King County EMS Stroke Quality Improvement Program

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Ashlee Reed
7 years ago
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1 King County EMS Stroke Quality Improvement Program A Report from the King County EMS Medical QI Section March 2012 Prepared by Sofia Husain, Jim Duren, and Norm Nedell OBJECTIVE The goal of the King County EMS Stroke QI program is to evaluate and improve upon the care provided to stroke patients in the pre hospital setting. We will also work with hospitals to obtain follow up information, including final diagnosis, treatment and outcome, on suspected stroke patients. These prehospital and hospital data will allow us to identify areas for improvement in pre hospital care. PROGRAM PLAN Over the last few months, KCEMS has been collaborating with a King County hospital to conduct a pilot of our Stroke QI Program. While encouraging, the results of the pilot, which are presented in this report, highlight areas for improvement in patient care. The pilot provides a strong impetus for establishing an ongoing clinical audit of pre hospital stroke patients. Going forward, we will collaborate with additional hospitals in King County and will expand our QI efforts to include all EMS patients who receive a final diagnosis of stroke in the hospitals. We intend on reviewing BLS and ALS Medical Incident Report Forms (MIRFs) and Computer Aided Dispatch (CAD) reports for these patients and we will emphasize complete documentation of patient care when a cerebrovascular accident (CVA) or transient ischemic attack (TIA) is suspected. We will evaluate CAD reports and MIRFs based on the following criteria: CVA/Stroke Protocol alerts are sent in all cases when dispatchers/call receivers suspect a stroke Complete documentation of vital signs blood pressure and heart rate in all cases Measurement and documentation of glucose levels in all suspected stroke patients ALS evaluation for all severely hypertensive (sys BP>200/diasBP>110), hypotensive (sysbp<90), or hyperglycemic (>300mg/dL) patients Documentation of all 4 components of the FAST exam (Face, Arms, Speech, and Time of last seen normal), listed individually, for all suspected stroke patients Documentation of call to hospital for all suspected CVA/TIA patients, even if transported by private ambulance A goal of on scene time of < 15 mins A goal of time from 911 call to hospital arrival of < 30 mins Focusing on these aspects of patient care will allow the entire KCEMS system to facilitate, when appropriate, rapid hospital initiation of care for stroke patients. Improving the provision of care to stroke patients in the pre hospital and hospital setting is an EMS priority.

We will also work with hospitals to obtain follow up information, including final diagnosis, treatment and outcome, on suspected stroke patients.

2 RESULTS OF THE PILOT The collaborating King County hospital reported 68 stroke patients who arrived via EMS from January to June Of those patients, 57 linked to King County patient records; the remaining were likely transported directly by private ambulance, without initiating a traditional EMS response. We reviewed BLS and ALS MIRFs and CAD reports for all 57 King County EMS patients. Study population Demographics of the 57 King County patients 58% female Median age = 72yrs; 68.5yrs for males; 74yrs for females 70% of incidents occurred at patients homes Summary of BLS and ALS MIRFs (Key points of interest are highlighted in red.) BLS MIRFs, n = 57 ALS MIRFs, n = 10 Documentation of blood pressure 55 (96%) 9 (90%) Hypertensive patients (sysbp>200/diasbp>110) 15 (27% of 55) 2 (22% of 9) o Received ALS evaluation 2 (13% of 15) Hypotensive (sysbp<90mmhg) 0 0 o Received ALS evaluation Documentation of glucometry 41 (72%) 5 (50%) Hyperglycemic (>300) 2 (5% of 41) 1 (20% of 5) o Received ALS evaluation 1 (50% of 2) Documentation of GCS 9 (90%) # of intubations 4 (40%) # of IV insertions 6 (60%) # of patients who received medications 4 (67% of 6) # of patients with 12 lead 3 (30%) Documentation of call to hospital 1 (2%) 6 (60%) Documentation of time to call 0 0 # of cases with Patient Type Code 234 or 238 or cases where 41 (72% of 57) 7 (70%) Assessment includes CVA/TIA # of cases with any documentation of FAST or any 39 (95% of 41) 7 (100% of 7) component of the FAST exam # of cases with documentation of Face 27 (66% of 41) 1 (14% of 7) # of cases with documentation of Arms 32 (78% of 41) 4 (57% of 7) # of cases with documentation of Speech 33 (80% of 41) 5 (71% of 7) # of cases with documentation of Time of last 38 (93% of 41) 7 (100% of 7) normal/onset # of cases with complete documentation of ALL components of FAST 23 (59% of 41) 1 (14% of 7)

We reviewed BLS and ALS MIRFs and CAD reports for all 57 King County EMS patients. Study population Demographics of the 57 King County patients 58% female Median age = 72yrs; 68.

