Innovations in Stroke Care: the Big Picture for EMS

EMS Stroke CareSaving Patients’ LifesbyRommie L. Duckworth, LP

The Problem of StrokeStroke is the leading cause of disability. 20% Institutionalized within 3 months. Approx. 25% die within 1 yr of 1st stroke.Stroke is 3rd 4th leading cause of death.

Target Stroke: Acute Care & EMS The sooner that rt-PA is given to stroke patients, the greater thebenefit, especially if started within 90 minutes of symptom onset.

The Connecticut Plan Stroke Prevention and Care Goals• Plan Goal: To create a coordinated system of stroke care and prevention in which it is possible for every Connecticut resident to access appropriate and timely care for optimal post stroke outcomes. A coordinated care system involves EMS, hospital stroke teams, specialized stroke units (where applicable), and standardized care protocols.• Emergency Medical Services (EMS): To facilitate timely access to EMS care, enhanced pre-hospital recognition and treatment, and rapid transport to the appropriate health care facility of patients experiencing a stroke event.

Stroke Center Designation

Stroke Center DesignationTrauma JCAHO CT NY VA TXLevel I CSC Level I I CSCLevel II PSC PSC DSC Level II II PSC Level ASRH Level III SSF III ED III Level Level IV IV

Connecticut and Surrounding PSCs

Why Not Better?

GOOD ENOUGH

Improving Stroke Care THE THE THE THE THE SWEETPROBLEM GOAL PATH RESISTANCE SUPPORT VICTORY

4 Steps for EMS

The Stroke ProcessIschemiaInfarctPenumbra

Cerebrovascular System

Types of Stroke

Stroke AssessmentAt the door

Stroke AssessmentAt the Bedside S - Sudden Onset, Hemiparesis, Focal Neuro Def. A – Aw, who cares! M - Coumadin, HTN, antiepileptics P - Stroke, Seizure, aneurysms, HTN, Mimics… L - Last Seen Normal E - Prior similar episodes, MI, Trauma, Surgery… V/S - Elevated B/P, Low Pulse, Low Resp, Glucose

Stroke Assessment Holding HandsCincinnati Pre Hospital Stroke Scale CPSS• SMILE• ARM DRIFT• PHRASE• Any Positive = greater than 70% chance stroke.Other Pre Hospital Stroke Scales• LAPSS• MEND

Stroke Assessment• Common Stroke Mimics Diff. Dx. • Hypoglycemia • Migraine – ABGT / Better w/Glucose – Past Hx. • Tumor – Photosensitivity – Slow & progressive onset • Head Injury • Abscess – Recent Trauma – Slow & progressive onset • Subdural • Seizure – Previous Trauma – Staring, Aura or shaking • Bell’s Palsy • OD / ETOH – Past Hx. – Acute Hx.

Stroke Assessment

Stroke Assessment• Won’t they just catch it in the ED anyway? – If stroke is missed by EMS… • Longer transport time. • Lower priority in the ED. • No EMS pre-notification = No ED Prep. • Longer time to CT scan = Missed Tx Opportunity. • Potentially missed altogether. • One Shoe!

In-Hospital Care • CT Scan in 30 minutes • CT Reader with CVA ExperiencePrimary • • Stroke team to patient in 15 minutes Physician experienced with TPa and NIHSS Stroke • • Door to Needle time <60 minutes Neurosurgeon with stoke experience <2 hours • Neurologists+ on callCenters • • Diagnostics such as MRI, CT Angiography, etc. Interventional capabilities incl IATPa • Neuro Rehab capabilities

ICH Management• Hemorrhage – ABCs – Seizure Prevention – BP Management – BS Management – Surgery

Thrombolytics• TPa – Systemic – 3-4.5 hours – off-label – At 1 hr is 3x as effective as at 3 hrs• IA-TPa – Delivered Directly – 6 hours – off-label – Earlier is better

Surgical Options

Best Practices THE BRAIN ATTACK COALITION

Best Practices: IDENTIFY• Decrease Time To 911 • Assure Correct EMS Notification Resources – Primary Education – Closest First Response• Prioritize EMS Dispatch – Closest Transport – Standardized Protocols – ALS – Sense of Priority • E911 Coverage – Consolidation of PSAPs – NG911 Coverage • Better Standardization • Single-Call 911

Best Practices: TRIAGE-IFY• Triage To Best Destination – Standardized Protocols – Local Implementation • State • Can Vehicles Leave • Regional Response District • Local • Patient Preference • Provider Preference – Education • Emphasis On Dx, Not Just Speed. • ED Interface Staff Feedback

Best Practices: NOTIFY• Correctly Identify Stroke In The Field – Validated Stroke Scores • Aggregate Data To • Sense of Priority Facilitate ED Diagnosis• ED Pre-Notification – Validated Assessments – Standardized “Code – Receipt of Assessments Stroke” – Telemedicine – Receipt of “Code – NEMSIS Stroke” – QA/QI

Best Practices: CARE-IFY• Extend The Time Frame • Reduce The Distance – Standard Supportive – Increase Accreditation Care of Hospitals as CSC, PSC, – Emerging Tx ASRH • EMS • Formal Accreditation – Field Admin of T-PA • “Survey” Stroke Centers – Therapeutic Hypothermia • Telemedicine • Hospital – IAT-PA – Clot Retrieval

Best Practices: Interfacility Transport• Transfer to Primary Stroke Centers• Prior Transport Arrangements• Critical Care Training• VS and NS q 15 minutes post tPA Admin

Questions

4 Steps for EMS

GOOD ENOUGH IS NOTGOOD ENOUGH

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Innovations in Stroke Care: the Big Picture for EMS

by Rommie Duckworth

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Innovations in Stroke Care: the Big Picture for EMS Presentation Transcript