Edward P. Sloan, MD, MPH, FACEP

Stroke Patient Care in the Stroke Patient Care in the Prehospital and ED Settings:Prehospital and ED Settings:

Should EMS Triage & Should EMS Triage & Inter-hospital Transfer Occur?Inter-hospital Transfer Occur?

Edward P. Sloan, MD, MPH FACEP

44thth EuSEM Congress EuSEM CongressCrete, GreeceCrete, Greece

October 5-7, 2006October 5-7, 2006

Edward P. Sloan, MD, MPH FACEP

Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL

Edward P. Sloan, MD, MPH FACEP

Attending PhysicianEmergency Medicine

University of Illinois HospitalOur Lady of the Resurrection Hospital

Chicago, IL

Edward P. Sloan, MD, MPH FACEP

DisclosuresDisclosures

• NovoNordisk, King Pharmaceuticals, UCB NovoNordisk, King Pharmaceuticals, UCB Pharma Advisory BoardsPharma Advisory Boards

• Eisai Speakers’ BureauEisai Speakers’ Bureau

• ACEP Clinical Policies CommitteeACEP Clinical Policies Committee• ACEP Scientific Review CommitteeACEP Scientific Review Committee• Executive Board, Foundation for Education Executive Board, Foundation for Education

and Research in Neurologic Emergenciesand Research in Neurologic Emergencies

Edward P. Sloan, MD, MPH FACEP

Session ObjectivesSession Objectives

• Discuss if and when direct EMS triage to Discuss if and when direct EMS triage to specialized stroke centers should take specialized stroke centers should take place. place.

• Determine under what circumstances the Determine under what circumstances the inter-hospital transfer of ED ischemic inter-hospital transfer of ED ischemic stroke patients should take place when stroke patients should take place when specialized stroke patient care is desired.specialized stroke patient care is desired.

Edward P. Sloan, MD, MPH, FACEP

Key Clinical QuestionsKey Clinical Questions

• Should pre-hospital stroke patients be directly triaged by EMS to specialty stroke centers?

• When should the ED inter-hospital transfer of stroke patients to specialty stroke centers occur?

Edward P. Sloan, MD, MPH FACEP

Case Presentation…• 62 yo male brought in by paramedics62 yo male brought in by paramedics• Paramedics called due to left face, arm Paramedics called due to left face, arm

and leg “going dead” and slurred and leg “going dead” and slurred speech while eating breakfastspeech while eating breakfast

• On paramedic arrival, he has a facial On paramedic arrival, he has a facial droop, slurred speech and L droop, slurred speech and L hemiparesishemiparesis

• Should this patient go to the closest Should this patient go to the closest hospital or a specialized stroke hospital or a specialized stroke center?center?

Edward P. Sloan, MD, MPH FACEP

Case Presentation…• This patient is taken to the closest This patient is taken to the closest

hospital for immediate ED evaluation.hospital for immediate ED evaluation.• The patient is stabilized and a head CT The patient is stabilized and a head CT

is obtained. Should he go to a stroke is obtained. Should he go to a stroke center for continued care?center for continued care?

• Does this decision depend on whether Does this decision depend on whether or not IV tPA is administered?or not IV tPA is administered?

Edward P. Sloan, MD, MPH FACEP

Direct Stroke Pt TriageDirect Stroke Pt Triage

• What are “specialized stroke centers”?What are “specialized stroke centers”?• Why do these special stroke centers Why do these special stroke centers

impart improved patient outcome? impart improved patient outcome? • Will direct EMS triage to these centers Will direct EMS triage to these centers

improve patient outcome? improve patient outcome? • Can these same clinical competencies be Can these same clinical competencies be

made in all hospital comprehensive EDs?made in all hospital comprehensive EDs?• Which is the preferred approach? Why?Which is the preferred approach? Why?

