Paramedic System of WisconsinTundra Lodge

September 18-20, 2013

Dot Bluma, RN Cathy Etter, BSN, CCEMT-PQI Stroke Specialist EMS QI Consult

MetaStar, Inc.www.metastar.com

Objectives

• 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 pre-hospital 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

Statistics

• 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

Target Stroke

American Heart/American Stroke Associations •Best Strategy Practices inception in early 2010•Target Stroke Goal:

At least 50 percent of patients receive IV tPA in 60 minutes or less → “The Golden Hour”

Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Target-Stroke_UCM_314495_SubHomePage.jsp

Coverdell Objectives

Right Care at the Right TimeCoverdell focuses on the continuum of patient care:•Support development of stroke systems of care •Eliminate disparities in care•Decrease rate of premature death and disability•Measure, track, and improve the quality of stroke care

Coverdell Goals for Wisconsin

• Develop statewide Stroke Systems of Care• Build a hospital stroke registry• Support hospital education and quality improvement• Support EMS education and quality improvement

Acute Stroke Care

“Time is Brain”•Timing and a fast response are critical•A stroke is a brain attack where time lost is brain lost!•During 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.

Emergency Room Care

Treatments•IV tPA within 3 hours; up to 4.5 hours for certain eligible patients•Endovascular procedures in carefully selected patients

– IA tPA– Mechanical Devices

Jauch et al, 2013. Stroke. Early Management of Acute Ischemic Stroke; 44:870-947.

Mode of Arrival to Hospital Q1 & Q2 2013

This Get With The Guidelines® (GWTG) Aggregate Data report was generated using the Outcome™ PMT® 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).

Emergency Room Care

Emergency Room Care of the Acute Stroke Patient Team Based Approach

• ER Physician• ED RN• Stroke Team• Radiology Department• Lab• Neurologist

• Radiologist• Pharmacy• Neurosurgeon• Physician Extenders (NP,

PA)• Interventional Radiology

Team

Emergency Room Best Practice Strategies

• Door to physician ≤ 10 minutes• Door to stroke team ≤ 15 minutes• Door to CT initiation ≤ 25 minutes• Door to CT interpretation ≤ 45 minutes• Door to drug ≤ 60 minutes• Door to stroke unit admission ≤ 3 hours

Jauch et al, 2013. Stroke. Early Management of Acute Ischemic Stroke; 44:870-947.

ED Arrival 2 hours from LKW Q1 & Q2 2013

This Get With The Guidelines® (GWTG) Aggregate Data report was generated using the Outcome™ PMT® 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).

ED Arrival 3 hours from LKW Q1 & Q2 2013

This Get With The Guidelines® (GWTG) Aggregate Data report was generated using the Outcome™ PMT® 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).

ED Arrival 2 hours from LKW Q1 & Q2 2013

This Get With The Guidelines® (GWTG) Aggregate Data report was generated using the Outcome™ PMT® 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).

Pre-notification

Stroke EMS Best Practice Strategies

• EMS Pre-notification– Priority Dispatch

• Stroke Tools – Protocols, Guidelines, Stroke Scales

• Rapid Triage Protocol – < 10 minute scene time– Blood Glucose monitoring– Blood Pressure measurement

Stroke EMS Best Practice Strategies

• Single Call Activation– Activate Stroke Team

• Transfer Directly to CT – Depends on patients stability– Airway management

Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Target-Stroke_UCM_314495_SubHomePage.jsp

On Scene Care

• Pre-Hospital Stroke Scale─ Cincinnati or FAST

─ Face─ Arm─ Speech

• Last Known Normal/Well Time─ Wake up impaired?

• Contact Name and Phone Number─ Who saw them last?

Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Target-Stroke_UCM_314495_SubHomePage.jsp

EMS Report to ED

• Signs/Symptoms of Stroke– Pre-Hospital Stroke Scale Results

• ETA– Early notification is vital

• IV 18g– Do NOT delay transport

• Additional Complaints/Information

EMS Report to ED

• Last Known Normal/Well Time• Medications– Anticoagulants are important

• Vital Signs– Blood Pressure– Blood Glucose

• Repeat ETA

Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Target-Stroke_UCM_314495_SubHomePage.jsp

EMS Goals

Less than 10 minute scene time Pre-Hospital Stroke Scale Reported Blood Glucose checked Blood Pressure measurement reported Early ED notification Direct to CT whenever possible

Hospitals & EMS: Improving Stroke Care

• Develop Quality Improvement Committee– Routine Quality Improvement review– Partner to share patient outcomes, review cases, and data– Timely feedback from ED– Review with all staff involved– Address any delays in transport– Discovery of learning opportunities

• Member recognition for a job well done• Continuing Education in stroke care– Mock stroke codes

Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Target-Stroke_UCM_314495_SubHomePage.jsp

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.

Questions?

Thank You!