. For local health services planning and quality improvement, it is important to continuously monitor the capacity of EMS systems to respond to and manage stroke patients. Further study is needed to understand how stroke capacity translates into actual EMS care received.