Confidence Impacts Utilization of Stroke and LVO Screening Tools in EMS Providers

Introduction Stroke screening and large vessel occlusion (LVO) tools are critical for prehospital triage, guiding recognition and transport destination. Provider confidence in applying these instruments may directly affect their frequency of use and reliability. Few studies have compared EMS provider confidence across different stroke screening tools or examined whether similar patterns exist for LVO‐specific assessments. Methods We analyzed responses from a Texas statewide EMS survey conducted in 2024. Providers reported their confidence in performing stroke screening tools (very confident, confident, somewhat confident, not confident) and LVO tools, along with which instrument they used most often. Associations between tool selection, confidence, training frequency, and utilization were assessed using chi‐square tests and Cramér's V effect sizes. Results Confidence significantly influenced stroke screening tool use but varied significantly by stroke screening tool used. Cincinnati was most frequently associated with higher confidence and greater utilization (χ 2 =15.7, p=0.0035, Cramér's V = 0.32), whereas FAST and LAMS demonstrated lower independent associations with confidence. LAPSS and Boston were rarely used. Importantly, providers who reported higher confidence in any stroke screening tool were also significantly more likely to report using the tool >75% of the time (χ 2 = 44.0, p < 0.001, Cramér's V=0.31). For LVO tools, overall confidence was lower compared with general stroke screening. Only 54% of VAN users reported being “very confident,” while fewer than half of FAST‐ED, C‐STAT, RACE, and LAMS users expressed high confidence. Utilization followed a similar pattern: > 50% of users for RACE, C‐STAT, VAN, and FAST‐ED reported they used their tool >75% of the time, whereas rates were lower for LAMS (43%). Training frequency varied, but providers receiving annual or more frequent training were more likely to express higher confidence across all LVO tools (trend consistent but not statistically significant). Importantly, confidence gaps in LVO tools were consistent across provider levels (EMT vs paramedic), though paramedics tended to report slightly higher confidence. Conclusions Confidence remains the strongest determinant of utilization for both stroke and LVO tools. Cincinnati was associated with the highest confidence and use among stroke screening tools, while VAN and C‐STAT were most common among LVO instruments, albeit with lower confidence overall. These findings highlight an urgent need for standardized, recurring education on LVO tools to strengthen provider confidence and consistency. Improving training may enhance the reliability of prehospital stroke triage and ultimately improve patient outcomes.