Stroke & the ems response final

Stroke & The EMS Response 07/08/2009 Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, Mercy Air, San Bernardino County FD, Barstow FD

Acute Stroke: US Societal Impact 1 st leading cause of adult disability 2 nd leading cause of dementia after alzheimers 3 rd leading cause of death (2 nd worldwide) ~800,000 new strokes each year >6 million stroke survivors $70 billion per year in the United States 1 in 6 Americans will be affected Of those who survive, 90% have deficit

What is a Stroke? Injury to the brain from blockage or rupture of a blood vessel Ischemic stroke Blockage of a blood vessel Brain cells deprived of oxygen/nutrients 83% of strokes in US, 65% of strokes in Asia Hemorrhagic stroke Rupture of a blood vessel Bleeding into the brain 17% of strokes in US, 35% of strokes in Asia

Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage

Warning Signs of Stroke “The Five Suddens” Sudden weakness or numbness Sudden change in vision Sudden difficulty speaking or understanding Sudden dizziness or loss of balance Sudden headache

Cerebrovascular Disease Pathogenesis Cardioembolic (30%) Lacunar (25%) (small vessel disease) Ischemic Stroke (83%) Hemorrhagic Stroke (17%) Subarachnoid Hemorrhage (30%) Cryptogenic (5%) Atherothrombotic Cerebrovascular Disease (30%) Intracerebral Hemorrhage (70%) Other (vasculitiis, dissection, hypercoagulable, etc (10%)

Ischemic Stroke None Intracerebral Hemorrhage None Subarachnoid Hemorrhage Nimodipine Intraventricular Hemorrhage None Acute Stroke Care 1990 Therapies with FDA Approval or Positive Trials

Ischemic Stroke Stroke Unit Care PO Aspirin < 48 hrs IV TPA < 3 hrs IV TPA 3-4.5 hrs IA fibrinolysis < 6 hrs IA Merci Retriever < 8 hrs IA Penumbra System < 8 hrs Endovascular temperature control Intracerebral Hemorrhage Stroke Unit Care Endovascular temperature control Acute Stroke Care 2010 Therapies with FDA Approval or Positive Trials Subarachnoid Hemorrhage Stroke Unit Care GDC coil, Matrix coil, stent assisted coiling Endovascular temperature control Nimodipine Magnesium sulfate Statins IA angioplasty for vasospasm Intraventricular Hemorrhage Intraventricular TPA and drainage Endovascular temperature control

In a typical acute ischemic stroke, every minute the brain loses 1.9 million neurons 14 billion synapses 7.5 miles myelinated fibers -- Saver, Stroke 2006

Stroke and the Golden Hour Narrow therapeutic time window Early intervention critical for stroke care Prehospital personnel 35-70% of stroke patients arrive by ambulance Unique position: first medical professional to come in contact with stroke patient

Emergent Stroke Care & The Chain of Survival Patient Calling EMS ED Stroke Stroke Knowledge 911 System Staff Team Unit

Stroke Systems Two Tier US Model EMS --Trained dispatchers, high priority triage --Paramedics trained in stroke recognition (e.g. LAPSS) --Deliver patients to nearest stroke capable hospital --Pre-arrival notification Primary Stroke Centers - Spokes --Able to provide initial, acute care --Able to use rt-PA and other acute therapies in a safe and efficient manner --Can admit patients if they have a Stroke Unit Comprehensive Stroke Centers - Hubs -- Able to care for complex patients --Advanced treatments (i.e. coils, stents, etc) --Trained specialists in key areas (Vascular neurology, Neurointerventional procedures, Neurocritical Care, Vascular Neurosurgery)

Certified Primary Stroke Centers in the United States (5/09) Joint Commission 545 HFAP (Osteopathic) 15 Dept of Health/EMS 290 Total 850

Primary Stroke Center Coverage of US Population in 2009 States Delaware Florida Georgia Illinois Maryland Massachusetts Missouri New Jersey New Mexico New York Oklahoma Texas Virginia Counties Alabama 7 counties Arizona Maricopa-Phoenix California Alameda Kern Los Angeles (partial) Orange Sacramento San Diego San Francisco San Mateo Santa Clara 13 states, multiple additional counties

