Screening for Balance and Vision Symptoms in Triage to Enhance Identification of Strokes in the Emergency Department
Tan H, Hannon C, Gopalan A, Alexander A, Patel J, Bergeon D, Andreoli L, Jarski R, McKeown T, and Gunaga S. 204 Screening for Balance and Vision Symptoms in Triage to Enhance Identification of Strokes in the Emergency Department. Ann Emerg Med 2019; 74(4):S81.
Ann Emerg Med
Study Objectives: Prompt identification of stroke is essential as primary interventions such as tissue plasminogen activator (tPA) and thrombectomies are extremely time sensitive. Time is brain and stroke screening scales such as the FAST (Face, Arms, Speech, Time) exam are critical in efforts towards early identification and aggressive treatment. Although FAST has commendable sensitivity and specificity, its ability in identifying posterior circulation strokes, which often only present with balance and visual symptoms, has been challenged. To address this, an augmented stroke screening scale, BE-FAST, was developed with the inclusion of two additional criteria (Balance, Eyes) to enhance stroke detection. The primary objective of this study was to evaluate the sensitivity, specificity, and impact on stroke core measures with the implementation of the BE-FAST scale in comparison to FAST in triage of a community emergency department (ED). Methods: An observational before-and-after quality improvement (QI) study was conducted for the two-month period before and after October 8th, 2018 when a formal BE-FAST triage screening educational module was taught to all ED clinical staff. The study sample included all patients who had stroke alerts activated based on their presenting symptoms in the ED. These patients were then divided into two groups: pre-intervention with FAST and post-intervention with BE-FAST criteria. Extensive chart review was then performed to collect the following variables: age, sex, primary identifying symptoms, time to stroke alert, time to CT/CTA, confirmation of stroke as final discharge diagnosis and hospital mortality. Categorical data were compared using the chi-square test for association, and between-group mean differences were compared by calculating t-tests for independent measures and analysis of variance. Results: 155 total stroke alerts were included in the study, with 69 in the pre-intervention and 86 in the post-intervention group. Mean ages for both study groups were similar (68.3, SD=17.0 and 64.3, SD=15.5) with a similar preponderance of females (60.9% and 62.8%). In the pre-intervention group, 29 (36.2%) had acute strokes and presented with ≥1 FAST criteria. In the post-intervention group, 27 (31.4%) had acute strokes, with 23 (85.2%) presenting with ≥1 FAST, and 26 (96.30%) with ≥1 BE-FAST criteria. FAST rendered a sensitivity of 84% and BE-FAST 88%; however, with the additional two criterions, specificity declined from 30% to 16% respectively. Description of sample demographics, times and outcomes are detailed in Table 1. Conclusions: BE-FAST demonstrates potential for improved stroke screening sensitivity, although in the setting of a community ED, this did not outperform FAST in a statistically significant manner. Yet, given the significant burden of long-term deficits and opportunities for early interventions, the identification of even a single additional stroke is arguably clinically significant. Larger trials evaluating the efficacy of BE-FAST should be conducted before widespread implementation into stroke protocols.