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Stroke Recognition and Response Recommendations

5th Edition
January 2015
  1. All members of the public should be educated that stroke is a medical emergency [Evidence Level C].
  2. Public education should focus on recognizing the signs and symptoms of stroke [Evidence Level C]. See Box 1.
  3. Public awareness campaigns and education should include use of the FAST (Face, Arms, Speech, Time) acronym to facilitate memory of these symptoms [Evidence Level B]. Refer to Box 1.
  4. Public education should emphasize the need to respond immediately by calling 9-1-1 or their local emergency number [Evidence Level B], even if symptoms resolve.
    1. The public should be prepared to provide relevant information and answer questions from the dispatcher, paramedics and others [Evidence Level C].  Refer to Box 2.
    2. The public should be aware of the importance of following instructions of the emergency medical system dispatch centre.
  5. Public education should include information that stroke can affect persons of any age from newborns and children to adults.  Education should also emphasize the benefits of early medical attention [Evidence Level C].   Refer to Rationale for details of early benefits.

For recommendations on Paramedic Services and Pre-Hospital Care, refer to the CSBPR Hyperacute Module, Section 2

Box 1  Signs of Stroke:  FAST

Heart and Stroke Foundation, www.heartandstroke.ca/fast

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Box 2: 

Core Information Required by Dispatch, Paramedics and Receiving Healthcare Facility

  • Location of patient
  • Stroke Symptom onset time if witnessed, and last seen well time if not witnessed
  • Current condition of the patient having a stroke, and changes in their condition since the stroke symptoms started
  • Current medications if known
  • Additional health problems, if known

When it comes to stroke, time is brain! Two million neurons die with every minute that lapses following symptom onset, leading to permanent damage to the brain.

Stroke is a medical emergency. Many people do not recognize the signs and symptoms of stroke or attribute the signs to a less serious health issue and therefore do not seek immediate medical attention. It is critical that all people with strokes arrive in the emergency department as soon as possible, as earlier assessment and treatment may allow time for life-saving intervention. People who experience a transient ischemic attack (TIA) are also considered a medical emergency and require rapid assessment and treatment.

Efforts to enhance emergency medical system response for people having a stroke and to encourage the public to recognize stroke signs and symptoms and contact emergency medical services result in treatment and better outcomes.

These recommendations apply across all geographic regions, and education should apply uniformly, regardless of local issues related to time to access care.

System Implications
  • Government funding and support for awareness initiatives to improve the recognition and recall of the signs of stroke and the importance of contacting 9-1-1 immediately.
  • Enhanced collaboration among community organizations and healthcare professionals to ensure consistency in public education of the signs of stroke with a strong emphasis on the urgency of responding when the signs of stroke are recognized.
  • Training and education for emergency medical services, physicians in primary and acute care, nurses and allied health professionals to increase ability to recognize potential stroke patients and provide rapid assessment and management.
  • Comprehensive systems in place to ensure all people in Canada have access to appropriate emergency medical services and stroke care regardless of geographic location.
Performance Measures
  1. Proportion of the population aware of the signs of stroke as presented in FAST (core).
  2. Proportion of people with stroke or TIA transported to acute care by paramedics (core).
  3. Median time (hours) from stroke symptom onset to arrival at an emergency department.
  4. Proportion of patients who seek medical attention within 3.5, 4, 4.5 and 6 hours of stroke symptom onset (core).
  5. Median time lapse between stroke symptom onset and first contact with emergency medical services (time call placed to 9-1-1 or local emergency medical system dispatch).
  6. Proportion of the population who live within 3.5, 4, 4.5 and 6 hours by ground transportation of a hospital equipped to provide hyperacute stroke care (i.e., has CT scanner onsite and ability to deliver tPA).

Refer to the CSBPR Hyperacute Stroke Care Module, Section 2 for additional performance measures related to pre-hospital care and transport.

Measurement Notes

  • Performance measure 1: data may be obtained from specific public polling on the signs of stroke, by the Heart and Stroke Foundation, and other organizations.
  • Performance measures 2 – 4: Data may be obtained from the Canadian Institute of Health Information NACRS and DAD databases and Stroke Special Project 340 and/or from primary chart audit.
  • Performance measure 3 – ED triage time should always be used as the proxy time for ED arrival, and this is available in CIHI NACRS, and a calculated value in the DAD.
  • Performance measures 3 and 4: Stroke symptom onset may be known if the patient was awake and conscious at the time of onset, or it may be unknown if symptoms were present on awakening. It is important to record whether the time of onset was estimated or exact. The time qualifies as exact provided that (1) the patient is competent and definitely noted the time of symptom onset or (2) the onset was observed by another person who took note of the time.
  • Performance measure 6 may be obtained by performing geo-spatial analysis based on location of ambulance base stations, location of hospitals with hyperacute stroke services and road geography for a specified region.
Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

