Rural Emergency Medical Services Perspectives on Improving Acute Stroke Care: A Qualitative Study

Abstract

OBJECTIVES:

For underserved rural communities with limited geographical access to comprehensive stroke centers, emergency medical services (EMS) play a crucial role in timely, high-quality acute stroke care. This qualitative study aimed to understand rural EMS perspectives on barriers and facilitators to optimal acute stroke care in rural communities.

METHODS:

Qualitative, individual semi-structured interviews were conducted with rural EMS professionals. Ten EMS agencies in North Carolina were contacted for participation in virtual 45–60minute interviews and interested agency professionals self-selected into the study. Covered topics included stroke training and education; stroke care experience and expertise; clinical and sociodemographic patient characteristics; EMS workflows; and system- and patient-level interactions and outcomes. Recorded interviews were transcribed and then coded using an inductive and deductive, iterative approach by two independent reviewers in MAXQDA software. Facilitators and barriers to optimal acute stroke care were derived from thematic analysis.

RESULTS:

Twelve EMS professionals from 4 rural EMS agencies and 1 mixed urban-rural agency were interviewed. Participants worked in clinical (6 Paramedics, 1 EMT) and leadership (2 chiefs, 1 supervisor, 1 field training officer, 1 quality assurance manager) roles for a mean of 4 years (range 1–11 years). Commonly noted facilitators of high-quality stroke care were comprehensive stroke assessment and destination decision protocols, as well as bidirectional communication between EMS and hospital staff. Identified barriers included patient and bystander delays in calling 9–1-1, long transport distances to stroke centers, and limited EMS staffing. EMS professionals noted challenges interacting with nursing home staff and hospital clinicians during patient transfer. Interviewees also discussed the importance of educating the public about stroke signs and symptoms and community engagement.

CONCLUSIONS:

Within rural populations, EMS professionals determined that public education and community engagement are high-priority needs. Professionals also noted EMS’ opportunities to enhance rural stroke care through consistent bidirectional communication and improved prehospital protocols. Future research is needed to further explore these themes in rural EMS agencies outside of North Carolina.

INTRODUCTION

Emergency medical services (EMS), as the first point of medical contact for most acute stroke patients, play a critical role in delivering timely, high-quality care. Early identification and appropriate triage by EMS can make a significant difference in times to treatment and outcomes of acute stroke, thereby resulting in a better quality of life for stroke survivors (1). The role of EMS is essential within rural communities, which are often underserved and often have limited geographical access to certified stroke centers. When considering the time sensitivity and severity of conditions like stroke, geographical access is especially critical (2). While 70% of urban United States (U.S.) residents are within a 30-minute drive to a certified stroke center, only 26% of rural residents are within that same travel time, making it substantially less likely for residents of rural areas to be evaluated at a stroke center (3).

While rural-urban differences in acute stroke care are generally attributed to geographical access to the nearest stroke center, additional sociodemographic, psychosocial, and chronic health factors are believed to contribute to rural stroke disparities (4). Lower socioeconomic status is common among rural residents, with a generally lower median income in rural areas ($10,000 less than in urban areas) (3). Correspondingly, rural communities typically have reduced tax revenues for local governments, experience hospital closures and staffing shortages, lower educational attainment, increased transportation obstacles, and heightened food insecurity (3, 5, 6). Rural residents are furthermore likely to be impacted adversely by socioemotional factors, such as depression (prevalence is 1.19 times higher), which are known to be related to incident stroke risk (3). From a biomedical perspective, the odds of hypertension, diabetes, and heart diseases are greater for rural versus urban communities (7). Well-developed and efficient regional stroke systems of care must consider these predisposing factors to address rural disparities.

While prior studies have found rural disparities in EMS stroke education and training, prehospital time intervals, and stroke screening and triage (8–12), few studies have directly captured the perspectives of rural EMS professionals on stroke care. An in-depth examination of rural EMS’s experiences and perceptions of acute stroke care has the potential to reveal unique challenges and identify system improvements to address rural gaps in prehospital stroke care. To this end, we conducted a qualitative study with EMS professionals from rural agencies in North Carolina (NC), to identify barriers and facilitators to optimal acute stroke care in rural communities.

