A Brief History of EMS And Why Stroke Patients Should Care

Transcription

1 A Brief History of EMS And Why Stroke Patients Should Care David Ghilarducci MD FACEP

2 A History of EMS in The US 1860s through the 1940s Hospital and volunteer based Physician staffed

3 A History of EMS in The US

4 A History of EMS in The US Approximately 50 percent of the country s ambulance services are provided by 12,000 morticians, mainly because their vehicles can accommodate transportation on litters.

5 A History of EMS in The US

6 A History of EMS in The US 1970s Paramedics introduced Seattle, Miami and LA County

7 Organization Public Municipal or County Fire Department Third Service Private/For Profit

8 Models for EMS Delivery Anglo-American vs Franco-German

9 Qualification Levels EMR EMT AEMT Paramedic RN

10 Medical Control Off Line Written policies and procedures On Line Real time radio or telephone contact

11 Innovations EMS Management of Stroke

12 3 EMS Stroke Goals 1. Rapidly Identify 2. Choose Best Destination 3. Facilitate Rapid Treatment Lancet 2004;363:768-74

13 Goal #1 Rapid Stroke Identification Dispatcher screening Call taking protocols Rapid processing and dispatch Immediate EMS response Field screening CPHSS, LAPSS, MENDS Minimal scene times (<15 minutes)

14 Figure 1. Total EMS response times among US counties. Times displayed are estimated, as the NEMSIS database does not contain county level data. To generate this figure, we determined the Census Division and urbanicity of each county. We then calculated the median total EMS response time in each Census Division stratified by urbanicity, and assigned the median time to each county. Published in: Jennifer Schwartz; Rachel P. Dreyer; Karthik Murugiah; Isuru Ranasinghe; Prehospital Emergency Care 2016, 20, DOI: / Copyright 2016 Taylor & Francis Group

15 Stroke 2010; 41:

16 Prehospital Stroke Scale Accuracy Neurology 2014;82:

17 Telemedicine Stroke. 2014;45:

18 Goal #2 Determine Appropriate Destination Factors Time Last Normal Severity (Large or Small) Hospital Capability Local Protocol Availability of Rapid Interfacility Transfer Geography, Weather, Traffic

19 Destination: Time Time Last Normal Is LKN within IV tpa window? Is LKN outside reasonable endovascular window?

20 Destination: Hospital Capability Where is the Closest source of IV tpa (ASRH, PSC or CSC) Bypass nearby stroke center to get to a CSC? If yes, how much additional delay is acceptable?

21 Guiding principles for field triage of patients with suspected acute stroke. Randall Higashida et al. Stroke. 2013;44: Copyright American Heart Association, Inc. All rights reserved.

22 Destination: Local Protocol Do off line medical control protocols allow for redirection to a stroke center?

23 EMS Stroke Protocols In California LEMSA Use of a stroke scale Type of stroke scale ELVO scale Alameda County EMSA Yes CPSS No Central California EMSA No N/A No City and County of San Francisco EMSA Yes CPSS No Coastal Valleys EMSA Yes CPSS No Contra Costa County Yes CPSS No El Dorado County EMSA Yes CPSS No Imperial County EMSA Yes LAPSS No Inland EMSA Yes Modified LAPSS No Kern County EMSA Yes CPSS No Los Angeles County EMSA Yes mlapss No Marin County EMSA Yes CPSS No Merced County EMSA No N/A No Monterey County EMSA Yes BEFAST No Mountain Valley EMSA Yes CPSS No Napa County EMSA Yes CPSS No Northern California EMSA Yes CPSS No North Coast EMSA No Motor, speech, aphasia, headache, visual problems altered mental status No Orange County EMSA No No seizure, <7 hrs, GCS 10 or greater, and pronator drift or facial paresis No Riverside County EMSA Yes CPSS No Sacramento County EMSA Yes CPSS No San Benito County EMSA Yes CPSS No San Diego County EMSA Yes CPSS No San Joaquin County EMSA Yes CPSS No San Luis Obispo County EMSA Yes FAST No San Mateo County EMSA Yes CPSS No Santa Barabara County EMSA Yes CPSS No Santa Clara County EMSA Yes BEFAST Santa Cruz County EMSA Yes CPSS No Sierra-Sacramento EMSA Yes CPSS No Solano County EMSA Yes CPSS No Tuolumne County EMSA No Weakness or paralysis, slurred speechbalance, inability to understand, difficulty in naming objects, confusion, difficulty swallowing, headache, visual disturbances (double vision, blindness, paralysis of No extra-ocular muscles) Ventura County EMSA Yes CPSS No Yolo County EMSA Yes CPSS No West J Emerg Med Mar; 17(2):