California Stroke Systems Status California 64 JC Certified Primary Stroke Centers 9 of 58 County EMS Stroke Systems Primary Stroke Center systems Alameda Kern Los Angeles (partial) Sacramento San Diego San Francisco Two Tier Primary and Comprehensive Stroke Center systems Santa Clara San Mateo Pure Comprehensive Stroke Center system Orange County – 9 (6) of 26 hospitals

Primary Stroke Center Coverage of US Population in 2009 Live in jurisdictions with direct routing to Stroke Centers 154 million Americans 51% of US population 23 million Californians 63% of California population Live in jurisdictions with routing to nearest hospital, not PSCs 150 million Americans 16 million Californians

The 6 Major Stroke Clinical Syndromes Syndrome Symptoms/Signs Cerebral Hemisphere Ischemia Contralateral hemiparesis, hemisensory Contralateral visual field defect Aphasia (left) / Hemispatial neglect (right) Brainstem Ischemia Decreased LOC Unilateral or bilateral weakness, sensory Dysconjugate gaze, dysarthria, dysphagia, vertigo Cerebellar Ischemia Ataxia, nystagmus Lacunar (small vessel) Ischemia Motor/sens/ataxia without language, neglect, visual Intracerebral Hemorrhage One of above focal syndromes, plus Headache, N/V, decreased LOC Subarachnoid Hemorrhage Thunderclap headache Neck stiffness Decreased LOC

How Did we Get Here? The NINDS Trail

IV TPA FOR STROKE 3-4.5 HR’s? ECASS 3

NIH Stroke Scale Designed for acute ischemic stroke trials Relatively quick (5-10 min) and reproducible Requires speech-&-language cards, safety pin Quantifies stroke deficit 11 items, 0-42 point scale (0 = nl) Valid, reproducible, assists in patient selection, facilitates communication Certification available from AHA website

NIH Stroke Scale: “Traditional” order of items 1a. LOC 1b. LOC questions 1c. LOC commands 2. Best gaze 3. Visual fields 4. Facial palsy 5a. Right arm motor 5b. Left arm motor 6a. Right leg motor 6b. Left leg motor 7. Limb ataxia 8. Sensory 9. Best language 10. Dysarthria 11. Extinction/ inattention

NIH Stroke Scale: Modified arrangement of items Mental Status LOC Questions Commands Language Neglect Cranial Nerves Visual fields Horizontal gaze Face strength Dysarthria Limbs R/L arm motor R/L leg motor Coordination Sensation

Stroke Scales NIH stroke scale 0-42 0-5 mild (in most patients) 6-10 moderate 11-20 severe > 20 very severe underestimates volume of infarct in non-dominant (R) hemispheric strokes

The NIHSS and Patient Selection for TPA No lower limit But most patients 4 or more No upper limit But FDA/AHA caution when NIHSS > 22 Risks “may be increased…and should be weighed against the anticipated benefits…”

Stroke Treatment In The Emergency Department < 3 Hrs = Hyperacute therapy when nearly all patients have penumbra

The Ischemic Penumbra Core Infarct Ischemic Penumbra: zone of salvageable tissue surrounding core infarct

Strategies to Identify Patients with Salvageable Ischemic Penumbra < 3 Hrs = > 3 Hrs Hyperacute therapy when nearly all patients have penumbra Time From Onset (Hours) % Patients with Penumbra Imaging required to assess pathophysiology

Provent Strategies in Acute Ischemic Stroke Therapy Supportive Care Recanalization Prevent Clot Propagation Early Implementation of Secondary Prevention

