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Wisconsin Coverdell Stroke Program
- 1. Paramedic System of Wisconsin Tundra Lodge September 18-20, 2013 Dot Bluma, RN QI Stroke Specialist MetaStar, Inc. www.metastar.com Cathy Etter, BSN, CCEMT-P EMS QI Consult
- 2. Objectives โข โข โข โข โข Appreciate the importance of a partnership between EMS and hospital providers Recognize the time-sensitive nature for treatment of an acute ischemic stroke patient Describe challenges and successful strategies in meeting prehospital stroke care Describe the recommended components of an appropriate pre-hospital assessment of a potential stroke patient Understand the recommendations of the American Stroke Association and Coverdell Stroke Program for pre-hospital providers
- 3. Statistics โข โข โข โข โข Stroke is the 4th leading cause of death in the United States Stroke is the leading cause of long-term disability More than 795,000 people have a stroke each year in the United States Total annual stroke costs to the nation are about $38.6 billion Transport by EMS of stroke patients to the hospital results in faster treatment, yet one-third of stroke patients do not call 911 to use EMS to get to the hospital Source: CDC State Heart Disease and Stroke Prevention Programs. Retrieved from http://www.cdc.gov/dhdsp/programs/stroke_registry.htm
- 4. Target Stroke American Heart/American Stroke Associations โขBest Strategy Practices inception in early 2010 โขTarget Stroke Goal: At least 50 percent of patients receive IV tPA in 60 minutes or less โ โThe Golden Hourโ Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/TargetStroke_UCM_314495_SubHomePage.jsp
- 5. Coverdell Objectives Right Care at the Right Time Coverdell focuses on the continuum of patient care: โขSupport development of stroke systems of care โขEliminate disparities in care โขDecrease rate of premature death and disability โขMeasure, track, and improve the quality of stroke care
- 6. Coverdell Goals for Wisconsin โข โข โข โข Develop statewide Stroke Systems of Care Build a hospital stroke registry Support hospital education and quality improvement Support EMS education and quality improvement
- 7. Acute Stroke Care โTime is Brainโ โขTiming and a fast response are critical โขA stroke is a brain attack where time lost is brain lost! โขDuring an ischemic event the average person loses 32,000 brain cells per second! The most important piece of information is an accurate last known well/normal time! Jauch et al, 2013. Stroke. Early Management of Acute Ischemic Stroke; 44:870-947.
- 8. Emergency Room Care Treatments โขIV tPA within 3 hours; up to 4.5 hours for certain eligible patients โขEndovascular procedures in carefully selected patients โ โ IA tPA Mechanical Devices Jauch et al, 2013. Stroke. Early Management of Acute Ischemic Stroke; 44:870-947.
- 9. Mode of Arrival to Hospital Q1 & Q2 2013 This Get With The Guidelinesยฎ (GWTG) Aggregate Data report was generated using the Outcomeโข PMTยฎ system. Copy or distribution of the GWTG Aggregate Data is prohibited without the prior written consent of the American Heart Association and Outcome Sciences, Inc. (Outcome).
- 10. Emergency Room Care Emergency Room Care of the Acute Stroke Patient Team Based Approach โข โข โข โข โข โข ER Physician ED RN Stroke Team Radiology Department Lab Neurologist โข โข โข โข Radiologist Pharmacy Neurosurgeon Physician Extenders (NP, PA) โข Interventional Radiology Team
- 11. Emergency Room Best Practice Strategies โข โข โข โข โข โข Door to physician โค 10 minutes Door to stroke team โค 15 minutes Door to CT initiation โค 25 minutes Door to CT interpretation โค 45 minutes Door to drug โค 60 minutes Door to stroke unit admission โค 3 hours Jauch et al, 2013. Stroke. Early Management of Acute Ischemic Stroke; 44:870-947 .
- 12. ED Arrival 2 hours from LKW Q1 & Q2 2013 This Get With The Guidelinesยฎ (GWTG) Aggregate Data report was generated using the Outcomeโข PMTยฎ system. Copy or distribution of the GWTG Aggregate Data is prohibited without the prior written consent of the American Heart Association and Outcome Sciences, Inc. (Outcome).
