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Resident PGY 1
Henry Ford Wyandotte
Introduction: By 2030, it is estimated that stroke will become the leading cause of adult disability in our country, afflicting 1 in 25 Americans. Prompt identification of stroke is essential because primary interventions such as tPA and thrombectomies, which may reduce long-term functional deficits, are extremely time sensitive. Given this, early identification through stroke screening scales such as the FAST (Face, Arms, Speech, Time) exam was developed, which have become commonplace in prehospital, emergency department (ED) and inpatient settings. Although FAST has commendable efficacy, its validity in identifying atypical or posterior circulation strokes, which often only present with balance and visual symptoms, has been challenged. To address this, a variant stroke-screening scale, BE-FAST, was developed with the inclusion of two additional criteria (Balance, Eye) to enhance stroke detection. Objective: Evaluate the sensitivity, specificity, and impact on stroke core measures with the implementation of BE-FAST in comparison to FAST in triage of a community emergency department. Methods: An observational before-and-after quality improvement (QI) initiative study was conducted for the two-month period before and after 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, time to stroke alert, primary identifying symptoms, time to CT and CTA, time to tPA, NIHSS score on arrival and discharge and confirmation of stroke as final discharge diagnosis. Categorical data were summarized as counts and percentages, and continuous data as means with corresponding standard deviations. 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 the pre- and post-intervention groups were similar (68.3, SD=17.0 and 64.3, SD=15.5, respectively) with a preponderance of females in both groups (60.9% and 62.8%, respectively). In the first group, 29 (36.2%) had acute strokes and presented with >1 FAST criteria. In the second group, 27 (31.4%) had acute strokes, with 23 (85.2%) presenting with >1 FAST, and 26 (96.30%) with >1 BE-FAST criteria. Although the difference was not statistically significant (p=0.35), given the deleterious consequences of delayed diagnosis, this may be of clinical significance; among the three additional strokes detected utilizing only BE symptomatology, one was given tPA. In summary, FAST rendered a sensitivity of 84% and BE-FAST 92.3%. However, this additional criterion reduced specificity from 30.0% to 16.5%. Conclusions: BE-FAST is more sensitive for identifying strokes, although at the cost of specificity. Given the significant burden of long-term deficits and the opportunity for early interventions that would otherwise be missed, this may be clinically significant, and larger trials should be conducted before widespread implementation.
Tan, Henry; Alexander, Adam; Gopalan, Anu; Hannon, Caroline; Gunaga, Satheesh; Patel, Jared; and Bergeon, Dylan, "The Efficacy Of BE-FAST In Identifying Strokes" (2019). Clinical Research. 17.