METHODS

Study design & setting

This study was conducted using a qualitative description approach to better understand the various perspectives of rural EMS personnel and the barriers and facilitators faced in providing prehospital stroke care (13). Individual, semi-structured interviews were conducted with rural EMS personnel from NC. Development of interview questions was guided by General System Theory (14), which states that outcomes are the product of multiple interrelated components of the system. Topics covered include stroke-related education and training; stroke care experience; patients’ sociodemographic and clinical characteristics; EMS workflows; processes of dispatch and transfer of care; patient- and system-level interactions; facilitators and barriers to stroke care; and suggested improvements, both within and external to EMS. See Supplemental File Appendix 1 for the full interview guide. This study was reviewed by the University of North Carolina at Chapel Hill Institutional Review Board and determined to be exempt from further review according to the federal regulations on research involving human subjects. This manuscript was prepared following the Standards for Reporting Qualitative Research guidelines to assure complete and transparent reporting (15).

North Carolina is an ideal setting in which to examine the role of rurality and sociodemographic factors in prehospital stroke care. Since 2010, the NC Office of EMS has required each of 100 county-based EMS systems to implement a locally-tailored suspected stroke patient care protocol and a stroke triage and destination plan on direct transport to stroke-capable hospitals (16). North Carolina is one of eight states that comprise the Stroke Belt; a region of the southeastern U.S. which reports disproportionately higher stroke mortality in comparison to the rest of the country (17). Compounded with a high stroke burden, approximately 21% of NC’s 10.4 million residents reside in rural areas (18). Only half of NC hospitals located in rural counties are certified as stroke capable (19). Further, rural NC populations experience higher rates of poverty compared to urban populations (17.8 and 12.3%, respectively) (18).

Study population

We recruited participants from a convenience sample of 10 rural NC EMS agencies participating in a prehospital quality improvement initiative led by the team (20). Initial recruitment emails were shared with EMS leadership (administrative directors or quality improvement coordinators) and distributed to personnel currently employed by the agency. Eligible participants included EMS clinicians and leaders. Further referrals were used to find other suitable participants from the contacts of those who had already participated, resulting in one participant from a mixed rural-urban agency choosing to participate. Involvement in the study was voluntary, and all participants recruited were provided with a brief written description of the study before the interviews were scheduled. Verbal consent was obtained at the time of the interview. A $25 prepaid card was offered as compensation for participation. Recruitment continued through the end of the 12-month funding period (July 2022).

Interviews

Individual, semi-structured interviews were completed virtually (June-August 2022) via ZOOM (21), generally lasting 45–60 minutes. Before conducting the interviews, the interview guide was revised and finalized according to feedback from subject matter and qualitative research experts. Interviews were completed by a single researcher-interviewer (MDP) with no prior relationship to the participants, mitigating the potential for confirmation bias. Interviews were recorded and then transcribed using audio transcription services through the Odum Institute at UNC (22). The transcripts for the first two interviews were evaluated (VTL) for quality and accuracy.

Qualitative data analysis

Thematic analysis was employed to systematically identify and interpret patterns within transcript data (23). To begin, a single reviewer (VTL) read each transcript and summarized them into individual memos. From these memos, two reviewers (MDP, VTL) individually created matrices to identify key points and potential major themes. Using an inductive and deductive, iterative approach, the initial codebook captured general themes derived from the semi-structured interview guide, memos, and matrices. The initial coding scheme included codes for information on respondent background, stroke care experience, patient characteristics, processes of care, barriers and facilitators to care, and outcomes. The first round of coding, with this initial version of the codebook, was completed by a single reviewer (ENJ). During that coding process, common themes that emerged under each preexisting code were assigned memos, then aggregated and labeled with a subcode. This sub-coding process continued until no new codes were identified (see Supplemental File Appendix 2 for the final codebook); a practice commonly utilized with qualitative research to ensure code saturation (24, 25). Two independent reviewers (ENJ, MVP) then coded each transcript individually with the full codebook using MAXQDA 2022 Analytics Pro software (26). In a consensus coding approach, each coded transcript was discussed between reviewers, examining code counts to search for any discrepancies and ensuring further refinement of the coding schematic (27). Where counts differed, reviewers compared the coded segments more closely to reach a coding consensus, adjusting codes in their respective transcripts as needed. Similarity analyses affirmed coding agreement across reviewer transcripts after consensus coding (97–100% similarity in code occurrence using a simple match analysis, where both existence and non-existence are counted as a match and the result is the percentage match). Crosstab analyses to compare code frequencies across groups, word trends, and code trends both within and across transcripts, and document and code maps to assess visual trends were run. Code reports were analyzed to identify, explore, and describe major themes as they relate to facilitators and barriers to optimal acute stroke care.