- 13. ED Arrival 3 hours from LKW Q1 & Q2 2013 This Get With The Guidelinesยฎ (GWTG) Aggregate Data report was generated using the Outcomeโข PMTยฎ system. Copy or distribution of the GWTG Aggregate Data is prohibited without the prior written consent of the American Heart Association and Outcome Sciences, Inc. (Outcome).
- 14. ED Arrival 2 hours from LKW Q1 & Q2 2013 Pre-notification This Get With The Guidelinesยฎ (GWTG) Aggregate Data report was generated using the Outcomeโข PMTยฎ system. Copy or distribution of the GWTG Aggregate Data is prohibited without the prior written consent of the American Heart Association and Outcome Sciences, Inc. (Outcome).
- 15. Stroke EMS Best Practice Strategies โข EMS Pre-notification โ Priority Dispatch โข Stroke Tools โ Protocols, Guidelines, Stroke Scales โข Rapid Triage Protocol โ < 10 minute scene time โ Blood Glucose monitoring โ Blood Pressure measurement
- 16. Stroke EMS Best Practice Strategies โข Single Call Activation โ Activate Stroke Team โข Transfer Directly to CT โ Depends on patients stability โ Airway management Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/TargetStroke_UCM_314495_SubHomePage.jsp
- 17. On Scene Care โข Pre-Hospital Stroke Scale โ Cincinnati or FAST โ Face โ Arm โ Speech โข Last Known Normal/Well Time โ Wake up impaired? โข Contact Name and Phone Number โ Who saw them last? Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/TargetStroke_UCM_314495_SubHomePage.jsp
- 18. EMS Report to ED โข Signs/Symptoms of Stroke โ Pre-Hospital Stroke Scale Results โข ETA โ Early notification is vital โข IV 18g โ Do NOT delay transport โข Additional Complaints/Information
- 19. EMS Report to ED โข Last Known Normal/Well Time โข Medications โ Anticoagulants are important โข Vital Signs โ Blood Pressure โ Blood Glucose โข Repeat ETA Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/TargetStroke_UCM_314495_SubHomePage.jsp
- 20. EMS Goals ๏ผ Less than 10 minute scene time ๏ผ Pre-Hospital Stroke Scale Reported ๏ผ Blood Glucose checked ๏ผ Blood Pressure measurement reported ๏ผ Early ED notification ๏ผ Direct to CT whenever possible
- 21. Hospitals & EMS: Improving Stroke Care โข Develop Quality Improvement Committee โ Routine Quality Improvement review โ Partner to share patient outcomes, review cases, and data โ Timely feedback from ED โ Review with all staff involved โ Address any delays in transport โ Discovery of learning opportunities โข Member recognition for a job well done โข Continuing Education in stroke care โ Mock stroke codes Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/TargetStroke_UCM_314495_SubHomePage.jsp
- 22. The Big Picture Link the care of the stroke patient between EMS providers and stroke-ready hospitals by identifying evidence-based, best practices through collaboration, education, and advocacy to improve patient outcomes.
- 23. Questions?
- 24. Thank You!
