Introduction: Ischemic stroke patients who arrive by emergency medical service (EMS) receive faster emergency department evaluations and improved rates of thrombolytic treatment. However, EMS stroke recognition and compliance with prehospital stroke quality measures are inconsistent. We hypothesized that EMS stroke care is influenced by a complex interaction of knowledge, beliefs, and system-level variables that influence behavior.
Methods: Focus groups of paramedics from a single urban/suburban county were assembled to discuss their experiences identifying and transporting stroke patients. Focus groups were conducted using a semi-structured interview format and audio recorded. Transcripts of focus groups were qualitatively analyzed to identify themes, subthemes, and patterns of paramedic responses. The Clinical Practice Guidelines Framework provided the initial coding scheme, which was modified during the coding process by three coders using grounded theory methods, who came to consensus on which codes to apply.
Results: Three focus groups (n=13) were conducted to reach theme saturation. Overall, paramedics reported high confidence in clinical gestalt for assessing stroke patients and a strong desire to “do the right thing,” but were unfamiliar with published guidelines. Paramedics identified variability in the clinical presentations of stroke, inadequate or inconsistent hospital guidance, and lack of feedback regarding care as principle barriers to ideal prehospital stroke care. Participants reported conflicting hospital guidance regarding the appropriate time frame for a high priority transport and hospital prenotification. Feedback regarding final diagnosis was viewed as critical for developing improved clinical acumen. Direct to CT protocols were cited as an effective way to integrate EMS into hospital stroke response.
Conclusion: In this qualitative analysis, paramedics expressed a desire for clear, hospital-directed guidance and consistent feedback regarding outcomes for suspected stroke patients.