A%20Rapid%20Ambulance%20Protocol%20for%20Acute%20Stroke

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A Rapid Ambulance Protocol for Acute Stroke

• Prof Gary Ford
• Freeman Hospital Stroke Service
• Newcastle Upon Tyne

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Assessment of Suspected Acute Stroke by Stroke
Teams

• Accurate early diagnosis and initiation treatment
  non-stroke present in 20 suspected acute
  stroke - Subdural haematoma, epilepsy,
  cerebral tumour
• Initiation early rehabilitation
• Early interventions thrombolysis, aspirin
• Improved early management stroke - carotid
  dissection, cerebral venous
  thrombosis, ic haemorrhage, diagnosis
  TIA complications dysphagia, DVT, fluids, BP

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Advances in Stroke Care

• Intravenous thrombolysis with alteplase in
  selected patients with acute ischaemic stroke
  within first 3 hours
• Aspirin in patients with cerebral infarction
  within first 48 hours
• Benefits of organised Acute Stroke Unit care
• Increasing evidence of the benefits of
  interventions to correct disturbed physiology
  (hypoxia, dehydration, fever, hyperglycaemia)
  early stages of stroke
• Possible extension thrombolysis time window and
  use neuroprotective agents within 5 hours

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NINDS rt-PA STROKE TRIALRESULTS - PART 23-Month
Outcome on Four Stroke Scales
Minimal/No Disability Moderate
Disability Severe Disability
Death
NIHSS rt-PA Placebo Barthel Index rt-PA Place
bo Modified Rankin rt-PA Placebo Glasgow
Outcome rt-PA Placebo
of patients
31 30 22 17
20 32 27
21
of patients
50 16
17 17
38 23 19
21
of patients
39 21 23
17
26 25 27
21
of patients
44 17 22
17
32 22 26 21
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Aspirin in Acute Ischaemic Stroke
IST / CAST Lancet 1997
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Requirements for Early Assessment of Stroke
Patients

• Awareness of signs/symptoms of stroke in
  community
• Rapid Admission to Hospital
• Rapid Assessment at Hospital
• Imaging when required
• Skills to administer interventions

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STROKE SYMPTOMS
999 Primary Care Physician
Paramedic Ambulance Assessment Transport
AE
Medical/Neurology Stroke Unit Wards
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Delays in Presentation

• Stroke admissions in Oxford 6 month period
• Prospective data collection 183 patients
• Uncertain onset time 55 (waking 28)
• 55 arrived within 3 hr, 76 within 6 hr
• 24/86 GP cases initially managed at home
• Symptom recognition to admission within 3 hr GP
  31 Ambulance 90
• Admission to assessment - 69 min

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Delays in Admission

• 15 Swedish Hospitals
• 329 patients stroke/TIA
• Hospital admission 4.8/4.0 hr
• Factors associated with delayed
  admission infarct, gradual onset, mild
  symptoms, not using ambulance, visiting GP
• Factors associated with delayed CT/Stroke unit
  admission large catchment area, mild/moderate
  deficit waiting for ER physician

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Acute Stroke
General Practitioner 999
Accident Emergency Dept
Acute Stroke Unit General Medical
Wards Freeman Hospital RVI
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Freeman Hospital Stroke Service

• Established Apr 1993
• First comprehensive stroke service UK
• Accepts all suspected acute stroke patients
• 10 acute stroke beds within General Medical Ward
• 10-14 Stroke rehabilitation beds non-acute
  hospital
• Multi disciplinary team both units
• Initially only GP referrals

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Freeman Hospital Stroke Service

• 1993 Stroke Discharge Team
• 1994 Commenced hyper-acute assessment stroke
  trials
• 1994 Multidisciplinary stroke review clinics
• 1997 Establishment cross city stroke
  rehabilitation ward (20 beds)
• 1997 Rapid Ambulance Protocol
• 1998 IV thrombolysis protocol Second stroke
  consultant
• 1999 14 bed Acute Stroke Unit
• 2000 City wide triage of stroke to unit 30
  bed Acute Stroke Unit Third Stroke
  consultant appointed

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Acute Stroke
999 General Practitioner
Rapid Ambulance A E Dept Protocol
Acute Stroke Unit General Medical Wards Freeman
Hospital RVI
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Rapid Ambulance Protocol
Acute Stroke Symptoms
Ambulance Control Paramedical team Paramedical
Assessment
radio control
notify unit
Suspected Stroke Non-stroke
Stroke Unit A E Dept
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Rapid Ambulance Protocol

• All 999 patient with suspected stroke not in coma
  GCS gt6 to be taken to FRH Emergency Admission
  Suite
• EAS to be informed of pre-arrival information
• FAST assessment to be used to identify and assess
  suspected stroke cases

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Rapid Ambulance Protocol
Directive City wide Letter to
Letter to Training East End Crews Protocol
Crews Crews Programme
Monthly Ambulance Stroke Unit Admissions
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Rapid Ambulance ProtocolMay 97 -Jul 98
123 Patients 102 Confirmed acute stroke/TIA 21
Non-stroke 5 acute confusional
state 5 collapse secondary to vascular
instability 3 fall/old CVA 3 cerebral
neoplasm 3 collapse secondary to other
cause 1 seizure 1 normal pressure hydrocephalus
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Rapid Ambulance Protocol Symptom onset to
admission
Median (range) GP referrals (n108) 6.0
(0.5-23.5) hr Rapid Ambulance Protocol 1.2
(0.5-18.7) hr Symptom onset to contact emergency
service 33 min Contact to arrival paramedical
team 8 min Arrival at home to arrival
stroke unit 22 min
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Purpose Paramedic Stroke Instrument

