REGIONAL STROKE TRIAGE PLAN

Transcription

1 1 REGIONAL STROKE TRIAGE PLAN Rappahannock EMS Council 435 Hunter Street Fredericksburg, VA Phone: (540) Fax: (540) Approved by Board of Directors: February 20, 2013

2 2 TABLE OF CONTENTS Executive Summary 3 Field Stroke Triage Decision Scheme 4 Guidance Materials 5 REMS Regional Patient Care Overview 6 Reperfusion Therapy Eligibility 8 Acute Stroke Patient Transport Considerations 9 Designated Stroke Centers 10 Inter-hospital Triage Considerations 11 Stroke Triage Quality Monitoring 12 Stroke Related Resources Appendix A Rappahannock EMS Stroke Guidelines 13 Appendix B EMS Stroke Alert Checklist 14

3 EXECUTIVE SUMMARY 3 Under the Code of Virginia , the Office of Emergency Medical Services, acting on behalf of the Virginia Department of Health has been charged with the responsibility of maintaining a Statewide Stroke Triage Plan. The Rappahannock EMS Council, Inc. (REMS) is responsible for establishing a strategy through a formal region-wide Stroke Triage System incorporating the regions geographic variations, variances within out-of-hospital providers capabilities and acute stroke care capabilities and resources including hospital capabilities and the capacity to transfer patients between community hospitals and tertiary care centers, such as Joint Commission certified Stroke Centers, or comparable process of care consistent with the recommendations of the brain attack coalition. The purpose of the Rappahannock EMS Council Regional Stroke Plan is to establish a consistent baseline of criteria for pre-hospital and inter-facility triage and transport of acute stroke patients with a goal to direct acute stroke patients to designated/primary stroke centers in a timely manner. The plan will identify formalized regional stroke plans to augment the state stroke triage plan to recognize and address variations with the regional EMS and hospital resources. This Regional Stroke Plan addresses patients experiencing an acute Stroke, defined as, a patient suspected of having an acute cerebral ischemic event or stroke with the onset of any one symptom within a three-hour period. The primary focus of this plan is to provide guidelines to facilitate the early recognition of the acute stroke patient and to expedite transport to a primary stroke center that is able to provide definitive care within the three-hour window; although acknowledgement of an extension of time beyond this may be appropriate in situations where advanced medical consult is available. The primary goal of the Rappahannock EMS Council Regional Stroke Plan is: To develop a Stroke Emergency Care System that, when implemented, will result in decreased stroke mortality and morbidity in the REMS Region. In order to accomplish this, a number of specific processes are essential. These are: 1. The ability to rapidly and accurately identify patients suffering from Stroke-like presentation. 2. Patients who have sustained an Acute Stroke event must receive care in a hospital that is a primary Stroke Center that is capable of providing immediate and comprehensive assessment, resuscitation, intervention, and definitive care. 3. The Rappahannock EMS Council must provide continuous and effective region-wide coordination of pre-hospital and hospital care resources, so Stroke patients will be most expeditiously transported to the closest available interventional center capable of performing stroke interventions, so patient care can be provided in a manner both appropriate and timely, while establishing and maintaining continuity. To accomplish this process there must be a method of tracking the care capability for Stroke patients and reviewing the quality of the process itself. 4. The regional plan must provide all hospitals in the region the opportunity to participate in the system (an inclusive system), and to receive Stroke patients if they are willing to meet the system and operational criteria, as established by this plan. 5. Provide quality EMS and patient care to EMS System citizens. 6. Continuously evaluate the EMS System based on established EMS performance measures for Stroke.