RESULTS

Twelve EMS professionals (4 female, 8 male; 1 Non-Hispanic Black, 11 Non-Hispanic White) from 4 rural EMS agencies and 1 mixed urban-rural agency were interviewed. Interviews lasted between 37–87 minutes, with a mean duration of 64 minutes. Participants worked in clinical (6 Paramedics, 1 Emergency Medical Technician (EMT)) and leadership (2 chiefs, 1 supervisor, 1 field training officer, 1 quality assurance (QA) manager) roles for a mean of 4 years (range 1–11 years). See Table 1 for a summary of participants’ characteristics.

Table 1.

Participant Characteristics (N=12)

	N	Percent (%)
Total	12	100%
Gender
Male	8	67
Female	4	33
Race
White, Non-Hispanic	11	92
African American, Non-Hispanic	1	8
Role in EMS
Chief	2	17
Supervisor	1	8
Quality Assurance Manager	1	8
Field Training Officer	1	8
Paramedic	6	50
EMT	1	8
Years in Current Role
0–5	9	75
6–10	2	17
11+	1	8
Current Organization
Organization A	1	8
Organization B	4	33
Organization C	3	25
Organization D	1	8
Organization E	3	25

Themes related to barriers and facilitators to the best practice of acute stroke care were examined. Participants discussed various prehospital factors that influenced care, acting as facilitators, barriers, or both. Comprehensive protocols for stroke assessment and destination decisions were mentioned by many participants as a strong facilitator to delivering optimal care. While bidirectional communication was mentioned as a facilitator by some participants (particularly hospital prenotifications and prehospital communication), others noted that there is still room for improvement in terms of quality patient data exchange and peer review. Commonly identified barriers included patient and bystander delays, long transport distances, and limited EMS staffing. Community engagement and education of the public are mentioned by most participants as a crucial component of preventing stroke and improving post-stroke quality of life.

Figures 1 and 2 contain visual representations of all common themes identified (including subcodes), separated by care barriers and care facilitators. To further illustrate participants’ perspectives, direct quotes are shown in italics and labeled ‘Leadership’ for participants in leadership roles (chiefs, supervisors, QA managers, field training officers) and ‘Clinician’ for participants in clinical roles (paramedics, EMTs).

Figure 1. Subcodes and Related Themes on Acute Stroke Care Barriers.

* The term “Resources” in this figure refers solely to health systems resources. Other, community-based resources are not included here.

The numbers in the figures represent the frequency of intersecting codes mentioned as care barriers. Bolded lines are proportionally thick to the number of intersections, with more intersections resulting in a thicker line. The red icons are specific subcodes of care-barriers and the grey icons are other codes that intersected with care-barriers throughout the coding process.

Figure 2. Subcodes and Related Themes on Acute Stroke Care Facilitators.

The numbers in the figures represent the frequency of intersecting codes mentioned as care facilitators. Bolded lines are proportionally thick to the number of intersections, with more intersections resulting in a thicker line. The green icons are specific subcodes of care-facilitators and the grey icons are other codes that intersected with care-facilitators throughout the coding process.

Barriers to optimal acute stroke care

During the initial stages of coding, 7 themes emerged related to care barriers: transport, health system resources, public knowledge, hospital clinicians, nursing homes, bloodwork, and hospital organization. A barrier to acute stroke care frequently discussed among participants was the lack of public knowledge. In general, participants describe a lack of stroke education in rural counties, hindering EMS’ ability to provide timely care. Participants mentioned the importance of “educating the public on the signs and symptoms of stroke” so that patients are knowledgeable enough to call 9–1-1 when symptoms start presenting (Leadership). One interviewee emphasized that stroke education should be treated similarly to fire education for young children, meaning these sorts of topics should be addressed regularly, starting from a young age, so that children know what to do in the case of a stroke emergency. Interviewees noted that many patients served had been experiencing symptoms for upwards of 24 hours, sometimes even days, before calling for medical assistance. For example, one clinician shared that “most of the time, 9–1-1 callers don’t know how to identify a stroke unless they’ve previously had a stroke” (Clinician). Participants shared how this lack of public knowledge, aside from delaying timely care, can also lead to issues on-scene, particularly when patients are not good historians of their health.

