Prehospital Stroke Care

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Prehospital Stroke Care
Ben Bobrow, MD
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Topics

• Importance of EMS to acute stroke care
• Current rationale behind prehospital stroke care
• Arizona stroke care issues to address

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Acute Stroke System of Care

• Public
• Emergency Medical Dispatchers
• Prehospital Providers
• Emergency Medicine
• Radiology/Neuroradiology
• Neurology/Stroke Neurology
• Internal Medicine
• Rehabilitation Medicine

Public Health PSC
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Where Can EMSMake A Difference in Outcomes?

• Cancer
• Pneumonia
• AIDS
• Kidney Disease
• Diabetes
• Alzheimers
• NOT YET

• Major Trauma
• Cardiac Arrest
• ST-Elevation MI
• Acute Stroke
• YES

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Premier EMS Agency

• Continuous ePCR data
• Commitment from Leadership
• On-going and CQI process
• Meet or exceed benchmarks
• Annual evaluation and renewal

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ResultsSurvival from Out of Hospital Cardiac
Arrest
(36/128)
CCR
30 25 20 15 10 5 0
ALS
28.1
Survival to Hospital Discharge ()
(38/348)
(55/598)
10.9
9.2
(61/1686)
3.6
All cardiac arrests
Witnessed with VF
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Relationship Between Time to Treatment and
1-Year Mortality
12 10 8 6 4 2 0
Y 2.86 ( 1.46) 0.0045X1 0.000043X2 Plt.001
1-Year Mortality ()
0 60 120 180 240 300 360
Ischemic Time (minute)
De Luca G, et al. Circulation. 20041091223-1225.
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Improving the System of Care for STEMI Patients
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The Ideal STEMI System of Care
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E.P.I.C.Excellence in Prehospital Injury Care

• Based upon Platinum 10 minutes for TBI
• Statewide CQI program focused on implementation
  of the latest BTF Prehospital TBI guidelines

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Why is EMS an Important Component of a Stroke
System?

• EMS is the initial point of contact with the
  medical system for approximately 50 of stroke
  patients
• EMS personnel must be able to detect stroke if
  the rest of the system is to be launched in a
  timely manner
• EMS protocols often dictate destination

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Stroke Chain-of-Survival

• Parallels with cardiac care striking
• Time sensitive illness
• Appropriate therapy to right patients
• Similar goal of reperfusion
• Similar challenges
• Pre-planned action pathways are key

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0 10 20 30 40 50 60 70
80 90 minutes
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Arizona EMS System

• Regionalization of Care
• Transporting patients to specialized facilities
  best suited to deliver optimum care
• Transporting patients via the right level of care
  (EMT/Paramedic/LS/ground/air)
• Getting the right patients to the right hospital
  in the right time frame
• Trauma
• ST-Elevation MI
• Cardiac Arrest
• Acute Stroke

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Patients Receiving Thrombolysis inPhoenix
1998-2005
Pre PSC
Post PSC
(320/1800)
20 15 10 5 0
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Receiving Thrombolysis for AIS ()
(4/2947)
Pre-PSC
Post-PSC
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Stroke System in Phoenix

• EMS providers routinely bypass non-PSCs with
  eligible stroke patients to transport to a PSC in
  most regions of Phoenix WHEN FEASIBLE

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Source University of Cincinnati College of
Medicine
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STROKE ALERT Program

• Pre-notification to expedite system at PSCs
• Initiated by EMS personnel
• ID potential acute intervention candidates
• Minimize stroke mimics
• ED staff begin process prior to patient arrival
• Stroke Team pager called,CT scan/radiologist/lab
• Especially important during peak season
• Builds EMS partnership and awareness

