EMS/ED Stroke Management

EMS/ED Stroke Management

According to the CDC, stroke is the fifth leading cause of death in the United States and is a major cause of adult disability.  About 800,000 people in the United States have a stroke each year.  One American dies from a stroke every 4 minutes, on average. (Credit: CDC)

Among other initiatives, Virginia Beach EMS is working with Sentara to improve the care for patients experiencing a stroke.  The goal for the hospital is to have a “door-to-needle” time of less than 60 minutes, which is the time of arrival in the ED to the start of the fibrinolytic (Alteplase) administration.  To expedite the initiation of Alteplase, early physician evaluation and rapid acquisition of brain imaging (CT) are essential.

Credit: Sentara
Credit: Sentara.com

As a general reminder, the following are the TEMS designated stroke centers (per the TEMS Stroke Triage Plan) to which Virginia Beach EMS would most likely transport (based on proximity):

  • Chesapeake Regional Medical Center
  • Sentara Leigh Hospital
  • Sentara Princess Anne Hospital
  • Sentara Virginia Beach General Hospital

The following are other facilities in the TEMS region that are designated stroke centers (per the TEMS Stroke Triage Plan):

  • Bon Secours DePaul
  • Bon Secours Harbourview
  • Bon Secours Maryview
  • Sentara Norfolk General Hospital
  • Sentara Obici Hospital
Direct Door-to-CT Protocol and Sentara Partnership

Portsmouth Fire Department and Bon Secours Maryview Medical Center have been working on a program that involves ALS providers drawing blood in the field (from the IV) and upon arrival at the hospital, taking the patient direction to the CT scanner on the EMS stretcher and the EMS ECG monitor.  ED staff members accompany EMS to the CT scanner with a hospital stretcher, the patient is transferred to the CT table, patient turnover is given in the CT room and EMS is now free to leave.

Sentara Virginia Beach General Hospital is working with Virginia Beach EMS to develop a Sentara pilot program, including blood draws, for suspected stroke patients being transported to SVBGH.  The current plan is for this process to begin with training a select group of ALS providers and possibly putting the plan into action in the beginning of 2016.  By drawing blood in the field, important lab tests will be able to be performed sooner which will expedite the administration of tPA to a patient having a stroke.  Without a prehospital blood draw, the CT could potentially be delayed.

Sentara Princess Anne Hospital is also working with Virginia Beach EMS to improve door-to-needle times.  SPAH is also looking at a direct door-to-CT protocol and lessons learned from SVBGH’s implementation will be utilized in developing that process.  SPAH has also reached out to Virginia Beach EMS to improve EMS involvement in the stroke quality improvement (QI) processes.  SPAH has already started sending feedback forms for suspected stroke patients with benchmark times and goals, the patient’s diagnosis and disposition, and any additional comments regarding the case.  SPAH is sending these feedback forms to the Virginia Beach EMS CQI officer who will, in turn, forward them to the crew members involved with the patient’s care.

Sentara Leigh Hospital is also working with Virginia Beach EMS to improve door-to-needle times and has already implemented a door-to-CT protocol.  SLH is interested in prehospital blood draws, but there will be a little time before that is put into place.  SLH is also sending feedback forms for distribution to the crew members involved with the patient’s care.  As of the posting of this article, their procedure is as follows for patients with a suspected stroke, an onset of less than 6 hours, a positive Cincinnati Stroke Scale, and a normal blood glucose level:

  1. A “soft” (internal to ED only) stroke alert will be called (the ED physician will be called over, CT will be called, and registration will be called to patient’s side)
  2. The ED physician will evaluate the patient on EMS stretcher
  3. If the ED physician agrees with the stroke diagnosis, a “full” stroke alert will be called overhead and EMS will take the patient to CT
    • If the ED physician does not suspect a stroke, we will take the patient to a room
American Heart Association/American Stroke Association – Target: Stroke – Direct to CT Protocol
Virginia Beach EMS Stroke Management

First and foremost, Virginia Beach EMS providers must adhere to the regional TEMS protocols and the TEMS Stroke Triage Plan.

In addition to the emergency care outlined in the TEMS protocols and Stroke Triage Plan, when a stroke is suspected, remember the following points:

  1. Per the AHA/ASA, the routine use of supplemental oxygen remains unproven, but supplemental oxygen to maintain oxygen saturations >94% is recommended
  2. Obtain glucometry to rule-out hypo-/hyperglycemia as a cause of the signs/symptoms; be sure to document both the vital sign and the “Blood Glucose Analysis” procedure
  3. Initiate cardiac monitoring and obtain a 12 Lead EKG for transmission to the hospital
  4. IV access should be established for suspected stroke patients; while the initial head CT does not require an IV, the patient may need a CTA, which requires an IV, and prehospital vascular access will expedite that process
  5. Do not delay transport for prehospital interventions
  6. Provide early notification to the receiving facility, being sure to include the following important points (this list is not all-inclusive) in your radio report:
    • Last known normal date/time (when did the stroke signs/symptoms begin or when was the patient last seen to be normal?)  — this is critical!
    • Cincinnati Stroke Scale results (positive/negative)
    • Blood glucose level
  7. Following your radio report, you may be requested to call the hospital on the phone to provide basic demographic information to facilitate preregistration of the patient which will help expedite the CT process
  8. For suspected strokes with a positive Cincinnati Stroke Scale, emergent (lights and siren) transport to the hospital is indicated
    • We do not decide whether or not a patient is still within a management window and we must do our part to help minimize door-to-needle times to help achieve the best patient outcome
    • A “stroke alert” will be called if the onset/last normal time is within 6 hours; tPA can be administered venously for up to 4.5 hours following the onset/last normal time and it can be administered arterially for up to 6 hours following the onset/last normal time; even beyond 6 hours, the patient may be a candidate for endovascular management with interventional radiology
    • Remember, “time is brain”!
Virginia Beach EMS Goals
  • Ambulance on scene times should be less than 15 minutes for suspected stroke patients 100% of the time (unless extenuating circumstances or extrication difficulties are present) (source: AHA/ASA)
  • Glucometry should be performed and documented for suspected stroke patients 100% of the time
  • The Cincinnati Stroke Scale should be performed and documented for suspected stroke patients 100% of the time
Virginia Beach EMS Performance Indicators
  • Onset of signs/symptoms with specific time of onset obtained and documented (if unable to determine specific time, attempt to determine the most accurate time range possible and document it)
  • Cincinnati Stroke Scale performed and documented
  • Glucometry performed and documented
  • EKG monitor applied with 12-lead EKG acquisition and transmission