Early Supportive Acute Stroke Care 5-15% Increase in Good Outcomes in Acute Stroke Unit Controlled Trials Treat hypoxemia Continuous pulse oximetry, supplemental oxygen as needed Maintain normothermia Early antipyretics/antibiotics Avoid hyperglycemia Avoid glucose infusions/use SSI/maintain glucose < 200 mg/dl Early parental fluid to support collaterals Maintenance normotonic IV fluids (IV NS 75-100 cc/h) Permissive hypertension to support collaterals Treat only if >220/120 DVT prophylaxis Compression boots/hep/LMWH Early mobilization Early swallow assessment to guide oral feeding

Preventing Clot Propagation Antithrombotics and Acute Stroke Aspirin 9 trials, 41,399 patients (Cochrane 2004) Minimally beneficial, OR = 0.94 (95%CI 0.91-0.98) 13 more per 1000 alive and independent NNT: 77 Heparin/LMWHs 21 trials, 23,427 patients (Cochrane 2004) No net benefit “ [H]eparin/heparinoids are not recommended for…acute ischemic stroke” AAN/AHA Joint Guideline 2002

Currently Available Recanalization Therapies in Acute Cerebral Ischemia Intravenous IV TPA under 3 hours FDA approved, guideline endorsed, RCT supported IV TPA 3-.4.5 hours RCT supported, guideline endorsement highly likely, FDA approval likely IV lytics 4.5-9 hours in advanced imaging selected patients Weakly RCT supported, not guideline endorsed or FDA approved Catheter Mechanical embolectomy ≤ 8 h (Merci devices) FDA approved for clot clearance, no RCTs Mechanical aspiration ≤ 8 h (Penumbra device) FDA approved for clot clearance, no RCTs Mechanical angioplasty/stenting FDA approved for secondary prevention, no RCTs IA fibrinolytics ≤ 6 h Off label, 1.5 positive RCTs, weakly guideline endorsed

IV TPA Under 3 Hours – Changes in Outcome Due to Treatment Outcome NNTB Nl/Near Normal 8.3 Improved 3.1 For every 100 patients treated with tPA, 32 benefit, 3 harmed --Saver, Arch Neurol 2004; 61:1066-1070; Stroke 2007; 38:2279-2283 --AAN/ACEP/AHA Patient Educational Tool 2008

Intravenous Treatment Beyond 3 Hours: Pooled Analysis of Initial IV TPA Trials (Lancet 2004) 6 trials, 4 with > 3h data ECASS 1, ECASS 2 ATLANTIS A, ATLANTIS B NINDS Trial 1, NINDs Trial 2 2775 patients OR favorable outcome Time (hrs) OR 1.0-1.5 2.8* 1.5-3.0 1.6* 3.0-4.5 1.4* 4.5-6.0 1.2

Intravenous TPA in the 3-4.5 Hour Window Outcome NNTB Normal/Near Normal 14 Improved 7.1 For every 100 patients treated with tPA, 16 benefit, 3 harmed --Saver et al, Neurology (submitted)

Using tPA in Routine Clinical Practice Overall only about 3%-4% of stroke patients receive tPA — mostly due to time delays Efficacy similar to NINDS trial Rate of ICH: 4%-6% Risk of ICH increases with protocol violations Time >3 hours Poor blood pressure control Using prohibited agents Wrong dose 0.9 mg/kg Maximum dose: 90 mg Elevated blood sugar also increases risk Adams HP, et al. ASA Stroke Council. Stroke. 2003;34:1056-1083.

Monitoring the Stroke TPA Patient Blood pressure Goal ≤ 180/105 x 24 hours Monitor for complications Bleeding complications Symptomatic intracranial (2-3%) Headache, sudden BP increase, increased focal deficits, N/V, decreased LOC Systemic (Uncommon) - Gums, IV sites Orolingual angioedema (1-2%) Typically mild, transient, contralateral Rx: benadryl, H2 blockers Severe: steroids, epinephrine, intubation