4 4 FIELD STROKE TRIAGE DECISION SCHEME Dispatcher suspects Acute Stroke (*) YES Attendant-in-Charge suspects Acute Stroke based on history and physical exam YES Assess blood glucose. Is Glucose greater than 60? NO Treat hypoglycemia YES Evaluate Cincinnati Pre-hospital Stroke Scale/FAST for acute onset of ONE or more positive findings upon exam YES NO Determine time of onset or time last known to be normal If 3 hours or less from onset of symptoms? Onset is uncertain or is more than 3 hours from onset of symptoms? Discuss case with on-line medical control as a potential acute stroke for assistance in destination determination and mode of transport (**) (*) See Appendix A for guidance regarding dispatch protocols / procedures. Non-stroke Center Rapidly initiate transport to Designated Stroke Center Make (**) effort If time to bring from witness symptoms or other onset individual is more able than to legally 3 hours, provide discuss case with on-line Medical Control as a consent potential for treatment acute stroke to hospital, treatment or at for a minimum, destination a phone determination (clot removal). Recall Interfacility that patients Triage and with Transfer number specific for acute the witness/consenting stroke types may benefit individual from intervention up to 24 hours, although the sooner an acute stroke is treated, the better the potential outcome. Based on patient time of onset and discussion with Medical Control, consider whether helicopter EMS will offer potential benefit to the patient, either in time to Designated Stroke Center, or for critical care management expertise. EMS does not determine whether a patient is excluded from Early any notification or all therapeutic of on-line options. medical Final control decisions regarding patient Provide eligibility care during for any transport given as intervention directed by will Protocols be or and/or determined Designated by the Stroke receiving Center physician(s). of patient with on-line medical control; complete a thrombolytic checklist if Acute Stroke presentation time permits

5 GUIDANCE MATERIALS 5 Cincinnati Pre-hospital Stroke Scale (CPSS / FAST) All patients suspected of having an acute stroke should undergo a formal screening algorithm such as the CPSS/FAST. Use of stroke algorithms has been shown to improve identification of acute strokes by EMS providers up to as much as 30%. Results of the CPSS/FAST should be noted on the pre-hospital medical record. ANY abnormal (positive) finding which is suspected or known to be acute in onset is considered an indicator of potential acute stroke. F-(Face) FACIAL DROOP: Have patient smile or show teeth. (Look for facial asymmetry) Normal: Both sides of the face move equally or not at all. Abnormal: One side of the patient s face droops or does not move. A-(Arm) MOTOR WEAKNESS: Arm drift (Have patient close eyes, extend arms, palms up for 10 seconds; if only leg is involved, have patient hold leg off floor for 5 seconds) Normal: Remain extended equally, drifts equally, or does not move at all. Abnormal: One arm drifts down when compared with the other. S- (Speech) Have the patient repeat, You can t teach an old dog new tricks (repeat phrase) Normal: Phrase is repeated clearly and correctly. Abnormal: Words are slurred (dysarthria) or abnormal (dysphasia) or none (aphasia). T-(Time) Time of SYMPTOM ONSET or LAST known to be NORMAL If patient awakened with symptoms, when were they last known to be normal? Results of the CPSS/FAST should be documented on the patient s pre-hospital medical record.

6 RAPPAHANNOCK EMS REGIONAL PATIENT CARE OVERVIEW 6 Cerebrovascular Accident (CVA and/or Transient Ischemic Attack - TIA) Introduction: Every minute 2 million brain cells die when a patient is experiencing a stroke. This is a time critical event which requires EMS to recognize and react to a patient that is presenting with Stroke/TIA like symptoms. Transient Ischemic Attack (TIA) with intermittent or resolved symptoms due to the risk of future stroke should follow the same REMS protocols as CVA. Signs and symptoms of Stroke/TIA include sudden onset of the following: (headache with Neurologic Deficit, difficulty speaking or understanding, sudden loss of vision, limb weakness or drift, loss of sensation on one side of the body, sudden onset of ataxia (limb un-coordination and/or difficulty walking). The patient with these symptoms is screened and identified by EMS using the Stroke Symptom Protocol (below), EMS Stroke Alert Process, Cincinnati Pre-hospital Stroke Scale that is included in the EMS Stroke Alert Checklist. REMS providers will provide rapid pre-hospital dispatch, assessment, transport, and management of the Stroke and/or TIA patient per the REMS Regional Stroke Plan as approved under the guidelines of the Virginia Stroke Triage Plan available at Purpose / Goal: The standard of Care for Rappahannock Emergency Medical Providers (REMS) is to minimize brain injury and maximize patient recovery. To accomplish this goal the Pre-hospital Provider is to optimize pre-hospital care by providing standardized EMS Stroke Care Protocols for patients with Stroke/TIA symptoms and provide expeditious transport. Perform Initial assessment: General Impression A-Airway Perform airway assessment while simultaneous assessing for signs of trauma. If patient has suspected trauma, perform airway assessment while protecting cervical spine stabilization and/or immobilization. If airway compromise is present, implement interventions per protocol to correct immediately, reassess, then continue with stroke protocol B-Breathing assess effectiveness If breathing compromise is present, implement interventions per protocol to correct immediately, reassess, and then continue with stroke protocol. C-Circulation assess for adequate circulation If circulation compromise is present, implement interventions per protocol to correct immediately, reassess, then continue with stroke protocol D- Disability Assess level of consciousness (AVPU) A-alert and responsive V-responds to verbal stimuli P-responds to painful stimuli U-unresponsive to painful stimuli Assess pupil size, shape, equality and reactivity to light Dilated pupils could indicate brain involvement. Assess for signs of trauma: Protect C-spine if indicated