3 BLS Patient Type Codes (pre hospital diagnosis by BLS) Frequency Percent 115 Trauma Head Closed internal injury Shortness of breath Seizure Syncope Headache Suspected CVA Decreased LOC Suspected TIA Other neurologic Dialysis problem Other alcohol/drug Fever / infection Other illness Total

8 234 Suspected CVA 34 59.6 236 Decreased LOC 4 7.0 238 Suspected TIA 4 7.0 239 Other neurologic 1 1.

4 Summary of CAD reports Initial Dispatch Codes Response Level Frequency Percent BLS Red IDCs ALS IDCs Upgrades 3 5 Medical Condition Frequency Percent Head/Neck OD/Poisoning Sick (unknown)/other Stroke Unconscious/Syncope Falls/Accident/Pain Breathing difficulty Cardiac arrest Chest pain Diabetic Stroke/CVA Protocol Alert Sent by Dispatch Number of incidents where Dispatch sent this alert to EMS prior to their arrival on scene = 17 Patient Transport Unit Frequency Percent ALS BLS Ambulance Unknown (not documented on MIRF) 1 1.8

5 Breathing difficulty 2 3.5 Cardiac arrest 1 1.8 Chest pain 2 3.5 Diabetic 4 7.

5 Summary of hospital data Final discharge diagnosis Ischemic stroke = 50 (88%) Intracranial Hemorrhage (ICH) = 6 (11%) Subarachnoid Hemorrhage (SAH) = 1 (2%) Description of the 50 ischemic stroke patients Number of patients who received IV and/or IA tpa = 10 (20% of 50 ischemic stroke patients) o Number of tpa patients evaluated by ALS = 0 o Transport: # of tpa patients transported by EMTs = 2 (20%) # of tpa patients transported by ambulance = 8 o FAST results for these tpa patients: Abnormal Face = 4 Abnormal Arms = 4 (+ 2 that talked about one sided weakness/weak grips) Abnormal Speech = 7 Documentation of time of last normal/onset = 9 Documentation of all components of FAST = 6 Time of last normal/onset based on pre hospital records: o <1 hr prior to 911 call = 21 (42%) o hrs prior to 911 call = 5 (10%) Response and Treatment Times (for all 57 patients, including 2 outliers with long hospital times) Time from First Unit Time from Call to First Unit On Scene to Call to Hospital Hospital Arrival to on Scene (min) Transport Start Time Arrival (min) CT (min) (min) Goal: 15 mins Goal: 30 mins Number of cases 55* Median Minimum Maximum * excludes 2 cases with an unknown on scene time excludes cases with unknown on scene times and those cases transported by ambulances excludes 1 case with an unknown hospital arrival time

2 (20%) # of tpa patients transported by ambulance = 8 o FAST results for these tpa patients: Abnormal Face = 4 Abnormal Arms = 4 (+ 2 that talked about one sided weakness/weak grips) Abnormal Speech

6 Response and Treatment Times (for 10 patients who received tpa) Time from First Time from Time from Time from First Call to First Unit On Scene to Call to Hospital Hospital Arrival Hospital Arrival Unit On Scene Call to IV tpa Unit on Scene Transport Start Arrival (mins) to CT (mins) to IV tpa (mins) to IV tpa (mins) (mins) (mins) Time (mins) Goal: 15 mins Goal: 30 mins Goal: 60 mins Goal: 90 mins Number of cases Median Minimum Maximum excludes cases transported by ambulances Final Discharge Disposition (of all 57 patients) Frequency Percent Home Hospice Home Hospice Health care facility Acute care facility Expired Left against medical advice Skilled nursing facility In patient rehab Total

mins Number of cases 10 2 10 10 10 10 10 Median 5.6 11.4 32.7 24.5 62.5 97.1 102.4 Minimum 4.2 10.2 28.0 15.0 48.0 74.6 79.2 Maximum 7.8 12.6 48.6 41.0 110.0 134.3 139.

STATE OF MAINE DEPARTMENT OF PUBLIC SAFETY MAINE EMERGENCY MEDICAL SERVICES 152 STATE HOUSE STATION AUGUSTA, MAINE 04333

STATE OF MAINE DEPARTMENT OF PUBLIC SAFETY MAINE EMERGENCY MEDICAL SERVICES 152 STATE HOUSE STATION AUGUSTA, MAINE 04333 PAUL R. LEPAGE GOVERNOR JOHN E. MORRIS COMMISSIONER SHAUN A. ST. GERMAIN DIRECTOR