Intra-arterial Recanalization Therapies

Intra-arterial Recanalization Approaches Thrombolytics Mechanical Techniques

Mechanical Endovascular Recanalization Devices in Acute Stroke Endovascular Thrombectomy Clot Retrieval Devices Merci Retriever Phenox Retriever Catch Device Microsnare Suction Thrombectomy Syringe suction Angiojet/Neurojet Penumbra system Mechanical Disruption Laser EPAR Device LaTIS Device Primary Angioplasty/Stenting Augmented Fibrinolysis Microwire passage Endovascular ultrasound

Merci Retriever Devices X5, X6 Five helical loops, conical, X6 more resistant to stretching L5, L6 Helical loops, cylindrical, arcading filaments K-mini Helical loops with counter-twist, cylindrical, smaller diameter V-Series 7 helical loops (2 small distal loops), filaments, variable spring rate

Merci ® Retrieval System Balloon Guide Flexible, helical shaped, tapered tip made of nitinol wire Merci = mechanical embolus retrieval in cerebral ischemia

Find it, Engage it, Retrieve it

UCLA – MCA Occlusion 30-Year-Old Female – Baseline NIHSS 24 Symptom Onset to Final Angiogram – 5:37 NIHSS 24 hours 1 mRS 5 days post 0 30 days post 0 90 day post 0

Penumbra System: Registration Trial 125 patients NIHSS 17.6 Recanalization (TIMI 2-3) Reported “82%” Likely lower using standard ratings SICH 11.2% Nondisabled (mRS 0-2) outcome 90 d 25% Death 90 d 33%

Penumbral Imaging and Mechanical Embolectomy 23 patients treated with Concentric Clot Retriever Mean age 62 (range 28-90) Median pretreatment NIHSSS 19 (range 10-26) 14 patients (54%) demonstrated pretreatment penumbral MRI pattern* Partial or complete recanalization 70% *(PWI - DWI diameter  20%)

Multimodal Diffusion-Perfusion MRI Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses DWI PWI MRA

Multimodal CT Imaging Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses CT PCT CTA

Intracerebral Hemorrhage Therapies BP control Ventriculostomy for Hydrocephalus Hemorrhage evacuation Cerebellar, cortical

Subarachnoid Hemorrhage Therapies With this approach, surgery is done to clip the aneurysm. First a window is made in the skull. This is called a Prevent rebleed Aneurysm coiling, clipping Ventriculostomy for hydrocephalus Treated delayed vasospasm

History 83 yo RH woman 7:05 PM – acute onset wobbling gait, slurred speech, right body weakness 911 called

EMS Evaluation Pulse 75, BP 170/75 Right weakness LAPSS positive for stroke Neurologist by phone confirms history and orders start of FAST-MAG neuroprotective trial study agent in ambulance

Primary Stroke Center BP 172/70 Aphasic – says “hi” repetitively Severe right hemiparesis NIHSS 24 H/o HTN, hypercholesterolemia Medications: Pravastatin, carvedilol, losartan, pantoprazole, levothyroxine

Noncontrast CT – L MCA hyperdense sign

Primary Stroke Center IV TPA 0.9 mg/kg Transfer to UCLA CSC

An 83 yo RH woman with sudden speech difficulty and right body weakness Last known well @ 7:05 PM 911 call @ 7 min Field NP study drug @ 33 min PSC ED arrival @ 49 min IV TPA @ 1 hr 54 min

An 83 yo RH woman with sudden speech difficulty and right body weakness Last known well @ 5:00 PM 911 call @ 7 min Field NP study drug @ 33 min PSC ED arrival @ 49 min IV TPA @ 1 hr 54 min CSC ED arrival @ 3 hr 17 min Multimodal MRI @ 3 hr 39 min 1 st Merci pass @ 4 hr 22 min Recanalization @ 4 hr 51 min

Acute Ischemic Stroke Care in the 21 st Century Symptoms Primary Stroke Center Neuroprotectants EMS 911 Comp Stroke Center EMS IV Lytic Imaging Imaging IA Mechanical or Lytic Angiogram Cath Lab Neuroprotectants Stroke Unit

