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Original research
Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore
  1. Hanzhang Xu1,2,
  2. Ying Xian3,4,
  3. Fung Peng Woon5,
  4. Janet Prvu Bettger3,6,
  5. Daniel T Laskowitz3,4,
  6. Yih Yng Ng7,
  7. Marcus Eng Hock Ong8,9,
  8. David Bruce Matchar9,10,
  9. Deidre Anne De Silva5
  1. 1 Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, United States
  2. 2 Duke University School of Nursing, Durham, North Carolina, United States
  3. 3 Duke Clinical Research Institute, Durham, North Carolina, United States
  4. 4 Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States
  5. 5 Department of Neurology, National Neuroscience Institute—Singapore General Hospital Campus, Singapore
  6. 6 Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, United States
  7. 7 HomeTeam, Government of Singapore Ministry of Home Affairs, Singapore
  8. 8 Department of Emergency Medicine, Singapore General Hospital, Singapore
  9. 9 Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
  10. 10 Department of Medicine (General Internal Medicine), Duke University School of Medicine, Durham, North Carolina, United States
  1. Correspondence to Hanzhang Xu; hanzhang.xu{at}duke.edu

Abstract

Background Emergency medical services (EMS) is a critical link in the chain of stroke survival. We aimed to assess EMS use for stroke in Singapore, identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment.

Methods The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore. Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment.

Results Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016, 68% arrived via EMS. Patients who used EMS were older, were less likely to be female, had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease. Patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min 34.3% vs 11.1%, OR=2.74 (95% CI 1.40 to 5.38)) and were more likely to receive intravenous tissue plasminogen activator (tPA, 22.8% vs 4.6%, OR=4.61 (95% CI 3.52 to 6.03)). Among patients treated with tPA, patients who arrived via EMS were more likely to receive timely treatment than self-transported patients (door-to-needle time ≤60 min 52.6% vs 29.4%, OR=2.58 (95% CI 1.35 to 4.92)).

Conclusions EMS use is associated with timely stroke evaluation and treatment in Singapore. Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.

  • stroke
  • emergency medical services
  • thrombolysis
  • registry
  • Singapore
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/svn-2019-000277

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    Footnotes

    • Contributors HX and YX had full access to the data in the study and took responsibility for the accuracy of the data analysis. Study concept and design: HX. Acquisition of data: YX and FPW. Analysis and interpretation of data: HX, YX, JPB and DADS. Drafting of the manuscript: HX, YX and DADS. Critical revision of the manuscript for important intellectual content: JPB, DTL, YYN, MEHO, DBM and FPW. Statistical analysis: HX and YX. Administrative, technical or material support: FPW.

    • Funding This research was supported by a Duke/Duke-NUS Research Collaborations Pilot Project grant.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data may be obtained from a third party and are not publicly available. Data may be obtained from the National Registry of Diseases Office, Singapore, and are not publicly available.