Developing a Dynamic Team Approach to Stroke Care. Emergency Medical Services 2015

Developing a Dynamic Team Approach to Stroke Care Emergency Medical Services 2015

Why Stroke, Why now? A recent study showed that 80 percent of people in the United States live within an hour s drive of a hospital able to treat stroke Of those 80 percent only 4 percent get recommended treatment (Either tpa or endovascular therapy) Every 15 minute delay in getting treatment increases the odds of that patient not being able to go home Treatment is the most successful if given in the first 90 minutes of onset We looked at our data and we did not like what we discovered

Improving Door to Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Association s Target: Stroke Initiative Gregg C. Fonarow, MD; Eric E. Smith, MD, MPH; Jeffrey L. Saver, MD; Mathew J. Reeves, PhD; Adrian F. Hernandez, MD, MHS; Eric D. Peterson, MD, MPH; Ralph L. Sacco, MD; Lee H. Schwamm, MD Stroke. 2011;42:00 00

Target: Stroke Target: Stroke is a national quality improvement campaign of the American Heart Association/American Stroke Association designed to improve outcomes for ischemic stroke patients by helping hospitals achieve door to needle (DTN) times of 60 minutes or less. By participating in Target: Stroke, hospital teams can work towards eliminating delays in treating stroke patients, with the ultimate goal of improving clinical outcomes.

In a Typical Acute Ischemic Stroke, Every Minute Until Reperfusion the Brain Loses: 1.9 million neurons 14 billion synapses 7.5 miles myelinated fibers Saver, Stroke 2006

Door To Needle Times 200 180 160 140 120 100 80 60 40 20 0 Minutes

Time to Treatment in Ischemic Stroke Pooled data from 6 randomized placebo controlled trials of IV rt PA. Treatment was started within 360 min of onset of stroke in 2775 patients randomly allocated to rt PA or placebo Odds of a favorable 3 month outcome increased as onset to treatment decreased (p=0.005). Odds were 2.8 (95% CI 1.8 4.5) for 0 90 min, 1.6 (1.1 2.2) for 91 180 min, 1.4 (1.1 1.9) for 181 270 min, and 1.2 (0.9 1.5) for 271 360 min in favor of the rt PA group. The sooner that rt PA is given to stroke patients, the greater the benefit, especially if started within 90 minutes of symptom onset Hacke, W., G. Donnan, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt PA stroke trials. Lancet 2004;363:768 74.

Goals Using AHA/ASA guidelines, we intend to improve our Door to Needle Times to: Less than or equal to 60 minutes in 75% of eligible patients Less than or equal to 45 minutes in 50% of eligible patients Attain Joint Commission Primary Stroke Center Certification in 2015 Begin doing endovascular cranial procedures with the help of our cardiac team in 2016 Attain Joint Commission Comprehensive Stroke Center Certification in 2016 Provide the most advanced Stroke Care with documented improved functional outcomes in our region.

Team Approach Each team member is integral in reducing times and improving outcomes. EMS the first leg of the relay team

1 st priority Educate our communities to recognize stroke symptoms and call 911 immediately

Treat a stroke as if it were a trauma Dispatch at the highest level of care EMSS response time <8 minutes Turnout time is <1 minute On scene time is <15 minute Taken from Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care policy statement

Advance Hospital Notification EMS providers should, when feasible, provide early notification to the receiving hospital when stroke is recognized in the field. Advance notification of patient arrival by EMS can shorten time to imaging and improve the timeliness of treatment with thrombolysis.

Guidelines from the AHA/ASA Monitor airway continuously Check Accucheck for hypoglycemia which can mimic Stroke Cincinnati Stroke Scale Assessment Facial Droop Arm Drift Speech

CINCINNATI PREHOSPITAL STROKE SCALE Facial Droop Normal: Both sides of face move equally Abnormal: One side of face does not move at all Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other Speech Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute

Guidelines Pre hospital Brief history H/o seizure Prior stroke Diabetic Hypertension Atrial fib Anticoagulation drugs (Asp,Plavix, Warfarin, Xarelto) recent surgery or trauma Time of LAST KNOWN WELL AND ONSET OF SYMPTOMS

Guidelines (cont d) EKG done by EMS and transmitted IV line placed by EMS Keep oxygen sats >94 percent Treat hypotension with systole <120 or lower than premorbid state treat with Normal saline Hypertension pre hospital intervention not proven to be beneficial Call ETA time as soon as possible Take patient to nearest Stroke Ready hospital (As we work on becoming a Comprehensive Stroke center this potentially will change) For hospitals that are not primary stroke center, will be working on a drip and ship

Stroke Code Will go live at HV February 18, 2015 Stroke Codes will be called on all patients presenting with stroke symptoms that are 4 hours from the time of onset or last known well. Based on information provided by you, the communication center will activate the Stroke Code by overhead paging and beepers similar to a trauma alert The communication center will overhead page your arrival The MD, RN, and registration will meet you in the assigned room or trauma bay The patient will go directly to the CT scanner Feedback will be provided on each individual patient

tpa administration Vital signs every 15 minutes times 2 hours beginning at the time of infusion initiation, then every 30 minutes times 6 hours, the every hour times 16 hours Assess Glasgow Coma scale every 15 minutes times 2 hours beginning at time of infusion initiation, the every 30 minutes times 6 hours, then every hour times 16 hours Perform NIH stroke scale 1 hour after the completed infusion of t PA ( notify receiving RN of time due) Notify physician if: patient has a decline in neurological status (decrease in GCS of 2 points or more) Notify physician if: patient systolic blood pressure greater than 180 or diastolic blood pressure is greater than 105 Notify physician if: patient develops sudden onset of severe headache, and/or nausea or vomiting No IV heparin, warfarin, or antiplatelet drugs during the infusion or for 24 hours post infusion Avoid blood draws, invasive lines, or procedures for 24 hours post infusion, if possible.