• EMS play a critical role in the emergency care of acute stroke patients. • Over 400,000 acute stroke patients are being transported annually by EMS providers. • Just over half of all stroke patients use EMS, but those who do comprise the majority of patients presenting within the 3 hour window for acute treatment. • EMS use decreases time to hospital arrival, physician exam, CT imaging, neurologic evaluation, and ability to implement acute stroke intervention Key Points

• There are more than 750,000 strokes per year. • 163,000 die from stroke every year in america • stroke is the third leading cause of death • stroke is the leading cause of disability in adults • 4.4 million survivors; only 50-75% of stroke survivors regain functional independence • estimated direct/indirect costs for 2007- $62.7 billion • 14% of persons who survive a first stroke or TIA will have another within one year The Impact of Stroke

A pea sized piece of brain dies for every 12 minutes that treatment is delayed. Each minute you wait you lose close to 2 million brain cells. Time is Brain

TPA For Stroke 3 hours of symptom onset (NINDS trial) 4.5 hours of symptom onset (ECASS 3) 7 D’s detection, dispatch deliverly, door, data, decision, drug Stroke & The EMS Response

Use of TPA for acute stroke 1999-2004 treatment rates for ischemic stroke: 1% Schumacher C et al: use of thrombolysis in Acute Ischemic Stroke. ANN Emerg Med. 2007;50:99-107 Stroke & The EMS Response

Stroke mimics cortical vs noncortical stroke cranial nerves awake breathing Stroke & The EMS Response

Left side right side at threshold of new therapies that require us as an EP to statify…in the same way we do with mi patients Stroke & The EMS Response

For the first time in a decade it will matter what type of stroke syndrome they have lacunar or cortical cortex..Big vessels mca, cath lab get rid of clot language involved you have just localized to the cortex… angiogram, cta, mra ventriculosotomy massive territory stroke do they need a ventriculostomy risk stratification…language on the left sensory exam more likely to be cortical lacunar infarcts characterized small vessel disease less likely to get edema Stroke & The EMS Response

Lacunar different treatment arm lacunar vs cortical You only have one ICU bed, which is more likely to have complications the cortical is! Stroke mimics dissection, infective endocarditis, ekg, vegitations, intermittent afib, cardiac cerebral axis… Stroke & The EMS Response

Mimics: Encephalopathy Endocrine Dissection Endocarditis MRI What do the Neurologist want? What is the right risk stratification test noncontrast ct Stroke & The EMS Response

Types of Specialized Studies: Tissue Groups ct perfusion studies…contast studies with special protocols that show blood flow, be able top ick out the dead the core infarct vs the pneumbra poor The Vessels diffusion weighted- MRI picks up a dead core of an infarct, picks up early changes in cell death dead core of an infarct perfusion weighted- shows us the blood flow… will help us hone our therapies Stroke & The EMS Response

CT…about the vasculature, can we see where the obstruction is CTA vs MRA MR…. Stroke & The EMS Response

ABC’s, tube em, what if they have a fever should we cool em fever associated with poorer outcomes, increase temp increase metabolic demmand, so do we cool them, tylenol, whats causing the fever ? Pneumonia one of the biggest killer of people having a stroke, keep patients NPO…is the fever because they aspirated… TPA candidate Blood pressure control under 185/110 220/120 it could be harmful to lower the blood pressure in these individuals acclimated to the higher blood pressures Stroke & The EMS Response

Background & Importance Stroke remains the third leading cause of death and a leading cause of long-term disability among Americans. Approximately 700,000 individuals suffer a new or recurrent stroke each year.

