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  • 1. EMS & Stroke NECC Peter Moyer MD,MPHMedical Director Boston EMS, Fire and Police 9/13/06
  • 2. • No financial interests to disclose
  • 3. EMS –key and underappreciated role in stroke• Stroke recognition by stroke victim and use of EMS <50%• Stroke Recognition at dispatch and in field• Recognition of hypoglycemia as stroke mimic• Thrombolytic contraindication check list• Transport –by air or ground- within 2 hours of symptom onset to stroke center• Pre arrival Notification to hospital
  • 4. EMS-Current State• IOM’s “EMS at the Crossroads” (2006) EMS underfunded -after initial start up funds in 70’s little subsequent federal $ -average salaries: EMT $18 K Paramedic $34 K -to date have received 4% of federal public safety (Fire, Police and EMS) antiterrorism $
  • 5. • IOM-cont. -EMS has no single national lead agency -variability of structure: 45% are Fire based (in cities its 80%);rest a combination of volunteer, private, hospital based and 3rd municipal service -variability in training: last national EMT training curriculum standard - 1994
  • 6. • IOM cont. EMT’s considered second class citizens in both public safety and medicine
  • 7. • IOM cont. new challenges : -emergency preparedness -emergency department overcrowding, diversions, closings -transport to newly defined specialty centers (stroke and STEMI in addition to trauma)
  • 8. EMT/Paramedics & Stroke priority dispatch medical oversight training monitoring feedbackregionalization of care
  • 9. EMT text• Brady’s Prehospital Emergency Care(2004): -refers to stroke as “brain attack” -refers to AHA ‘s 7D’s noting that first 3-Detection , Dispatch and Delivery- belong to EMS -describes Cincinnati and LA stroke scales noting importance of obtaining a sugar -notes importance of delivering patient to hospital within 2 hours
  • 10. Paramedic text• Mosby’s paramedic textbook (2005): covers same plus management of -hypertension -seizures -compromised airway
  • 11. Mass stroke Point of Entry Plan• EMS operational definition of acute stroke: Presence of symptoms < 2 hr duration (or since last seen at baseline) according to the Boston Stroke Scale (BOSS) or other concerning neurologic signs consistent with stroke. Other• neurologic signs include:• • sudden onset dizziness with inability to walk • double vision and eye movement abnormalities • weakness affecting the leg• 1• Following the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke, establish a diagnosis of possible acute stroke based• on BOSS scale (Protocols Appendix Q)• 2. Establish time of onset and last time seen at baseline 3. If stroke symptoms present and time from onset of symptoms to hospital arrival will be < 2 hours, transport patient to nearest• appropriate IDPH-designated Primary Stroke Service (PSS)• 4. Notify receiving facility as early as possible
  • 12. Massachusetts Department of Public HealthOffice of Emergency Medical Services Stroke Point of Entry
  • 13. PurposeTo provide EMTs with the fundamentalknowledge needed to recognize andmanage potential stroke in the pre-hospitalsetting and make appropriate transportand hospital notification decisions basedon the Stroke POE Plan. Photo source: UMass Memorial LifeFlight
  • 14. Objectives• Identify the two major categories of stroke• List common signs & symptoms of stroke• Provide several risk factors for stroke• Explain the importance of rapid stroke therapy• Describe pre-hospital assessment and care, including the BOSS and thrombolytic checklist• Describe the MA and Regional Stroke POE plan• Discuss appropriate treatment and transport modalities• Describe detailed stroke documentation
  • 15. Boston EMS• Stroke is dispatched as a priority 1, EMT call typeAPCO(a proprietary dispatch algorthym)- after determining patient is breathing and conscious, caller is asked if patient acting normally; if answer is no, asked if “new onset of one sided weakness, paralysis or inability to speak” ~ 50% sensitive
  • 16. RTQI- SYSTEM PERFORMANCE EVALUATIONS/AUDITS Boston EMS September 2005 CASES B.O.S.S.•43 of 50 cases had B.O.S.S. neuro 50 EXAMexam (86%) 50 43 21 of 50 had blood glucose 40 BloodDocumented (42%) Glucose Stroke 30 21 1 case documented a pre-hospital Symptomology 20notification 10 All but 1 case went to a BostonStroke Center 0 1 2
  • 17. Monthly Act on issues &Performance Review Implement training Reassess
  • 18. Following up on the NeuroSeptember Stroke results, 100% GlucoseRTQI In–service training for Stroke ImpOctober focused on the areas 80%where we saw need for Notify 60%improvement. 40%•Documentation of Stroke asan Impression. 20%•Obtaining a blood glucose 0% 1•Notification to the E.R. Stroke Imp 82% Results in Neuro 100% November 2005 Glucose 92%Showed improvement Notify 57% In all categories