On-scene issues were not exclusive to the stroke patients themselves; multiple participants noted that interactions with patients’ family members can also cause delays. One clinician further iterated that “families typically like to be involved in destination decision, just on any call in general. But strokes… a lot of times it is an elderly population, or an older population, or a population that’s not super healthy to begin with. So, there’s usually family around… everybody likes to weigh in with their opinion” (Clinician). These opinions became hindrances to timely care when knowledge about the nearest stroke-capable facilities was limited, and EMS spent additional time on-scene educating the family to go to the destination determined by stroke protocol. In addition to discussions around hospital destinations, the act of transport itself can act as a barrier, particularly in rural communities where there are long distances to travel to the nearest capable facility. One participant elaborated that “scene issues and traffic are two of the biggest things… It’s just one of those things where to save every minute in it is pretty critical” (Clinician). Furthermore, participants shared that EMS regularly encountered scene issues when caring for patients in nursing homes and reported challenging interactions with nursing home staff. Several participants described similar experiences of delays to care as this clinician, who shared that “with nursing homes specifically, when they call 9–1-1, half the time they don’t have any paperwork ready, so then we’re standing around waiting for paperwork or standing around waiting for a nurse to come by and give us all the information” (Clinician).

Delays to care were not limited to issues on-scene or during transport but also were prevalent in the hospital setting. Participants described how during transfer of care in the Emergency Department, EMS work closely with hospital clinicians and experience several obstacles to the delivery of timely care. Participants were particularly concerned with the notion that hospital clinicians “think that [EMS clinicians are] just ambulance drivers and [they] don’t know what [they’re] talking about” (Clinician). Oftentimes, participants found that these hospital clinicians “don’t trust EMS to actually identify a stroke” (Clinician). There are additional inefficiencies at the hospital level in terms of bloodwork. While some participants noted bloodwork being discarded due to labeling issues by EMS personnel, some participants also shared that errors in the stroke kits distributed by the hospitals (such as missing tubes) can lead to blood samples collected by EMS being discarded once they reach the lab. However, interviewees acknowledged that hospital organization and efficacy vary from hospital to hospital. Participants noted how poor hospital organization delays care, particularly in getting the stroke patient to computed tomography (CT) promptly.

Lastly, the lack of health system resources by both EMS and the hospitals acted as a barrier to care. Participants described how increasing call volumes caused issues on both ends, with not enough EMS staff and resources to meet the need, as well as hospitals forced into diversion because of limited bed and staff availability. In rural areas, resource issues such as diversion caused serious slow-downs and bottlenecks, as EMS was required to navigate to the next-nearest stroke-capable hospital (which could be a great distance away in certain remote areas). One participant elaborated on hospital diversion and lacking resources, stating that when a “CT scanner’s down [it’s a challenge], and just being in a rural service area. That’s a challenge in and of itself” (Leadership).

Facilitators to optimal acute stroke care

Five themes on care facilitators emerged during the coding process: protocols, communication, assessments, community paramedicine, and air medical. The most common care facilitator addressed by participants pertains to comprehensive stroke patient care protocols. Among these, participants noted specifically their use of stroke triage and destination plans. An important component of destination decisions is that they “advocate for bypassing the non-certified hospitals” (Clinician). Bypassing certain hospitals is a critical aspect of delivering timely care, particularly in rural communities where travel times can vary greatly. Also of significance was the use of innovative problem-solving in modifying protocols to suit the unique needs of each EMS agency. For example, one participant described their solution to bloodwork being thrown out upon arrival: “[EMS put] name and date and time on the stickers so the paramedics will fill that out and seal the bag with that sticker. And that tells the phlebotomist ‘This is who it belongs to, what time it was drawn, and what day it was drawn on’” (Leadership). Several participants indicated that they are well-trained to execute these various protocols, which is why they work well for their systems. One participant elaborated on their organization, saying “We’ve got a really good system, it’s thought through, it’s trained well” (Clinician). Similarly, multiple interviewees discussed feeling adequately prepared and trained to perform various stroke assessments The NC Office of EMS requires a standard stroke screening tool, but individual systems decide which one(s) to use (28). In this study, stroke screening and severity tools mentioned were the Cincinnati Prehospital Stroke Scale, Los Angeles Prehospital Stroke Screen, Face Arm Speech Time, Rapid Arterial oCclusion Evaluation, and Vision Aphasia Neglect. Being confident in completing the stroke assessment on-scene and en-route allowed EMS to work more efficiently and get the patient to suitable care promptly.

