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Open Access Research article

The use of Cincinnati prehospital stroke scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms

Assunta De Luca1*, Paolo Giorgi Rossi2, Guido Francesco Villa3 and The Stroke group Italian Society pre hospital emergency Services

Author Affiliations

1 Health Direction of Regional Authority of Emergency Services (ARES 118) Lazio Region Italy. New affiliation, Health Direction of Sant’Andrea Hospital Sapienza Rome University, Via Tronto 32, Roma, CAP 00198 Italy

2 Servizio interaziendale di epidemiologia AUSL, Reggio Emilia, Italy

3 Pre hospital emergency Operative Center of Lecco and coordinator of Italian Group Pre-hospital management of acute stroke – Italian Society of pre hospital emergency Services (SIS118). New affiliation: Azienda Regionale Emergenza Urgenza (AREU), Milan Lombardy, Italy

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BMC Health Services Research 2013, 13:513  doi:10.1186/1472-6963-13-513

Published: 11 December 2013



Timely and appropriate hospital treatment of acute cerebrovascular diseases (stroke and Transient Ischemic Attacks - TIA) improves patient outcomes. Emergency Medical Service (EMS) dispatchers who can identify cerebrovascular disease symptoms during telephone requests for emergency service also contribute to these improved outcomes. The Italian Ministry of Health issued guidelines on the management of AC patients in pre-hospital emergency service, including Cincinnati Prehospital Stroke Scale (CPSS) use.

We measured the sensitivity and Positive Predictive Value (PPV) of EMS dispatchers’ ability to recognize stroke/TIA symptoms and evaluated whether the CPSS improves accuracy.


A cross-sectional multicentre study was conducted to collect data from 38 Italian emergency operative centres on all cases identified with stroke/TIA symptoms at the time of dispatch and all cases with stroke/TIA symptoms identified on the scene by the ambulance personnel from November 2010 to May 2011.


The study included 21760 cases: 18231 with stroke/TIA symptoms at dispatch and 9791 with symptoms confirmed on the scene. The PPV of the dispatch stroke/TIA symptoms identification was 34.3% (95% CI 33.7-35.0; 6262/18231) and the sensitivity was 64.0% (95% CI 63.0-64.9; 6262/9791). Centres using CPSS more often (>10% of cases) had both higher PPV (56%; CI 95% 57–60 vs 18%; CI 95% 17–19) and higher sensitivity (71%; CI 95% 87–89 vs 52%; CI 95% 51–54).

In the multivariate regression a centre’s CPSS use was associated with PPV (beta 0.48 p = 0.014) and negatively associated with sensitivity (beta -0.36; p = 0.063); centre sensitivity was associated with CPSS (beta 0.32; p = 0.002), adjusting for PPV.


Centres that use CPSS more frequently during phone dispatch showed greater agreement with on-the-scene prehospital assessments, both in correctly identifying more cases with stroke/TIA symptoms and in giving fewer false positives for non-stroke/TIA cases. Our study shows an extreme variability in the performance among OCs, highlighting that form many centres there is room for improvement in both sensitivity and positive predictive value of the dispatch. Our results should be used for benchmarking proposals in the effort to identify best practices across the country.

Cincinnati Prehospital stroke scale; Emergency medical system; Stroke; TIA; Stroke and/or TIA symptoms