7 Administer O2 per patient assessment Obtain full set of baseline vital signs (blood pressure, pulse rate, pupils and respiratory rate) Perform interventions to correct vital signs per protocol, and then continue with stroke protocol. Perform comprehensive physical/neurological assessment Complete EMS Stroke Alert Checklist (includes the Cincinnati Stroke Scale) Determine Transport Decision If symptoms < or equal to 3 hours transport to a Designated Stroke Center and contact Medical Control of the closest Designated Stroke Center to determine mode of transport ( ground vs. air). If ground transport time is greater than 30 minutes, consider air transport to the nearest Designated Stroke Center. (#1 below) If stroke symptoms > 3 hours or time uncertain contact closest Medical Control for assistance in destination determination and mode of transport. (* see #2) Immediate patient transport in position of comfort to the designated hospital Bring a witness or contact phone number for witness. Reassess and document Initial assessment Cincinnati Pre-Hospital Scale Vital signs Advise receiving hospital of any critical changes in patient presentation Keep patient NPO (nothing to eat or drink by mouth) Follow the Patient Care Protocol 7 The Commonwealth of Virginia defines a Designated Stroke Center as a hospital that has achieved Primary Stroke Center Certification by the Joint Commission. A current list of the Joint Commission Primary Stroke Centers that meet the definition of Virginia Designated Stroke centers is available at by entering the state of interest at If time from symptoms onset is more than 3 hours, or onset uncertain, discuss case with on-line medical control as a potential acute stroke for destination determination. Patients with specific acute stroke types may benefit from intervention up to 24 hours (i.e., clot removal), although the sooner the acute stroke is treated, the better the potential outcome. EMS does not determine whether a patient is excluded from any or all therapeutic options. Final decisions regarding patient eligibility for any given intervention will be determined by the receiving physician(s).

8 8 ACUTE STROKE PATIENT TRANSPORT CONSIDERATIONS Mode of Transportation: Consideration should be given to hospitals available to the region and the resources they have available to acute stroke patients. Stroke patients who meet any of the criteria of the Cincinnati Prehospital Stroke Scale/FAST, indicative of an acute stroke, shall be transported to the closest appropriate certified Stroke Center within a 3-hour time from symptom on-set; if the certified Stroke Center is within a 30-minute ground transport time. Stroke patients, not within 30 minutes ground transport time to a certified Stroke Center should be transported to the closest hospital, unless they can be delivered to a certified Stroke Center more rapidly by a HEMS service. Transport of acute stroke patients, as defined in this plan, by helicopter EMS (HEMS) should: 1. Significantly lessen the time from scene to a certified Stroke Center compared to ground transport. 2. Be utilized to achieve the goal of having acute stroke patients expeditiously transported to a Designated Stroke Center, within three hours of symptom onset; unless consultation with on-line medical control has occurred. 3. Be to non-stroke certified hospitals in very unusual circumstances and following consultation with on-line medical control. In general, if HEMS resource is used, the patient will be transported directly to a certified Stroke Center. NOTE: Any patient with a compromised airway or impending circulatory collapse must be transported to the closest hospital Emergency Department. Rapid Transportation: Because stroke is a time-critical event, time is of the essence, and EMS providers should initial rapid transport once acute stroke is suspected. Consideration should also be given to pre-hospital resources, including use of helicopter EMS (HEMS), available at the time of the incident, and other conditions such as transport time, road and weather conditions. Use of HEMS can facilitate acute stroke patients reaching certified Stroke Centers in a time frame that allows for acute treatment interventions. The likelihood of benefit of acute stroke therapy decreases with time, but there are several therapy options which offer definite benefit outside the standard 3-hour window; consultation with on-line Medical Control is STRONGLY encouraged in the situation of a patient being unable to arrive at a certified Stroke Center within the 3-hour window from symptom onset. NOTE: The use of the term rapid transport does not relieve the operator of the vehicle from exercising due regard, and should not be interpreted as requiring the use of red-lights and siren. Rather it is a reminder to reduce time on-scene to minimize out of hospital time.