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Stroke / Stroke Alert Adult ( 14 y/o)
Stroke / Stoke Alert - Adult
Obtain blood glucose
Establish IV access and determine FAST score
Facial droop (1) Arm Drift (1) Speech (1)
Time (time of symptom onset)
Positive FAST Score
Call Stroke Alert in report to receiving
facility and transport to nearest Primary Stroke
Center (PSC)
Transport to Nearest Facility
No
Yes
Plan During their courtesy notification (CN),
EMS personnel will give pre-notification of acute
stroke patients that may be candidates for acute
intervention. When the paramedic identifies such
a patient, he/she will provide telemetry
notification that they are in transit with a
Stroke Alert patient and give an estimated time
of arrival. EMS personnel will document the
patients FAST Score (Face asymmetry, Arm drift,
Speech deficit, Time of symptom onset) along with
standard Vital Signs, Blood Sugar and if another
center was bypassed to go to a primary stroke
center. Action At the beginning of the CN, the
paramedic will clearly state that they have a
Stroke Alert patient. This same term will be
used to notify the in-hospital stroke team and
ancillary services. Candidates for Stroke Alert
Any patient with acute neurological deficit such
as facial asymmetry, arm drift or slurred speech,
beginning within 3 hours. Non-candidates for
Stroke Alert Patients with complaint
exclusively of generalized weakness, dizziness,
seizure, headache, or neurological complaints of
greater than 3 hours duration as determined from
last time patient known to be without
deficit. Additional Treatment Do not treat
hypertension in patients suspected of having
acute stroke unless directed to do so via online
medical direction. Transport to closest
emergency department. Time-if the time of
symptom onset is not clear, use the time the
patient was last seen normal
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ASPIRE EMS Data Form
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EMS transport to a PSC Average 18
minutesPatient contact 9-1-1 time - Average 122
minutes
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Emergency Medical Dispatch System Accuracy at
Predicting Stroke
Joshua C. Poles1, Suchita Mandair2, Daniel
Donahue3, Bentley J. Bobrow2,4, Nadine Lendzion5
, Pat Miller5, Bart M. Demaerschalk5, Timothy
Ingall5 1Kansas City University of Medicine and
Biosciences, Kansas City, Missouri 2Department
of Emergency Medicine, Mayo Clinic Hospital, and
the Mayo Clinic College of Medicine, Phoenix,
Arizona 3Phoenix Fire Department, Phoenix,
Arizona 4The Arizona Department of Health
Services and Bureau of Emergency Medical Services
and Trauma System, Phoenix, Arizona 5Department
of Neurology, Mayo Clinic Hospital, and the Mayo
Clinic College of Medicine, Phoenix, Arizona
Table 1 Accuracy Rate of Stroke Determination by
EMD

• Introduction
• The ability of Emergency Medical Dispatch (EMD)
  to quickly and accurately identify acute stroke
  is essential for a stroke system to optimize
  outcomes.
• Phoenix EMD is unique in that the individual
  dispatcher is responsible for selecting a
  designated diagnostic category based on reported
  symptoms. Many other dispatch systems use an
  automated computer system to manage diagnostic
  algorithms.

• Results
• Data was collected for 187 patients.
• Complete data were available for 96 patients
  discharged with an ICD code 430-437.
• Using all chief complaints, 68/96 (71) of
  patients were categorized with a diagnostic
  category of stroke by EMD.
• Using cardinal symptoms of stroke (F.A.S.T.),
  91.75 of patients were categorized with a
  diagnostic category of stroke by EMD.
• EMD dispatched 65/68 (96) of the determined
  stroke calls code 2 or 3 (lights and sirens due
  to life threatening circumstance).
• Accuracy rates of stroke-determination based on
  reported chief complaints are shown in Table 1.
• The most common symptoms reported to EMD are
  shown in Figure 1.

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100

90

• Purpose
• To evaluate the accuracy of EMD determination of
  stroke in a metropolitan matrix of primary stroke
  centers (PSC).

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• Methods
• We performed a retrospective analysis of
  prospectively collected data between January
  2005-December 2006.
• Data was analyzed from a single participating
  PSC, multiple fire departments, and private
  ambulances servicing Maricopa County, Arizona.
• We included patients 18 years or older who were
  discharged from a primary stroke center with an
  ICD code 430-437.
• Based on chief complaint and patient criteria,
  EMD assigned 1 of 32 pre-determined diagnostic
  categories.
• Data from the Phoenix EMD Center included
• Age Gender
• Diagnostic category
• Caller Identification
• EMS Priority Category
• Chief Complaint
• Facial Droop / Arm Weakness / Slurred Speech /
  History of Stroke
• We compared the callers initially reported chief
  complaints to the EMD-designated diagnostic
  category.