Edward P. Sloan, MD, MPH FACEP

Stroke CentersStroke Centers• US Model via JCAHOUS Model via JCAHO• Joint Commission for the Accreditation of Joint Commission for the Accreditation of

Healthcare Organizations Healthcare Organizations • Designated as a Primary Stroke Center Designated as a Primary Stroke Center • Institutional commitment to the delivery Institutional commitment to the delivery

of the highest quality care to stroke of the highest quality care to stroke patients, including that provided in EDpatients, including that provided in ED

• As of October, 2006, there are 260 in USAs of October, 2006, there are 260 in US• 3 States designate separately3 States designate separately

Edward P. Sloan, MD, MPH FACEP

Tertiary CentersTertiary Centers

• Provide specialized careProvide specialized care• Often are university-affiliatedOften are university-affiliated• Treat the most complex medical casesTreat the most complex medical cases• Most are primary stroke centers or are in Most are primary stroke centers or are in

the planning processthe planning process• These tertiary centers often have These tertiary centers often have

capabilities beyond some hospitals that capabilities beyond some hospitals that are primary stroke centersare primary stroke centers

Edward P. Sloan, MD, MPH FACEP

Comprehensive Stroke CentersComprehensive Stroke Centers

• Highest level stroke patient careHighest level stroke patient care• Expected to be university-affiliated and/or Expected to be university-affiliated and/or

tertiary centerstertiary centers• Will provide 24/7 interventional radiology, Will provide 24/7 interventional radiology,

advanced diagnostics such as MRI, MRA, advanced diagnostics such as MRI, MRA, CTA and conduct extensive researchCTA and conduct extensive research

• Limited number, as with Level I traumaLimited number, as with Level I trauma• Unknown if direct EMS triage plannedUnknown if direct EMS triage planned

Edward P. Sloan, MD, MPH FACEP

Improved Outcome BasisImproved Outcome Basis

• Related to stroke care systems

• Often due to advanced nursing care and decreased stroke-related complications

• Reduced aspiration, DVT, infections

• May be related to increased rate of tPA use and/or fewer tPA complications, or from advanced therapeutics use

• The latter has not been demonstrated

Edward P. Sloan, MD, MPH FACEP

Direct EMS TriageDirect EMS Triage

• Trauma triage established in US

• Some cities now require EMS triage to stroke centers

• Will get stroke patients to stroke centers

• May negatively impact non-stroke centers

• Could lead to most hospitals becoming primary stroke centers, which is what is desired by the JCAHO & stroke advocates

Edward P. Sloan, MD, MPH FACEP

Acute ED CompetenciesAcute ED Competencies

• Rapid diagnosis and systems use

• Head CT interpretation quick, correct

• IV tPA use often assessed, used

• NINDS protocol successfully followed

• Comparable tPA effects and outcomes

• In other words, clinical effectiveness in the acute treatment of ED stroke pts

• Ability to transfer complex cases

Edward P. Sloan, MD, MPH FACEP

The Preferred ApproachThe Preferred Approach

• Majority of hospitals become stroke centers by any means possible

• Institutional buy-in to stroke patient care

• IV tPA use often assessed, used

• Clinical effectiveness in the acute treatment of ED stroke pts

• Limited need for transfer out of hospital

• Increased capacity for optimal care

Edward P. Sloan, MD, MPH FACEP

Key Clinical QuestionsKey Clinical Questions

• Should pre-hospital stroke patients be stroke patients be directly triaged by EMS to specialty directly triaged by EMS to specialty stroke centersstroke centers?

• No. Not if it is possible to increased competencies and capacity for excellence in stroke patient care, including acute ED care

Edward P. Sloan, MD, MPH FACEP

Inter-hospital TransferInter-hospital Transfer

• When help is needed, it is providedWhen help is needed, it is provided

• What can happen after IV tPA is provided? What can happen after IV tPA is provided? • What can happen if IV tPA is not used? What can happen if IV tPA is not used? • Should IV tPA be deferred for another Rx?Should IV tPA be deferred for another Rx?• Do long-term indications support transfer?Do long-term indications support transfer?• Which is the preferred approach? Why?Which is the preferred approach? Why?