9 DESIGNATED STROKE CENTERS 9 The Commonwealth of Virginia defines a Designated Stroke Center as a hospital that has achieved Primary Stroke Center Certification by the Joint Commission. The process of Stroke Designation/Certification is entirely voluntary on the part of the hospitals and identifies hospitals that have established and maintain an acute stroke program which provides a specific level of medical, technical, and procedural expertise for acute stroke patients. Designation ensures that the hospital is prepared to provide definitive acute stroke care at all times and has an organized approach to providing clinical care, performance improvement, education, etc. As of April 2, 2012, the current regional Stroke Designated Centers accessible with minimum delay in and near the Rappahannock EMS Council region are: Designated Stroke Centers Within REMS Designated Region: Mary Washington Hospital Fauquier Hospital Fredericksburg Warrenton Outside Area Stroke Centers/Hospitals Used By REMS Region Agencies: Bon Secours Regional Medical Center Mechanicsville Martha Jefferson Hospital Charlottesville Bon Secours Richmond Community Richmond Parham Doctors Hospital Richmond Bon Secours-St. Mary Hospital Richmond Retreat Doctors Hospital Richmond Chippenham Hospital Richmond University of Virginia Hospital Charlottesville Inova Alexandria Hospital Alexandria VCU Health Systems Richmond Inova Fairfax Hospital Falls Church Winchester Medical Center Winchester Inova Mount Vernon Hospital Alexandria Johnston Willis Hospital Richmond A current list of all The Joint Commission Primary Stroke Centers that meet the definition of Virginia Designated Stroke Centers is available at or by entering the state of interest at

10 10 INTERHOSPITAL TRIAGE CRITERIA Various hospitals meet many of the components of a Designated Stroke Center based on national survey results and would be the next logical choice. The closest hospital may not be the most appropriate hospital. Resource information via self-reported data on the level of acute stroke care provided by hospitals which are not Designated Stroke Centers is available at Non-stroke center hospitals within the REMS region must develop transfer guidelines and agreements in place for the expeditious and appropriate management of acute strokes when the care required exceeds their capabilities. This is especially critical for transfer of patients following thrombolysis since specific protocols must be followed by diminish the risk of cerebral or systemic hemorrhagic complications. The Rappahannock EMS Council does not presume to direct hospitals with regard to inter-facility transfer of patients.