• Conclusion
• The overall accuracy of EMD determination of
  stroke in the Phoenix metropolitan matrix of PSCs
  demonstrates a highly effective dispatch system
  that provides customers the highest chance of
  survival and favorable outcome.
• EMDs dispatch of stroke as a lights and sirens
  response demonstrates appropriate prioritization
  of stroke diagnostic category.
• While a small number of stroke patients access
  9-1-1 with other complaints slurred speech, arm
  weakness, and facial droop were found to be most
  commonly associated with acute stroke.
• Appraising the accuracy of EMD stroke
  determination, patient destination, response
  level, and outcomes within a metropolitan area is
  critical to improving large systems of stroke
  care.
• The ability to link EMD and hospital discharge
  data is a critical tool to measure system wide
  efficacy.

Figure 1 Number of Chief Complaints Reported to
EMD
Phoenix Fire Department Emergency Medical
Dispatch Diagnostic Questions For Stroke

• Stroke
• Key Questions
• Tell me why you think he/she is having a stroke?
• When did the symptoms begin?
• Is the patient alert and able to respond to you?
• Did the patient complain of a headache?
• Has the patient had a stroke before?
• Does the patient have a history of high blood
  pressure?

• Acknowledgement
• We thank the Phoenix Regional Dispatch Center and
  the Phoenix Fire Department for their assistance
  with this study and their tremendous service to
  our community.

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Utilization of a Prehospital Stroke Scale in an
Urban Matrix of Primary Stroke Centers

• CPSS 0 (54) transported to PSC
• CPSS 1 (61) transported to a PSC
• CPSS 2 (65) transported to a PSC
• CPSS 3 (66) transported to a PSC
• Conclusion
• - CPSS scores correlate with final transport
  destination to a PSC.
• - There is evidence of over-triage and under-
  triage of patients to PSCs
• - The effects of diverting acute stroke patients
  to pre-designated PSCs warrants further
  investigation.
• Bobrow B, Demaerschalk B, et al. NAEMSP 2006

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• Retrospective analysis comparing non-PSC vs. PSC
• -Thrombolysis rate/Functional outcome/Survival
• Methods
• -Using probabilistic linkage between prehospital
  and hospital discharge databases searching for
  ICD-9 Code of 430-437 or 99.10
• Dates 9/04 12/06 (N1,304)
• Demaerschalk BM et al. Stroke. 200839(2)527-729.
  

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Results

• 142/394 (36) transported to a non-PSC
• Only 4/142 (2.8) received IV-tPA
• 252/394 (64) transported to a PSC
• 17/236 (6.7) received IV-tPA (p0.096)

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Results

• Functional Outcome at Discharge
• Non-PSC - 51/142 (35.9) Independent
• PSC - 78/252 (31.0) Independent (p0.313)
• Survival to Hospital Discharge
• Non-PSC - 10/142 (7.0) Survived
• PSC - 16/235 (6.3) Survived (p0.790)

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Conclusion
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MCH EMS Stroke Alert Data

• 9/1/08 3/31/09
• 110 Stroke Alerts
• 85 (77) met FAST criteria
• 25 (23) Stroke Alerts did NOT meet criteria
• 3 (12) symptoms resolved
• 8 (32) FAST gt 12 hours
• 14 (56) No FAST symptoms

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MCH EMS Stroke Alert Outcomes

• Stroke or TIA 69 (63)
• Other Dx 41 (37)
• Approximately 50 are AMS or Seizure
• Migraine, Bells Palsy, Conversion Disorder, etc.

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Future of Stroke Care

• Any hyperacute therapy will need to involve
  prehospital medicine to rapidly identify and
  possibly initiate treatment

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Key EMS Stroke Issues

• EMS knowing which centers are PSCs
• Formalize EMS Bypass Protocols
• Need for Customized Stroke Alert Protocols
  Timing Issues
• Formalize PSC EMS outreach

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Tasks

• Phoenix Stroke Initiative Needs to Form an
  Executive Committee which will
• Regularly Review PSC Status/ Matrix Membership
• Establish and Assure System Benchmarks
• Interface with AEMS and ADHS
• Assure all EMS agencies are part of system
• Coordinate Telemedicine Activities for the rest
  of Arizona

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Example of PSC System Benchmarks

• ___ of Patients Receiving Prehospital Stroke
  Screen with Prenotification to PSC
• (?80)
• At least 20 of Patients Receiving Acute Stroke
  Treatments IV tPA or IA Tx

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Acknowledgement

• We are grateful to all the EMS providers in the
  state of Arizona participating in the Premier EMS
  Agency Program.
• This presentation is dedicated to the
  prehospital professionals who risk their lives
  everyday to save others.
• Bobrowb_at_azhs.gov