BP Control Nipride less popular toxicity concern difficult to use problem in renal failure dilates cerebral vessels steal phenomenon with some Labetolol 10mg iv….up to about 300mg longer half life no concern about cocaine Nicardipine titratable less toxic effects Stroke & The EMS Response

Hyperglycemia trend towards tighter control trauma, sepsis, stroke most of this literature of an association type 80-140 UK study flies in the face of that should we use heparin, doesn’t appear to have any of the benefits of TPA not indicated in acute ischemic stroke…so if you have a cardio embolic source they have been waiting 72 hours to a week to put them on anticoagualtion. hypotension Stroke & The EMS Response

Don’t combine the ASA with TPA what about plavix? 7mg 5 days to steady state many are loading 300mg….jury still out moderate hypothermia does it work for stroke, most neuroprotective therapies have failed in human trials vasodilators…no carotid endarectomy…no doesn’t work, its too late endovascular interventions…look promising up to 8 to 9 hours Neuroprotective agents…don’t really have a good one yet 2007 Stroke & The EMS Response

Attention to the basics swallow eval, pneumonia, dvt, sepsis, head of the bed up, npo in the ed. Treatment of acute neurological complications lie at the nexus between medical and surgical disease, dense hemiparesis cortical- sensory, language, spatial, perception problem along with it. Get drowsy likely to go down hill. Cerebellar infarct- posterior strokes, bleed is a surgical emergency, infarct may also be surgical patient need decompression, your swelling in a confined space. Stroke & The EMS Response

Malignant MCA syndrome Roy was attached by montecue the tiger hemicraniectomy, they realized that he would die without it. Venticulostomy to relieve pressure hemorrhagic transformation seizures- treat them, they generally don’t recommend prophylaxis, latter with scaring they then tend to generate the epilogenic foci. Stroke & The EMS Response

Stokes Mimics 24 hour cardiac monitoring from time of onset think about the heart brain axis cortical vs noncortical vs lacunar imaging noncontrast dead vs not quite dead is there an ischemic pneumbra that would could save treat pain, drain bladder, npo, keep hob elevated good BP control get all your specialist involved tight glycemic control ? What do we want to do? Stroke & The EMS Response

Important Role of EMS & EMSS in optimizing stroke care EMS - Emergency Medical Services Full scope of pre-hospital services, including: 9-1-1 activation and dispatch emergency medical response triage & stabilization in the field transport by ground or air ambulance to a hospital or between facilities. EMSS - Emergency Medical Service Systems Delivery systems organized on a local, regional, statewide, or nationwide basis using public or private resources. The successful integration of one (and often multiple) EMSS is critical to ensuring the effectiveness of a stroke system of care.

Recommendation One Stroke Systems should Require Appropriate Processes that ensure Rapid access to EMS for Acute Stroke Patients Ensure: Access to enhanced landline & wireless 9-1-1 (W-E911). EMS communicators recognize stroke signs & symptoms reported by callers. Stroke patients are dispatched at the highest level of care available in the shortest time possible. ensuring use of emergency medical dispatch guidelines reflecting the current ASA/AHA guidelines.

Measurement Parameters (cont.) 100% of 911 call centers use dispatch guidelines that prioritize stroke patients at the highest care level available. Ensure that the time period between the receipt of the call and the dispatch of the response team is less than 90 seconds for 90% of calls involving stroke. EMS communicators correctly identify a max % of callers experiencing stroke and dispatch EMS responders at the highest priority for these calls.

Recommendation Two For EMS responders, EMSS should use protocols, tools and training that meet current AHA/ASA guidelines for stroke care . Identify acute stroke patients rapidly by ensuring that EMS responders use validated screening algorithms effectively. Establish goals for the EMSS response time for suspected stroke patients. The EMSS response time comprises the dispatch time, the turnout time, and the travel time.

Measurement Parameters Ensure that 100% of EMSS use validated pre-hospital stroke screening tools to identify stroke patients. Ensure that when EMS responders screen patients for stroke, they err on the side of over-identification. Initially, EMSS should establish a goal of over-triage of 30% for the pre-hospital assessment of acute stroke. As part of the CQI process, EMS responders’ stroke screening assessment should be compared against final patient diagnoses to identify failures to identify patients who were experiencing a stroke (under-triage). These data should be used to develop and adjust EMS responder training and protocols for the use of stroke screening forms.