Another prominent facilitator that contributed greatly to the timely delivery of care was bidirectional communication between EMS staff and hospital clinicians. This included hospital prenotification calls made by EMS, any patient data exchange before or during the transfer of care, and peer review regarding EMS performance and patient outcomes. One participant referenced how communication is often more reliable on the prehospital end, for example, when they make “that code stroke call over the radio en-route to the hospital, in theory they should literally be waiting there for us… and we go straight to CT… Which is really nice… it’s come a long way in the last decade” (Clinician). Additional aspects of communication that participants found to function well for EMS included building agency rapport both between and within agencies, as well as providing comfort and establishing trust with patients. Community paramedicine was also discussed as a care facilitator, particularly for patients that one participant referred to as “frequent fliers” (Clinician). These patients may consistently call 9–1-1 after a severe instance, such as a stroke, for minor issues (like medication refills) that are not meant to be handled by EMS. Community paramedicine helped to ensure adequate care of these patients without overutilization of EMS resources. Additionally, participants discussed how building rapport with patients through programs like community paramedicine allows for more frequent follow-ups, increasing the ability to assess long-term patient outcomes.

Lastly, participants shared that air medical acted as a care facilitator in areas where long travel time becomes a concern. EMS personnel who utilize air medical are “not afraid to call for a helicopter if they need to [and] they’re not hesitant to call stroke code and alert that medical facility” (Leadership).

Themes identified as both barriers and facilitators

Intersections between code occurrences were examined, revealing instances in which certain factors acted as both barriers and facilitators to stroke care (Figure 3). Although bidirectional communication did not show up as frequently as an intersection (it was generally discussed as a facilitator), some participants critiqued current methods of peer review and feedback as often limited and not easily accessible to EMS personnel, making bidirectional communication both a facilitator and barrier. Similarly, when describing interactions on the patient care level (the code that most commonly intersected, as seen in Figure 3), participants noted the potential for such interactions to act as either barriers or facilitators to care. As demonstrated in the final codebook, interactions on the patient care level incorporate numerous different types of exchanges. These included interacting with clinicians at various community hospitals and regional stroke centers during the process of transfer of care — a process one participant described as entailing “a lot of people… normally two or three [medical doctors] MD’s, [physicians assistants] PA’s and… a whole bunch of nurses” — as well as with fire departments, families, and bystanders on-scene (Clinician).

Figure 3. Major Code Intersections Identified.

The numbers in the figures represent the frequency of intersecting codes mentioned as both care barriers and care facilitators. Bolded lines are proportionally thick to the number of intersections, with more intersections resulting in a thicker line.

Inclusive as a subcode for interactions on the patient care level, the clinician code encapsulated a range of interactions, both positive and negative in nature. Hospital clinicians generally tended to be distrusting of EMS to correctly identify stroke, and thereby spent additional time assessing the patient during the transfer of care, delaying that patient from receiving timely treatment. However, one participant mentioned how “the optimal experience of trust came with two rounds with this doctor” (Clinician). During the first round, this participant told the doctor that his test would be inconclusive, to which the doctor responded by completing the assessment still for themselves, only to find it inconclusive. The next time this participant and doctor had an encounter, the doctor simply sent the patient to CT after hearing the participant’s full report. Here, rapport and trust gained between EMS and hospital clinicians over time facilitates positive interactions on the patient care level, which ultimately leads to more timely and adequate care.

DISCUSSION

In qualitative interviews with 12 EMS clinicians and administrators, this study identified several barriers and facilitators to delivering effective and efficient prehospital stroke care in rural communities. Barriers included challenges with long transport distances and times, extensive patient and bystander delays in calling 9–1-1, and complex interactions on-scene and at the hospital. Facilitators included the use of standard protocols and assessment tools, bidirectional communication between EMS and hospitals, and leveraging community paramedicine and air medical resources. While the study findings mostly confirmed barriers and facilitators identified in urban and suburban settings, our study design allowed for an in-depth investigation of these issues in the context of dispersed populations, limited heath care resources, and other challenges encountered in rural settings. The perspectives of rural EMS captured in this study are useful to inform initiatives for improving regional stroke systems of care to address rural stroke disparities.

Study participants noted opportunities to improve rural stroke care with prehospital protocols and enhanced communication between health care clinicians. To improve prehospital protocols, there is a need for continuing education with an emphasis on efficiency, especially for time-sensitive scenarios like stroke. Such continued education should also not be limited solely to EMS professionals within the medical realm. Multiple participants note interactions demonstrating a poor base level of stroke knowledge with nursing home staff and even professionals in the hospital setting. Given the time sensitivity of stroke, such instances of poor stroke knowledge contribute to delays to care, impeding patients’ access to timely treatment. This finding supports the American Heart Association/American Stroke Association’s recommendation of continued educational efforts for improved clinician competency (29).