Summary of the Evidence 2015

Stroke Recognition and Response Evidence Tables

The results from many cross-sectional surveys indicate that, among members of the general public, knowledge of the signs and symptoms associated with stroke is poor. Failure of recognition on the part of the person witnessing a stroke and/or those experiencing a stroke event can delay the time to contact emergency services, which may in turn decrease a patient’s opportunity to receive time-sensitive treatment. Mochari-Greenberger et al. (2014) surveyed 1,205 women aged ≥25 years living in the United States, who had participated in the American Heart Association National Women’s Tracking Survey. Participants were contacted by telephone and asked standardized questions related to stroke warning signs and actions to take in the event of stroke. Sudden weakness and/or numbness of the face or limb of one side were the most commonly-cited symptom (51%). Loss of/trouble with understanding speech was also frequently recognized as a symptoms among 44% of respondents, while headache, unexplained dizziness and loss of vision in one eye were recognized by 23%, 20% and 18%, respectively. In the UK, Robinson et al. (2013) surveyed 1,300 individuals in public areas, places of work, and academic institutions. Among those surveyed, 70% were aware of the FAST campaign and 80% recalled the ‘burning face’ image. Over 75% of participants were able to recall all three FAST stroke symptoms and >90% were able to recall at least one. Stroke warning signs not included as part of the FAST campaign were not as well recognized. Lundelin et al. (2012) conducted telephone surveys of 11,827 adults living in Spain who had participated in the Study on Nutrition & Cardiovascular Risk in Spain study to assess their ability to identify stroke symptoms, including sudden confusion or trouble speaking, numbness of face, arm or leg, sudden trouble seeing in one or both eyes, sudden chest pain (decoy), sudden trouble walking, dizziness or loss of balance or severe headache. 65.2% of the participants could correctly identify 4-6 symptoms of stroke, although only 19% could identify all 6 symptoms correctly and 11.4% were unable to identify a single symptom. 81.1% of participants indicated that they would call an ambulance if they suspected someone was having a stroke. Persons who could identify more stroke symptoms were more likely to call for an ambulance.

The number of Public Health campaigns designed to increase the recognition of the signs and symptoms of stroke has increased over the past decade. One of the most recognized programs is FAST, a mnemonic standing for F-face drooping, A- Arm weakness, S-speech difficulties and T-time to call 911. The results of several studies evaluating the effectiveness of these campaigns indicates that that persons exposed to the campaigns become more aware of the signs and symptoms of stroke. Bray et al. (2013) surveyed 12,439 individuals ≥40 years of age from the general population in Australia and reported that from 2004 to 2010, there had been a significant increase in the number of respondents who were aware of the national multimedia stroke awareness campaigns (31% vs 50%), which included FAST and in the number or participants able to name ≥1 (69% vs 81%), ≥2 (43% vs 63%), and ≥3 (19% vs 32%) warning signs of stroke. Respondents who could identify ≥2 warning signs were significantly more likely to be aware of the campaign (OR= 1.88, 95% CI 1.74 to 2.04). Jurkowski et al. (2010) also reported that following a public awareness campaign to increase awareness of FAST, respondents who were exposed to a 3-phase multimedia campaign over a 7-month were more likely to be aware of the campaign and its primary message to call 9-1-1. The percentage of respondents who reported they would call 9-1-1 in response to specific stroke symptoms increased from 9%-12% for specific symptoms identified in oneself and 4%-12% for specific symptoms, from pre-to post campaign, compared to those who had not been exposed to the campaign.

Most recently, Rasura et al. (2014) conducted a review of 22 studies, of which 14 targeted the general public using mass media campaigns, which varied in duration from 3 months to 4 years and 6, which targeted specific groups with the interventions lasting 3 minutes-12 hours. Three popular stroke signs and symptoms were included in all of the studies using mass media campaigns: FAST, SUDDEN and Give-Me-Five. Effectiveness of the interventions was assessed in most studies through questionnaires administered pre and post intervention. The authors concluded that large public health campaigns using mass media are expensive and short lived and may not be effective, although the increased costs could be mitigated through more prompt treatment with t-PA. They also indicated that, to be effective, the message being delivered must direct the person to call an ambulance. They also reported that the dose of the campaign appeared to be as important as the message, television was found to be the most effective medium and while online campaigns can also be successful, they tended to attract a self-selected group (e.g. well-educated women).