Joey Araiza, RN, BSN LifeFlight Eagle

Presenter Disclosure Information Joey Araiza, RN, BSN VP Clinical Services LifeFlight Eagle Kansas City, MO Financial Disclosure: No relevant financial relationship exists No Disclosures

Introduction Background LifeFlight Eagle since 2007 Clinton, MO (Flight Nurse) Currently VP Clinical Services Community based Non-for profit Partner together with several agencies and facilities for several outreach education opportunities for the communities we serve (150 miles)

Objectives Chain of survival Talk about state (MO) requirements for transport/destination of stroke patients Goals of rapid identification and transport of stroke patients Challenges/Barriers Overcoming challenges/barriers Examples of solutions used to overcome barriers and case study proving!

Stroke Chain of Survival LinkAmerican Stroke Association 1. Rapid recognition and reaction to stroke warning signs 2. Rapid EMS dispatch 3. Rapid EMS system transport and pre-arrival notification to receiving facility 4. Rapid diagnosis and treatment in hospital Source- American Stroke Association

Time Critical Diagnosis System for Emergency Medical Care H-E-L-P: Helicopter Early Launch Process guidelines-consider if first response EMS is 20 min or greater from patient with the certain mechanisms or conditions: Stroke-Suspected inability to talk, difficulty speaking or paralysis on one side

Time Critical Diagnosis System for Emergency Medical Care Recent announcement of designated stroke centers Enforcement of statutes for EMS to follow for transport of patients to designated stroke centers (Department of Health & Senior Services, Bureau of Hospital Standards)

Overall Goals of Rapid Transport Expedite safe patient transfer to stroke center Decrease out-of-hospital time Provide highest level of clinical care possible Improve patient outcome Increase satisfaction: sending agency, receiving agency, and the patient

Challenges in EMS Inability to find out time of onset Inability to obtain past history/events prior to stroke Unresponsive patient-unwitnessed Financial concern for patients Patients want to stay in local communities Limited resources

Delay of Definitive Care The two biggest delays in the US are: Excessive time in rural ED Waiting for transportation (air or ground)

Reasons for Transfer Delays

Barriers to Timely Stroke Treatment Distance Education/knowledge of symptoms Lack/limited local resources Denial/atypical symptoms Financial

Overcoming Barriers and Challenges Air ambulance/ground Critical Care Transport options Outreach Education/community health fairs

Overcoming Barriers Air Ambulance-Ground Critical Care Bridging gap-advanced care-rapid Availability/locations Memberships/Insurance

Overcoming Barriers-Air Ambulance Transport Why Air? Transport times significantly reduced Times from outlying service area to receiving facility generally ½ to ¼ ground transport Early launch-as soon as possible-initial EMS call or receiving facility Consider time of day (heavy traffic) Case study-36 minutes to destination hospital (90 miles)

Overcoming Barriers-Air Ambulance Transport Advanced training Have several years experience (busy ALS transport, Critical Care) RNs and paramedics-advanced certifications, rigorous ongoing education and training Invasive Skills Labs, Simulation training, online ongoing training Must have advanced certification within 2 years of hire Equipment Flying Emergency Room and ICU Ventilator (included BiPap) Multiple IV drips Invasive Procedures (Needle decompression, intubation, pericardiocentesis, IO)

Overcoming Barriers Outreach Education Identify need/barriers Collaborate with referring agencies Design program to fit needs of requestor-partner with receiving agencies to provide comprehensive training and education

Overcoming Barriers Community Health Fairs Provide written/posted resources Mock drills Community health fairs/involvement

Early Recognition of Symptoms/Consideration of Transport History Numbness or weakness of face, arm, or leg, especially unilateral Confusion or difficulty understanding other people Difficulty speaking

Early Recognition of Symptoms/Consideration of Transport Visual disturbances Difficulty walking or balance/coordination issues Dizziness Severe headache Location of patient

Stroke Assessments Standard training for paramedics in stroke recognition=sensitivity of 61-66% for identifying patients with stroke Stroke Assessment tool (Cincinnati Prehospital Stroke Scale and/or Los Angeles Prehospital Stroke Screen) training for paramedics in stroke recognition=sensitivity of 86-97% for identifying patients with a stroke Source: Maggiore, W. A.