Bidirectional communication across the stroke continuum of care was commonly discussed among participants regarding sharing patient outcomes to improve clinician performance. Multiple participants critiqued current methods of feedback, in that they are generally limited if provided at all. Some participants mentioned how they can follow up with their supervisors concerning patient outcomes, however, it is often something they must seek out on their own and is not standard practice among clinicians. Similar evaluations through the Community-Engaged Assessment to facilitate Stroke Elimination (CEASE) study found communication between health care clinicians to be essential in improving team member competency in acute stroke care, with an emphasis on delivering patient-centered care (30). Quality and timing of feedback are essential for not only education and growth but also overall preparedness of EMS in subsequent responses (31, 32). In EMS quality improvement, timely assessment of patient outcomes is a crucial component to adequately dissecting where exactly EMS treatment and protocols have room for improvement.

On-scene interactions with both patients and family/bystanders can have a large impact on EMS’ ability to effectively do their job. One issue is that both the family and the patient themselves are particularly poor historians of the patient’s health. People often have difficulty pinpointing the onset of symptoms, which can cause issues for EMS in delivering care. Advancing the general knowledge of the signs and symptoms of stroke, as well as emphasizing the importance of providing an accurate timeline, has the potential to mitigate on-scene times, especially when the patient, their family or bystanders are knowledgeable of the time-sensitive nature of stroke.

Opportunities for improvement were noted in the areas of public education and community engagement. Interviews with EMS discussed lack of public education as a major hindrance to the delivery of stroke care, impacting many areas of the EMS process including 9–1-1 activation, stroke screening, and triage and routing. In rural communities, stroke public education is particularly important given the high burden of stroke risk factors and social determinants of health. Community engagement is also an important component of building public trust; distrust of EMS to arrive quickly results in patients hesitating to call 9–1-1 in the first place (30). By facilitating stronger relationships between health systems and the communities they serve, patients will be more likely to utilize resources such as EMS and are thereby more likely to receive optimal care. The complex nature of community engagement suggests multilevel interventions are necessary to achieve the goal of promoting future community wellbeing (33).

Future Directions

In exploring clinician perspectives, it was evident just how important it is to engage with patients and hear their perspectives on the efficacy of EMS and hospital care. Therefore, our study team is exploring this concept further and completing semi-structured interviews with stroke survivors and caregivers. These interviews have the potential to contribute greatly to quality improvement within EMS and identify how best they can interact with communities. Additional implications apply to stroke education for the public, continued training for clinicians, and EMS stroke triage and transport policies. By identifying these gaps in knowledge, interventions can be better tailored for rural and other underserved populations.

LIMITATIONS

The study has some notable limitations. Our recruitment and enrollment efforts were limited by the 12-month project duration and availability of funding. Therefore, the achieved sample size was relatively small; a larger sample size would have allowed us to more robustly examine nuances within and between themes. While we did not identify any new subcodes, indicating that code saturation was reached, there may be a lack of nuanced understanding within certain themes, formally called “meaning saturation” in qualitative research (25). Potentially underdeveloped themes include community and organization outcomes, improvements within and external to EMS, and interactions on the organizational level. The 10 EMS agencies approached for recruitment were a convenience sample of rural EMS agencies in NC. As participants in an ongoing Pediatric Emergency Care Coordinators program, our sample could be more representative of high-performing rural agencies and may not generalize to other rural agencies in NC and other states. Of these 10 agencies, we had participation from only four, so there is the potential for selection bias due to non-participation at the personnel- and agency-levels. For example, our results are likely skewed toward the attitudes of agency leadership and clinicians who view prehospital stroke care as an important topic. Lastly, while the potential for confirmation bias is present, EMS clinician and administrator respondents are less likely to have been unduly influenced by an EMS researcher-interviewer compared to someone in a clinical or administrative EMS role.

CONCLUSIONS

This qualitative study of rural EMS professionals in NC elucidates the barriers and facilitators of prehospital stroke care and provides valuable insights for EMS medical directors and other EMS leaders to advocate for the rural EMS perspective in designing and optimizing regional stroke systems of care. Enhancing bidirectional communication between EMS and hospital clinicians was identified as a means to diminish delays during the prehospital phase and incorporate patient-centered outcomes for quality improvement purposes. There remains a major need for further community engagement and education regarding stroke. Our findings add to the limited number of qualitative studies assessing EMS perspectives regarding stroke care and can be used to facilitate positive change in providing stroke care for rural communities.

DATA SHARING STATEMENT:

Not applicable.