Knowledge Level of Pre-Hospital Emergency Staff about Acute Stroke and Indications of Code 724

INTRODUCTION

Cardiovascular diseases are the second most common cause of death around the world and are the sixth leading cause of disease around the world, which is expected to rank fourth by 2020 [1]. More than 5.5 million people around the world and thousands in Iran die because of stroke annually and two-thirds of deaths occur in developing countries. The rate of stroke-caused death varies from one country to another, depending on social class and geographical area. In industrialized countries, the rate of stroke is 5 per 1000 people, but it is about 5-10 per 1000 people in developing countries [2]. Despite several epidemiological studies, population-based information is still low in developing countries. In recent studies on differences between males and females, the general incidence of stroke was 33% higher in males than that in females and few studies conducted in this regard used small sample sizes and yielded poor results. In Europe, the annual incidence of stroke is 1.0 to 9.2 per 1000 people in males and 6.0 to 9.1 per 1000 people in females [3]. The rate of strokes is likely to increase with epidemiological changes and with increasing age. According to a study conducted by Ferry et al. in 2011, the general rate of strokes in urban areas was higher than that in rural areas, and the levels of disability and dependency among stroke survivors were significantly higher in urban areas [4].  Cerebrovascular disease is a disorder in the cerebrovascular system in the form of ischemia, infarction, or bleeding that is manifested with different symptoms.

However, stroke symptoms are usually sudden and without warning, but the warning signs occur slowly [5]. Pre-hospital emergency staff, who are at the first-line of caring for patients, must be able to analyze a situation, quickly assess a situation, and implement effective and life-saving treatment approaches [6]. One of the most important activities of the pre-hospital emergency department is dealing with patients who suffer an acute stroke. This emergency department is known as Code 724, which is a sign of 24-hour activity for 7 days of a week. With any delay, nerve lesions increase and once the lesions emerged, no treatment will be effective [7]. The benefits of the pre-hospital unit include reducing transfer time, performing supportive and therapeutic measures in the ambulance, activating the stroke code and transfer to the appropriate hospital, ‌accelerating vital measures in the hospital in golden time, and recording information, and improving planning based on it. Accordingly, the importance of familiarizing pre-hospital staff with the signs and symptoms of acute stroke and the indications of Code 724 is highlighted [8]. Indications for this code announcement include the presence of measurable neurological impairment according to the FAST protocol, the time interval between the last healthy visit of the patient and reaching the hospital triage less than 3 hours, age over 18 years, and relevant calls according to the local protocol. Absolute indications for transfer also include a change in consciousness, shortness of breath or abnormal breathing, and the presence of any symptoms or stroke [9]. Given what was stated above and considering the importance of initial dealing with patients and the importance of activities provided by the pre-hospital emergency and since limited studies have been conducted in this area, the importance of this evaluation and reviewing the results are highlighted. Thus, in the present study, the aim was to evaluate the level of knowledge of pre-hospital emergency staffs about the signs and symptoms of acute stroke and the indications of Code 724 to provide appropriate policies to increase the level of knowledge of pre-hospital staffs to improve the health of people exposed to this system.