Editor's Notes
- {"16":"The Coverdell Stroke Program team will be working with those hospitals participating in the Coverdell program. We will be providing Outreach Educational Opportunities to work with EMS, ED and Stroke Coordinators to help establish Stroke Teamโs, EMS notification and activation prior to arrival, and working with the ED physicians to quickly evaluate the patient as they continue to the CT scanner without delay. \n","5":"Brief history of Coverdell:\n2001 Paul Coverdell National Acute Stroke Registry (PCNASR) was established by the CDC\nGeorgia Senator died while serving in Congress\nInitial three-year pilot study showed large gaps between national recommended guidelines and hospital practices. \n2004 Four states chosen to implement state-wide stroke registries: (GA, IL, MA, NC)\n2007 Increased number of participating states to six: (GA, MA, NC, MI, MN, OH) \nCollaborated with The Joint Commission & American Heart Association to adopt standardized stroke measure set. \n2012 Wisconsin chosen to receive funding. Eleven states participating in registry\nWI Dept of Health Services received the grant from the CDC\nIntroduce: Julie, Coverdell Program Director and \nContracted with MetaStar for QI portion:\nCathy and me\nPartners for implementation:\nKatie, AHA\nCDC funding for WI supports the toc between ems and hospitals. \nOne state Massachusetts received the total toc btwn. ems to hospital and hospital to improving access to rehab. and opportunities for recovery after stroke\nThe development of regional systems of care assists in the development of standardized transport protocols.\nBenefits for EMS:\nEnhance identifying stroke in the field by EMS\nImprove field pre-notifications from EMS to ED\nBenefits for hospitals:\n-Identify and recognize individual hospital capabilities \n-Provide evidence-based stroke care to improve stroke treatment rate\n-Identify an appropriate triage plan for referring hospital transfers\n","22":"Maintain patient privacy and confidentiality\n","17":"In WI, we looked at data from the Southeast and Southcentral regions. What we found is that not all services are using a prehospital stroke scale, or are not documenting the results if one is being used. The Cincinnati Stroke Scale is used more often than any other. \nDocumentation of the Last Known Normal/Well is not being captured in WARDS data at this time. We have asked the State EMS office to work with Image Trend to revamp the current stroke section. We want to be certain this is well documented and that we are able to show this when data is analyzed.\nOne of the newest recommendations from the American Stroke Association is to obtain a contact name and cell phone number of a witness to the event, and who could poitentially help determine the last known normal. \n","6":"Hospital registry and recruitment efforts:\nYear one goals (ended June 30th) is to have 20 hospitals\nGoal of 30 by June 2015\n","12":"Time from Patient Arrival to Stroke Team Activation\n","18":"When EMS is enroute to the ED, giving at least a 100 minute ETA is recommended. \nA radio report should include:\n-prehospital stroke scale results- reporting all abnormal results\n- call for activation of the stroke team\n- Whether an IV was established. ASA recommends an 18g when possible. However, NEVER delay transport of the stroke patient to establish an IV\n[next slide]\n","7":"Coverdell focuses on the transition of care between EMS and hospitals. The WI Coverdell Stoke Program offers QI assistance to participating hospitals in the form of educational opportunities, facilitating coordinator meetings, and re-abstraction processes to meet accrediting bodies recommendations. \n","13":"Time from triage (ED arrival) to initial imaging work-up for all patients who arrive < 3 hours from time Last Known Well\n","19":"- Last known normal time\n- anticoagulation medications they may take. Not every medication a patient takes needs to be reported over the radio\n- vital signs including level of consciousness and blood glucose\n-repeat the ETA so all parties are prepared for arrival\n","8":"Time-sensitive treatments\n","14":"Percent of cases of advanced notification by EMS for patients transported by EMS from scene.\n[Cathy next slides]\n","20":"The ASA recommends that EMS work toward these goals:\n-less than 10 minute on scene time. Most cares can be completed enroute instead of staying on scene\n- obtaining and reporting the prehospital stroke scale results\n- report the blood glucose\n- BP measurement\n- Providing at least a 10 minute pre-notification to the ED of arrival\n- working with the ED physician and staff to take the patient directly to the CT scanner for immediate scan\n[Dot next slides]\n","15":"What role does EMS play in stroke care? In WI less than 50% of patients suffering a stroke call 911. For those that do call, EMS plays a huge roll in a safe and effective transport to the appropriate hospital for care. Working with your local ED to establish a trusting relationship where EMS can call a stroke activation prior to arrival, utilizing the appropriate prehospital stroke tools and guidelines, and reporting Last known normal, Blood Glucose, and Cinncinnati stroke scale to the ED will help expidit care. \n","4":"Strategies:\n- EMS Pre-notification\n- Stroke Tools\n- Rapid Triage Protocol and Stroke Team Notification\n- Single Call Activation System\n- Transfer Directly to CT Scanner\n- Rapid Acquisition and Interpretation of Brain Imaging\n- Rapid Laboratory Testing (Including Point of Care Testing if Indicated)\n- Mix IV rtPA Ahead of Time\n- Rapid Access and Administration of IV rtPA\n- Team-Based Approach\n- Prompt Data Feedback\n","21":"Maintain patient privacy and confidentiality\n"}