• Identification stroke - direct to Stroke
  Unit - rapid transfer - obtain
  relevant information at scene - administer
  neuroprotective therapies
• Identification non-stroke
• Increase profile stroke

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Cincinnatti Instrument

• 74 patients treated in thrombolysis trial and 225
  non-stroke patients evaluated in ER
• NIHSS all patients
• Facial palsy, motor arm and dysarthria identified
  100 stroke patients (specificity 92)
• Out-of Hospital scale facial palsy, arm weakness,
  language disturbance

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Cinicinnati EMS experience

• 4413 evaluations
• Paramedic diagnosis Stroke/TIA 96 2
• Confirmed in 62/86 72 22 paramedic
  interventions
• Mean time to scene 3 min after 911 call
• Earlier arrival with basic units compared to
  paramedics (40 vs 45 min)
• Physician assessment (10 vs 20 min) and CT (47
  vs 69 min) earlier with paramedics

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Los Angeles Instrument

• Exclude agelt45 yrs, seizure, symptoms gt24 hr,
  patient wheelchair bound or bedridden
• Arm strength, facial smile, grip
• Evaluated in patients entered 6 hr intervention
  trials
• 41 ischaemic stroke by ambulance
• 93 would have been identified

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San Francisco Instrument

• 4 items
• Language - 3 step command, name objects, speech
  fluency
• Motor - Smile, pronator drift, lift each leg
• Visual fields - confrontation testing
• Gait

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San Francisco experience

• Retrospective review stroke admissions and
  paramedic evaluations
• Paramedics identified 49/81patients
• 15 patients identified by paramedics non-stroke
• Patients/families waited 2.5hr before calling 911

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FAST assessment

• Face Arm Speech Test
• Facial Palsy
• affected side
• Arm Weakness
• affected side
• Speech Impairment

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FAST Assessment
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Paramedic Training Package

• Lecture notes
• Handout
• Overheads / slides
• Video
• MCQ test

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Paramedic knowledge

• MCQ assessment before/following training package
  57 ambulance staff
• Score 14.0 before 16.8 following
• Errors GCS scoring affected side Cerebral
  haemorrhage commonest cause Headache present
  gt80 patients Depressed conscious level most
  patients

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Identification non-stroke

• Male 75 yrs admitted with suspected stroke via
  General Practitioner, symptoms dizziness
• Ambulance personnel undertake FAST assessment -
  negative
• Examine patient - bradycardic
• Complete Heart block - pacemaker insertion

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Acute Stroke
999 AE Dept General Practitioner NGH
(Hospital Direct)
Rapid Ambulance Protocol
Acute Stroke Unit Medical Wards FRH - - - - -
- - (single Trust) - - - - - - - - RVI
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Rapid Ambulance Protocol
Directive City wide Letters to
Training AE East End Crews
Protocol Crews Programme
Reconfig
Monthly Ambulance Stroke Unit Admissions
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Rapid Ambulance Protocol
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Diagnostic Accuracy Stroke Referrals1 Feb 00
31 May 00

• GP AE Paramedic Total
• Stroke/TIA 89 45 95 229
• Non-stroke 34 12 24 70
• Proportion of referrals 28 21 20

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Paramedic Stroke Detection

• 1 Feb 31 May 2000
• 129 stroke patients initial contact 999
• 97 admitted directly via RAP
• 75 detection
• 80 accuracy

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Stroke Referrals - subtypes

• Paramedic GP
• (n84) (n73)
• TACS 37 10 plt0.001
• PACS 37 34 n.s.
• LACS 14 33 plt0.01
• POCS 2 14 plt0.01
• PICH 10 10 n.s.
• 4 month period (Feb-May 00)

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Hospital Assessment

• Emergency Room staff
• Acute medical team
• On call Acute Stroke Team nurse / stroke
  doctor

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SWAT Team

• Stroke Watch Action Team
• St Lukes Hospital, Kansas City
• SWAT beeper
• Nurses trained to identify stroke and summon
  doctor

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Links with Accident Emergency

• AE doctors used to acting quickly
• Clear protocol - who requests imaging?
• Need for stroke recognition instrument
• Support of stroke team
• Admission to Stroke unit vs AE

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Freeman Stroke Service

• Admission suite staff notify stroke nurse
• Collect data from paramedics
• Stroke nurse undertakes initial evaluation
  (SNSS/NIH) takes bloods, speaks to/contact
  relatives
• Contacts stroke doctor further neurological
  evaluation
• If non-stroke direct further management in
  discussion with stroke consultant
• Urgent CT requested if required
• Thrombolysis/neuroprotectant trials initiated in
  Admission unit

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Freeman Thrombolysis Experience

• 17 patients treated in 2 years (2 referrals)
• 15 admitted via 999 contact
• Main contraindications, delayed admission and
  co-morbidities
• Outcomes similar to NINDS trials
• 1 symptomatic intracerebral haemorrhage as
  complication

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Establishing an Ambulance Protocol

• Go the top
• Establish agreement colleagues across district
• Incorporate stroke instrument in patient report
  form
• Protocol must be unambiguous and simple
• Initiate audit and involve ambulance staff
• Regular feedback to crews on the ground
• Change takes time

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Acute Stroke Patient Flow
Suspected Acute Stroke Community
education Emergency Services Primary Care
Physician Paramedic Paramedical
assessment Professional Education Training Acute
Stroke Unit Emergency Room Organised
rehabilitation Health Care Purchasers