Stroke Patient Care in the Prehospital and ED Settings: Should EMS Triage

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Stroke Patient Care in the Prehospital and ED
SettingsShould EMS Triage Inter-hospital
Transfer Occur?
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4th EuSEM CongressCrete, GreeceOctober 5-7, 2006
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Edward P. Sloan, MD, MPH FACEP
ProfessorDepartment of Emergency
MedicineUniversity of Illinois College of
MedicineChicago, IL
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Attending PhysicianEmergency
MedicineUniversity of Illinois HospitalOur
Lady of the Resurrection HospitalChicago, IL
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Disclosures

• NovoNordisk, King Pharmaceuticals, UCB Pharma
  Advisory Boards
• Eisai Speakers Bureau
• ACEP Clinical Policies Committee
• ACEP Scientific Review Committee
• Executive Board, Foundation for Education and
  Research in Neurologic Emergencies

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Session Objectives

• Discuss if and when direct EMS triage to
  specialized stroke centers should take place.
• Determine under what circumstances the
  inter-hospital transfer of ED ischemic stroke
  patients should take place when specialized
  stroke patient care is desired.

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Key Clinical Questions

• Should pre-hospital stroke patients be directly
  triaged by EMS to specialty stroke centers?
• When should the ED inter-hospital transfer of
  stroke patients to specialty stroke centers occur?

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Case Presentation

• 62 yo male brought in by paramedics
• Paramedics called due to left face, arm and leg
  going dead and slurred speech while eating
  breakfast
• On paramedic arrival, he has a facial droop,
  slurred speech and L hemiparesis
• Should this patient go to the closest hospital or
  a specialized stroke center?

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Case Presentation

• This patient is taken to the closest hospital for
  immediate ED evaluation.
• The patient is stabilized and a head CT is
  obtained. Should he go to a stroke center for
  continued care?
• Does this decision depend on whether or not IV
  tPA is administered?

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Direct Stroke Pt Triage

• What are specialized stroke centers?
• Why do these special stroke centers impart
  improved patient outcome?
• Will direct EMS triage to these centers improve
  patient outcome?
• Can these same clinical competencies be made in
  all hospital comprehensive EDs?
• Which is the preferred approach? Why?

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Stroke Centers

• US Model via JCAHO
• Joint Commission for the Accreditation of
  Healthcare Organizations
• Designated as a Primary Stroke Center
• Institutional commitment to the delivery of the
  highest quality care to stroke patients,
  including that provided in ED
• As of October, 2006, there are 260 in US
• 3 States designate separately

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Tertiary Centers

• Provide specialized care
• Often are university-affiliated
• Treat the most complex medical cases
• Most are primary stroke centers or are in the
  planning process
• These tertiary centers often have capabilities
  beyond some hospitals that are primary stroke
  centers

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Comprehensive Stroke Centers

• Highest level stroke patient care
• Expected to be university-affiliated and/or
  tertiary centers
• Will provide 24/7 interventional radiology,
  advanced diagnostics such as MRI, MRA, CTA and
  conduct extensive research
• Limited number, as with Level I trauma
• Unknown if direct EMS triage planned

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Improved Outcome Basis

• Related to stroke care systems
• Often due to advanced nursing care and decreased
  stroke-related complications
• Reduced aspiration, DVT, infections
• May be related to increased rate of tPA use
  and/or fewer tPA complications, or from advanced
  therapeutics use
• The latter has not been demonstrated

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Direct EMS Triage

• Trauma triage established in US
• Some cities now require EMS triage to stroke
  centers
• Will get stroke patients to stroke centers
• May negatively impact non-stroke centers
• Could lead to most hospitals becoming primary
  stroke centers, which is what is desired by the
  JCAHO stroke advocates

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Acute ED Competencies

• Rapid diagnosis and systems use
• Head CT interpretation quick, correct
• IV tPA use often assessed, used
• NINDS protocol successfully followed
• Comparable tPA effects and outcomes
• In other words, clinical effectiveness in the
  acute treatment of ED stroke pts
• Ability to transfer complex cases

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The Preferred Approach

• Majority of hospitals become stroke centers by
  any means possible
• Institutional buy-in to stroke patient care
• IV tPA use often assessed, used
• Clinical effectiveness in the acute treatment of
  ED stroke pts
• Limited need for transfer out of hospital
• Increased capacity for optimal care

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Key Clinical Questions

• Should pre-hospital stroke patients be directly
  triaged by EMS to specialty stroke centers?
• No. Not if it is possible to increased
  competencies and capacity for excellence in
  stroke patient care, including acute ED care

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Inter-hospital Transfer

• When help is needed, it is provided
• What can happen after IV tPA is provided?
• What can happen if IV tPA is not used?
• Should IV tPA be deferred for another Rx?
• Do long-term indications support transfer?
• Which is the preferred approach? Why?

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Providing Higher Level of Care

• US standard provide help when asked
• If you cant provide care, another will
• Some problems with financial triage
• Some problems with wallet biopsy
• Raises question of why not direct triage
• Interhospital transfer agreements common
• AMI PCI Poorer outcomes not seen

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Providing Higher Level of Care

• One example in Reno, Nevada in US
• Central tertiary hospital (Hub) with 27 outlying
  hospitals that transfer (Spokes)
• Annual review of acute care and transfers
• Four man neurology group takes calls from all
  referring EDs, with teleradiology
• Telemedicine the next step, now in Boston area
  out of Harvard hospitals?

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Stroke Care After IV tPA

• The following have not been demonstrated to
  improve stroke patient outcome after IV tPA
• Combination thrombolytic therapy
• Mechanical interventions after IV tPA
• It is likely that systematic care after acute
  care is superior, but this should be able to be
  provided in most hospitals

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Therapies Other Than IV tPA

• Merci device is FDA approved for clot retrieval,
  but not standard of care
• Why? It is surgical device, not a therapeutic
• It therefore is approved for use but not able to
  be used by all operators, hospitals
• All other additional therapies experimental
• Are advanced diagnostics therapeutic in that they
  lead to other therapies? This is unknown.

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Should IV tPA Be Deferred?

• No. IV tPA should ever be deferred when
  indicated and able to be provided in a clinically
  effective, safe manner.
• When IV tPA can be provided in a referring
  hospital, it should be given expeditiously
• This is not a rationale for inter-hospital
  transfer

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The Preferred Approach

• All EDs provide IV tPA when indicated
• Transfer agreements for acute care or continued
  care if necessary
• Conduct research that answers the important
  questions of advanced diagnostics and
  therapeutics, including mechanical devices
• Determine over time how care should be divided up
  as the pie grows bigger

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Key Clinical Questions

• When should the ED inter-hospital transfer of
  stroke patients to specialty stroke centers
  occur?
• Inter-hospital transfer should occur when it is
  apparent that advanced care is needed and/or that
  this advanced care is demonstrated to improved
  stroke patient clinical outcomes

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Conclusions

• Specialty care centers raise the bar
• Need to assess best outcomes and best use of
  resources
• Research will answer important questions
• Stroke care will improve
• Lessons can be learned from
• EU models of care

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Recommendations

• Maximize the use of IV tPA
• Get buy-in for optimal stroke pt care
• Know when and how to transfer
• Study effectiveness locally
• Conduct multi-centered research (NETT)
• Continue to explore best approaches

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Questions?
www.FERNE.org edsloan_at_uic.edu 312 413 7490
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