Edward P. Sloan, MD, MPH FACEP

Providing Higher Level of CareProviding Higher Level of Care

• US standard: provide help when askedUS standard: provide help when asked• If you can’t provide care, another will If you can’t provide care, another will • Some problems with “financial triage”Some problems with “financial triage”• Some problems with “wallet biopsy”Some problems with “wallet biopsy”• Raises question of why not direct triageRaises question of why not direct triage• Interhospital transfer agreements commonInterhospital transfer agreements common• AMI & PCI: Poorer outcomes not seenAMI & PCI: Poorer outcomes not seen

Edward P. Sloan, MD, MPH FACEP

Providing Higher Level of CareProviding Higher Level of Care

• One example in Reno, Nevada in USOne example in Reno, Nevada in US• Central tertiary hospital (Hub) with 27 Central tertiary hospital (Hub) with 27

outlying hospitals that transfer (Spokes)outlying hospitals that transfer (Spokes)• Annual review of acute care and transfersAnnual review of acute care and transfers• Four man neurology group takes calls Four man neurology group takes calls

from all referring EDs, with teleradiologyfrom all referring EDs, with teleradiology• Telemedicine the next step, now in Boston Telemedicine the next step, now in Boston

area out of Harvard hospitals?area out of Harvard hospitals?

Edward P. Sloan, MD, MPH FACEP

Stroke Care After IV tPAStroke Care After IV tPA

• The following have not been The following have not been demonstrated to improve stroke patient demonstrated to improve stroke patient outcome after IV tPA:outcome after IV tPA:• Combination thrombolytic therapyCombination thrombolytic therapy• Mechanical interventions after IV tPAMechanical interventions after IV tPA

• It is likely that systematic care after acute It is likely that systematic care after acute care is superior, but this should be able care is superior, but this should be able to be provided in most hospitalsto be provided in most hospitals

Edward P. Sloan, MD, MPH FACEP

Therapies Other Than IV tPATherapies Other Than IV tPA

• Merci device is FDA approved for clot Merci device is FDA approved for clot retrieval, but not standard of careretrieval, but not standard of care

• Why? It is surgical device, not a Why? It is surgical device, not a therapeutic therapeutic

• It therefore is approved for use but not It therefore is approved for use but not able to be used by all operators, hospitals able to be used by all operators, hospitals

• All other additional therapies experimentalAll other additional therapies experimental• Are advanced diagnostics therapeutic in Are advanced diagnostics therapeutic in

that they lead to other therapies? This is that they lead to other therapies? This is unknown.unknown.

Edward P. Sloan, MD, MPH FACEP

Should IV tPA Be Deferred?Should IV tPA Be Deferred?

• No. IV tPA should ever be deferred when No. IV tPA should ever be deferred when indicated and able to be provided in a indicated and able to be provided in a clinically effective, safe manner.clinically effective, safe manner.

• When IV tPA can be provided in a referring When IV tPA can be provided in a referring hospital, it should be given expeditiouslyhospital, it should be given expeditiously

• This is not a rationale for inter-hospital This is not a rationale for inter-hospital transfer transfer

Edward P. Sloan, MD, MPH FACEP

The Preferred ApproachThe Preferred Approach

• All EDs provide IV tPA when indicated• Transfer agreements for acute care or

continued care if necessary• Conduct research that answers the

important questions of advanced diagnostics and therapeutics, including mechanical devices

• Determine over time how care should be divided up as the pie grows bigger

Edward P. Sloan, MD, MPH FACEP

Key Clinical QuestionsKey Clinical Questions

• When should the ED inter-hospital transfer of stroke patients to specialty stroke centers occurcur?

• Inter-hospital transfer should occur when it is apparent that advanced care is needed and/or that this advanced care is demonstrated to improved stroke patient clinical outcomes

Edward P. Sloan, MD, MPH FACEP

ConclusionsConclusions

• Specialty care centers raise the bar

• Need to assess best outcomes and best use of resources

• Research will answer important questions

• Stroke care will improve

• Lessons can be learned from

EU models of care

Edward P. Sloan, MD, MPH FACEP

RecommendationsRecommendations

• Maximize the use of IV tPA

• Get buy-in for optimal stroke pt care

• Know when and how to transfer

• Study effectiveness locally

• Conduct multi-centered research (NETT)

• Continue to explore best approaches

Edward P. Sloan, MD, MPH FACEP

Questions?Questions?

www.FERNE.org

edsloan@uic.edu 312 413 7490

ferne_eusem_2006_sloan_emstfer_100606_finalcd04/18/23 15:22