11 STROKE TRIAGE QUALITY MONITORING 11 The Rappahannock EMS Council will report aggregate acute stroke triage findings on an intermittent basis, but no less than annually, to assist EMS systems and the Virginia Stroke Systems Task Force improve the local, regional and Statewide Stroke Triage Plans. A deidentified version of the report will be available to the regional agencies and will include, minimally, as defined in the statewide plan, the frequency of: (i) (ii) (iii) over- and under- triage to Designated Stroke Centers in comparison to the total number of acute stroke patients delivered to hospitals Helicopter EMS (HEMS) utilization EMS Benchmarks as identified annually The Rappahannock EMS Council Performance Improvement Committee will produce a report which will be used as a guide and resource. This report will have three primary evaluation areas: timeliness of care, treatment provided, and outcomes of care. The fields identified are critical to analyses for the following reason: they allow linking of EMS data and hospital Stroke data, they allow for real time collection of data focused upon process improvement, and they allow for retrospective systemic analyses. The ultimate goal of collecting this data is to provide actionable information, to the REMS Regional Stroke Committee and the REMS Medical Direction Committee, relative to the care processes and outcomes associated with their treatment of Acute Stroke patients as it relates to EMS. STROKE RELATED RESOURCES Virginia Stroke System Web page: Virginia Office of EMS Stroke Web page: Joint Commission:

12 APPENDIX A: RAPPAHANNOCK EMS STROKE GUIDELINE DISPATCHER Obtains Caller information Determines patient is having stroke like systems Determines patient meets criteria for Stroke Alert Dispatches appropriate pre-hospital resources EMS PROVIDER Performs initial assessment (ABCD) Assesses general impression of patient Administers oxygen per patient assessment Obtains full set of vital signs Perform and documents neurological exam Determines patient is a STROKE ALERT Determines appropriate receiving hospital Advises dispatch patient is a confirmed STROKE ALERT Dispatch gives immediate pre-notification to receiving hospital of STROKE ALERT (pre-notification information will only include STROKE ALERT and ETA) Bring witness or obtain witness information/contact # Initiate immediate transport of patient to appropriate hospital Patient STROKE ALERT report given to receiving hospital EMS provider will not delay transport for IV attempts Reassess patient and document on EMS Stroke Checklist Advises receiving hospital of any critical changes in patient presentation Keep patient NPO (nothing to eat or drink by mouth) Hand off of patient to hospital provider will include verbal report, EMS Pre-hospital Patient Care report, and EMS Stroke Alert Checklist. REMS defines Stroke Alert as a patient having signs or symptoms of stroke / TIA that include sudden onset of the following: Severe headache, difficulty speaking or understanding, visual impairment-loss of vision or double vision, limb weakness, loss of sensation on one side of the body, limb in-coordination, and/or difficulty walking.

13 APPENDIX B: EMS STROKE ALERT CHECKLIST 13 SYMPTOMS EMS STROKE ALERT CHECKLIST Date: What time did the symptoms start? (If the patient awoke with stroke symptoms, the time that the PT fell asleep is considered the onset time) Onset of Symptoms Witnessed By: Witness Contact Number: Severe Headache with Neuro Deficit Difficulty speaking or understanding Visual impairment (i.e. loss of vision/double vision) Limb weakness or drift Loss of sensation on one side of the body Sudden onset ataxia(i.e. limb un-coordination/ difficulty walking if abnormal Initial Reassess Does the patient have any of the above abnormal symptoms? Deficit not likely due to head trauma? Blood glucose greater than 60? Blood Glucose Result Time of onset less than 3 hours? If answer is YES to ALL of the above questions, CALL STROKE ALERT & TRANSPORT TO NEAREST STROKE CENTER EXAMINATION Pre-hospital Stroke Scale Level of Consciousness ( A V P U ) (Circle One) Speech (repeat "You can't teach an old dog new tricks") Facial Droop (show teeth or smile) Arm Drift or arm/leg weakness (close eyes and extend arms or leg) TPA EXCLUSION CRITERIA (PT may still be a Stroke Alert even if excluded from TPA) Recent (within 30 days) surgery or biopsy of an organ Recent (within 30 days) trauma with internal injuries or ulcerative wounds Recent (within 90 days) head trauma or prior stroke Any Active or Recent (within 30 days) hemorrhage Known hereditary or acquired hemorrhagic condition Terminal illness (such as end stage cancer, end stage HIV, or severe Alzheimer's Disease) Coma Seizure occurring concurrently with stroke symptoms Patient on anticoagulants (Coumadin, Heparin or Lovenox) Contact Nearest Primary Stroke Center per Regional Stroke Triage Plan Patient's Name/Age: EMS Signature: Date/Time: if abnormal Initial Reassess