MATERIALS AND METHODS

The present study is a descriptive-analytical one conducted in 2019 on pre-hospital emergency staff working in the emergency department of Ahvaz Jundishapur University of Medical Sciences. The total number of staff during the study was 600. Using the Morgan table and considering the probability of 10% dropout in samples, 260 people were randomly selected and entered into the study. Inclusion criteria of the study included having personal consent to participate in the study and being male. The staff willing to participate in the study were excluded from the study. The data collection tool was a researcher-made questionnaire that included demographic variables and questions related to the level of knowledge on the signs and symptoms of acute cerebrovascular conditions and indications of Code 724. This questionnaire includes 22 questions in 3 subscales (staffs knowledge of stroke symptoms = 8 questions, staffs knowledge of stroke signs = 9 questions, and staffs knowledge of indications of Code 724 = 5 questions). The questions were scored on a 5-point Likert scale (very low = 1, low = 2, medium = 3, high = 4 and very high = 5). The highest score obtained from the questionnaire was 110 and the lowest score was 22. Therefore, the highest score obtained from stroke symptoms was 40 and the lowest score was 8. Besides, the highest score obtained from stroke signs was 45 and the lowest score was 9. The highest score obtained from indications of Code 724 was 25 and the lowest score was 5. This questionnaire was designed using other similar studies and national protocol 724. To evaluate its validity, the opinions of experts such as supervisors and advisors were used. The CVI obtained from the questionnaire was higher than 70%, which indicated the good validity of the questionnaire. To examine its reliability, the test-retest method was used. For this purpose, 26 people or 10% of the samples (pre-hospital emergency staffs) completed the questionnaire and they completed it again after two weeks. The reliability of the questionnaire was obtained at 0.82, indicating good reliability of the questionnaire. Sampling started after obtaining permission from the ethics committee of Ahvaz University of Medical Sciences and the permission of emergency department officials. To observe the ethical standards, questionnaires were collected anonymously. The researcher distributed the questionnaire among the staff by attending the research environment (pre-hospital emergency) and by submitting an informed consent form and taking measures such as informing the samples of the confidentiality of their information, and they took the questionnaire after completing it. Finally, the data were analyzed using SPSS 25 software and Chi-square test at a significance level of 0.05.

RESULTS AND DISCUSSION

Out of 260 studied staff, 126 (48.46%) were pre-hospital emergency staff between 30 to 40 years old. 108 of the staff (40.5%) had a bachelor's degree and 137 (52.7%) had an employment history of 5 to 10 years (Table 1). In terms of knowledge of pre-hospital emergency staffs about the symptoms of acute stroke, results of the Mann-Whitney test showed that question 6, entitled "Can imbalance be one of the symptoms of an acute stroke?" had the highest mean of 3.88 and question 3 entitled "Can difficulty in swallowing one of the symptoms of an acute stroke?" with a mean of 3.32 had the lowest mean of pre-hospital emergency staffs information about the symptoms of acute stroke (Table 2). Results on pre-hospital emergency staffs’ level of knowledge of the signs of acute stroke based on the Mann-Whitney test showed that question 9, entitled "Can paralysis be one of the signs of an acute stroke?" with a mean of 3.67 had the highest mean and question 3 entitled "Can sense of touching be one of the signs of an acute stroke?" with a mean of 3.15 had the lowest mean in pre-hospital emergency staffs’ level of knowledge signs of acute stroke (Table 3). Besides, the results obtained about the level of knowledge of pre-hospital emergency staffs about the indications of Code 724 based on the Mann-Whitney test showed that question 2 entitled "Are measurable neurological disorders including sensory and motor disorders indications of Code 724?" with a mean of 3.60 had the highest and question 5 entitled "Are the relevant calls and the announcement of acute stroke according to the local protocol indications for the announcement of Code 724?" with a mean of 3.21 had the lowest mean knowledge of pre-hospital emergency staffs of the indications of Code 724 (Table 4). The results of multivariate analysis of variance showed that the level of knowledge of pre-hospital emergency staffs about the symptoms of acute stroke had no significant relationship with demographic variables of the level of education and employment history (P< 0.05), but it showed a significant relationship with age (P <0.05). The knowledge of pre-hospital emergency staff about the signs of acute stroke and indications of Code 724 did not show a significant relationship with demographic variables of age, level of education, and employment history (P> 0.05) (Table 5). Finally, the level of knowledge of pre-hospital emergency staff separately based on dimensions showed that the knowledge of staff with a mean of 3.13 ± 27.40 was at the desired level (Table 5).

Table 1. Distribution and Frequency Percentage of the Sample Group in terms of Demographic Information

Table 2. Pre-hospital Emergency Staffs Level of Knowledge of Symptoms of Acute stroke

Table 3. Pre-hospital Emergency Staff Level of Knowledge about the Signs of Acute Stroke

Table 4. Level of Knowledge of Pre-hospital Emergency Staff about the Indications of Code 724

Table 5. Level of Knowledge of Pre-hospital Emergency Staffs about the Signs, Symptoms, and Indications of Code 724 of Acute Stroke according to Demographic Variables and Level of their Knowledge

Multivariate Analysis of Variance