Measurement Parameters (cont.) Ensure EMSS response time is <9 minutes for at least 90% of acute stroke patients. Response time reflects the amount of time elapsed from the receipt of the call by the dispatch entity to the arrival on the scene of a properly equipped and staffed ambulance. Ensure that dispatch time is <1 minute, turnout time is <1 minute, and travel time is equivalent to trauma or acute myocardial infarction calls. Ensure that the on-scene time is <15 minutes (unless extenuating circumstances or extrication difficulties). Report all times using the fractile method (e.g. 90th percentile). For accurate data collection, all clocks capturing these times in the EMSS should be synchronized.

Potential Solution Samples Integrate EMS within ED stroke care & CQI activities for stroke. Collaborate with state or local coalition of healthcare providers, experts, and regulators to develop improved EMSS processes & protocol enhancements. Advocate for funding of professional education training for pre-hospital providers. Collaborate with state or local coalition of healthcare providers, experts, and regulators to develop improved EMSS point-of-entry (transport destination) plans.

Measurement Parameters Ensure pre-arrival notification of hospitals is provided for all suspected stroke patients. Ensure that 100% of EMS providers complete a minimum of 2 hours of instruction on stroke assessment and care as part of their required CME for certification and re-licensure. Ensure the total EMSS contact time (from the receipt of the 9-1-1 call or presentation at a non-stroke center hospital to arrival at a stroke center) is measured for 100% of stroke patients. EMSS should consistently strive to decrease this time.

Measurement Parameters (cont.) Ensure on-scene time is <15 minutes before transport, unless there are extenuating circumstances. This also applies to emergent interfacility transportation of stroke patients. EMSS & hospitals should develop policies & procedures to streamline paperwork and equipment issues. Ensure EMS response time to reach a stroke patient for emergent interfacility transfer is the same as the time from dispatch to transport (less than 9 minutes at least 90% of the time or as determined appropriate by the local EMSS).

Measurement Parameters (cont.) Ensure that 100% of stroke patients are included in CQI activities and that EMSS receives feedback from the hospital on all confirmed & suspected stroke patients they provided pre-arrival hospital notification for. Implement continuous monitoring of standard measures as part of the CQI process including: stroke history obtained stroke assessment using validated screening tools stroke history checklists that document eligibility for acute therapies properly completed whether on-scene time was appropriate whether the hospital transport destination decision was appropriate.

Recommendation Four Patients should be transported to the nearest Stroke Center for evaluation & care if located within a reasonable transport distance & transport time. The determination needs to take into account regional issues such as the availability of Stroke Centers & geography and whether transportation to a Stroke Center is possible within the appropriate time for acute therapeutic interventions.

Recommendation Four (cont.) Assess stroke patient eligibility for acute stroke therapies using a stroke history checklist or algorithm consistent with AHA/ASA guidelines. Establish EMSS transport destination protocols that reflect optimal patient care with transport to a certified Stroke Center. Establish protocols for the transfer of stroke patients from non-stroke center hospitals to certified Stroke Centers. Transport stroke patients to stroke-ready hospitals regardless of the patients’ geopolitical location.

Potential Solution Samples Ensure the use of stroke triage & transport protocols that reflect current recommendations for assessing stroke patients for eligibility for acute stroke therapies, including thrombolytic therapy. Ensure that EMS responders have adequate education & training to screen patients accurately for acute therapies. Advocate for a statewide plan for EMS protocols to ensure stroke patients receive high-priority care at recognized certified Stroke Centers. Advocate for the development of a public statewide hospital identification system identifying hospitals that meet the criteria for Primary or Comprehensive Stroke Centers.

Measurement Parameters Ensure that stroke history checklists are completed for at least 90% of all suspected stroke patients. Ensure that the amount of time EMS responders spend collecting the clinical history at the scene is < 10 minutes. Total on-scene time should not exceed 15 minutes. Work within existing coalitions with representatives of the emergency medicine, political, and pre-hospital communities. Establish model policies & regulations for patient transportation protocols that are consistent with AHA/ASA guidelines and can be adopted at state, regional, & local levels.

THANK YOU Questions? You can contact me at: [email_address] 1-951-544-5433

Stroke & the ems response final

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