Enhancing Rapid transport- LifeFlight Eagle Need: identified in community-tcd patients (stroke)-specific county and or EMS Agency identified (need for training, no local hospital-closest non-tertiary facility at least 30 minutes-tertiary at least 90 by ground Collaboration: Local fire and EMS contacted, (or contacted us) for opportunity to provide education and training and identify a solution

Enhancing Rapid Transport- LifeFlight Eagle Design the Program Provided education and CEs to EMS/Fire on Stroke/TCD (identification, treatment, outcomes, evidence-based practices) Set pre-designated landing zones for rendezvous points LZ training completed with Fire/EMS

Enhancing Rapid Transport- LifeFlight Eagle Extensive training done in conjunction with receiving agencies to trim off minutes-enhanced processes Laminated maps and informational sheets with phone numbers, stickers for phones, stethoscope tags placed in hospitals and given to EMS

Enhancing Rapid Transport- LifeFlight Eagle Shaving off Time-Time is Brain Complete transfer sheet EMTALA form Patient in gown Remove jewelry Have patient void Let family know transfer will happen quickly

Enhancing Rapid Transport- LifeFlight Eagle Shaving off Time-Time is Brain Upon arrival of flight crew- Rapid assessment and obtain report Change IV drips over in helicopter Activate Code Neuro/Stroke rapidly at receiving (if not already aware) Require only EMTALA form Assist with obtaining an accepting physician if needed

Enhancing Rapid Transport- LifeFlight Eagle Mock drills with referring and receiving agencies (EMS/Fire/Hospitals) in real time

Case Presentation 0630- Calhoun, MO- patient M.J. wakes up, normal day.so far 0630-Odessa, MO-Deb, RN (Flight nurse) and Mike EMT-P (Flight Paramedic) report for their duty shift at LifeFlight Eagle 0650-, M.J. s Right side becomes flaccid and she encounters slurred speech

Case Presentation 0650-Odessa, MO-Flight crew is shiftbriefing with the pilot and checking the helicopter s equipment for the day s shift 0705- M.J. s Symptoms resolve 0705-Odessa, MO- Flight crew is continuing to inspect the helicopter and complete daily checklists

Case Presentation Approximately 0705-Calhoun, MO-M.J. s symptoms return and she cannot ignore them any longer, local EMS is summoned 0724-local EMS is responding to M.J. s residence and summons LifeFlight Eagle due to stroke-like symptoms and need for rapid transport

Case Presentation 0759-LifeFlight Eagle meets with local EMS ambulance and assumes care of M.J. 0844-LifeFlight Eagle arrives at destination hospital with M.J. 0850-M.J. arrives in Emergency Room and is becoming slightly confused (NIH 13)

Case Presentation Criteria met for IV tpa CT perfusion and angiography showed blocked M1 segment of left middle cerebral artery, and she went to IR for mechanical embolectomy-successful! Stent placed in left internal carotid Patient discharged to home and received 3 OT visits, life returned to normal

Case Presentation What if M.J. had waited to call? What if local EMS went by ground, local facility without needed resources? Window for IV TPA= up to 3-4.5 hours Window for intra-arterial tpa=up to 6 hours Window for mechanical clot retrieval=up to 8 hours

Team Approach It is very clear from listening to directors of successful programs that working closely with EMS providers (Air and Ground) is a key component to the enhancing positive patient outcomes of CODE Neuro/Stroke patients All about the patient!

References American Stroke Association. (2014). Chain of Survival. Retrieved from http://www.heart.org/heartorg/cprandec C/WhatisCPR/AboutEmergencyCardiovascula rcareecc/chain-of- Survival_UCM_307516_Article.jsp Maggiore, W. A. (2012, June 4). Time is brain in prehospital stroke treatment. Journal of Emergency Medical Services, 37(6). Retrieved from http://www.jems.com/articles/print/volume- 37/issue-6/patient-care/time-brain-prehospitalstroke-treatment.html

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