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25 Destination: Interfacility Transfer (IFT) Are systems in place for rapid transfer between PSC and CSC? Helipad 911 resources Does local SOP allow paramedics to monitor IV tpa infusions? If not, then built-in 1 hour delay

26 Destination: Geography, Weather, Traffic Geography and Traffic Tradeoff: Longer drive times to a CSC will delay IV tpa that could be provided at a closer PSC or ASRH Weather can affect helo availability Some hospitals have GPS approach helipads with lower weather minimums

27 Destination: Stroke Severity Scales Emergency Large Vessel Occlusion (ELVO) Prehospital Scales LA Motor Scale (LAMS) Rapid Arterial Occlusion Evaluation (RACE) NIHSS LEGS 3I-SS

28 Figure. Receiver operating curve showing specificity (asterisks) and sensitivity (open circles) of LAMS Scores in predicting persisting large vessel occlusion. Receiver operating curve showing specificity (asterisks) and sensitivity (open circles) of LAMS Scores in predicting persisting large vessel occlusion. Bijen Nazliel et al. Stroke. 2008;39: Copyright American Heart Association, Inc. All rights reserved.

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30 Stroke. 2014;45:87-91

31 False-Negative Rate, False-Positive Rate, and Accuracy of Published Cutoffs for Various Clinical Scores to Predict Large-Artery Occlusion Stroke 2016;47:00-00

32 Goal #3 Facilitate Rapid Hospital Treatment Pre-notification Helsinki Protocols Mobile Stroke Units Bring the hospital to the patient Prehospital BP Management

33 Rapid Treatment: Pre-notification Reduces DTN Improves treatment rates

34 EMS Pre-Notification Rates Lin et. Al. J Am Heart Assoc August; 1(4)

35 Pre-notification Increases TX rate JAMA Neurol. 2013;70(9):

36 Tuukka Puolakka et al. J Am Heart Assoc 2016;5:e002808

37 Pre-notification Reduces DTN Circ Cardiovasc Qual Outcomes. 2012;5:

38 Brain and Behavior, 2015; 5(10)

39 Rapid Treatment: Helsinki Protocol Reduces DTN by 25 Minutes 1. Ambulance Pre-notification 2. EMS Gurney to CT Scanner 3. tpa delivered in CT Suite directly after imaging Neurology Sep 17;81(12):1071-6

40 Rapid Treatment: Mobile Stroke Unit Franco-German Model of EMS Bring the hospital to the patient

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42 Expert Rev Cardiovasc Ther. 2015; 13(9):

43 Expert Rev Cardiovasc Ther. 2015; 13(9):

44 Other Possibilities for MSU Screening for ELVO Triage for AIS and ELVO Additional Imaging for Selecting IA candidates Triage for ICH/SAH Head Trauma

45 Financial Considerations Santa Cruz County California Costs for an MSU Startup $633,000 2 Ongoing $79,000 or $216/day 2 Staffing costs at $180/hr = $4320/day EMT + Advanced Practice Nurse = $180/hr Daily cost = $4536/day Cost per call Stroke 1.4% of all EMS calls or 1.3/day Cost per Call = $3489/call Reimbursement Medi-cal (California Medicaid) = $117/call Medicare = $690/call Commercial = $1000 Net Loss Per Call $2589 to $ Clinicoecon Outcomes Res Feb 23;8: Stroke. 2015;46:

46 Outcomes of pre-hospital thrombolysis Lancet Neurol 2016; 15:

47 Rapid Treatment: Prehospital HTN Am J Emerg Med Jul;34(7):

48 Questions