Stroke Care is a Team Sport

1. Stroke Care is a Team Sport Jay MacNeal, DO, MPH, NREMT-P EMS Medical Director Nichelle Jensen, BSN, RN, CCRN Stroke Program Coordinator Mercy Health System Janesville, WI

2. Rock County • Population: 160,000 • 2 Municipal fire based paramedic services • Remainder of EMS at EMT level • Emergency Medical Dispatch • 1 Primary Stroke Center

3. Objectives • Highlight current EMS guidelines and recommendations • Discuss EMS protocols and education in Rock Co. • Identify barriers of stroke care from field to hospital

4. AHA/ASA Guideline • Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association • Published January, 2013

5. Stroke Chain of Survival • Detection – recognition of s/s • Dispatch – immediate activation of 911 • Delivery – transport to PSC/pre-hospital notification • Door – immediate ED triage • Data – stroke team activation, lab, rad • Decision – Diagnose and determine therapy • Drug – administration of appropriate therapy • Disposition – admit to stroke unit or transfer Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

6. AHA/ASA Guideline • Educational programs for physicians, hospital staff, and EMS are recommended to increase quality of care • Dispatchers should make stroke a priority dispatch • Pre-hospital stroke assessment tools should be utilized • Cincinnati Stroke Scale Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

7. AHA/ASA Guideline • EMS should begin initial management of stroke in field • ABC’s • cardiac monitoring • 02 to maintain sat>94% • establish IV • BGM and treat accordingly • determine onset of symptoms • Triage to nearest stroke hospital (PSC or CSC) • Notify hospital of pending stroke patient (initiate code stroke) Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

8. EMSCare in Rock Co. • Neuro Exam – (code stroke if indicated) • Blood sugar • 12 lead EKG • IV and blood draw If transferring: • “Drip and ship” protocol • Continuous monitoring • Aggressive BP control

9. EMS Education • Initial training • Refresher training • Run reviews • QA • Medical Director on scene • Feedback from stroke program

10. EMS Education • Simulation lab • ICU and ED clinical rotations • Standardized patients • Lab draw and high pressure tubing • New protocol education

11. Community Education • Radio • TV • Billboards – F.A.S.T. • Social Media • Community Events • Rock County Fair • Walk and Talk

12. EMS Opportunities • Improves stroke screening • Improve communications of apparent stroke to ED • Increase critical care capability to transport “drip and ship” stroke patients

13. ED Care • Rapid assessment immediately upon EMS arrival - <10 min • STAT labs – POCT • STAT Head CT • NIH scoring after CT • 12 lead EKG after CT • Immediate discussion with reading radiologist and neurologist

14. ED Care • Continuous re-assessment and telemetry • TPA indications/contraindications and discussion with family • If not stroke center, arrange for transfer • “drip and ship” or “send and pray”

15. Neurology Care • Notified after CT scan results if pt is tPA candidate • If in-house they respond to ED • Phone consultation available 24/7 with video conferencing • Joint decision between neurology, ED physician and pt/family to give tPA

16. Neurology Care • Continue to coordinate care with ICU physician • Available on consult after transfer to floor • Follow-up care after discharge

17. Hospital Care • Admit to Stroke unit • ICU post tPA, SCU, Ortho/neuro • Imaging/Testing • MRI, echo, carotid duplex • Cardiac, BP, blood glucose monitoring

18. Hospital Care • Core/quality measures • DVT prophylaxis • Rehab consults • LDL monitoring • Dysphagia screening • Discharge teaching and medications

19. Case 1 • EMS and MD-1 dispatched to scene for 85 y.o. female with stroke symptoms who pushed Lifealert. Pt with left sided weakness and slurred speech starting approximately 15 prior to EMS arrival. • Pt initally requested to go to community hospital, MD on scene able to council on importance of primary stroke center.

20. MD-1

21. Case 1 • EMS care: • ABC’s assessed and intact • positive CSS, NIHSS 8 at scene • last well know time determined to be within 15 min • BGM 99 • IV started and blood drawn for labs • Code Stroke called to Mercy ED • Patient rapidly transported with MD in ambulance

22. Case 1 • Hospital Care: • Code stroke called 6 minutes PTA • Door to CT time 16 minutes • Negative for bleed • Initial BP >200 mmHg • Labetolol given x 2 with BP lowered to <180 • Door to Needle time > 60 minutes • Pt developed N/V and lethargy in ICU • CT showed ICH • Pt admitted to Inpatient Rehab

23. Case 2 • 52 y.o. Female brought to critical access hospital ED with left sided weakness. Pt sent to CT and decision made to transport to PSC for tPA. MD felt the delay in preparing tPA and calling for critical care transport would be longer then sending the pt without tPA administration.

24. Case 2 • Hospital Care: Code Stroke was called en route to Mercy, CT/lab results were viewed through Epic prior to arrival. tPA was administered with 12 minutes. • No acute findings during stroke work-up. • No deficits at discharge. • Diagnosis: complicated migraine

25. Case 3 • EMS dispatched and arrived to find 62 y.o. male with slurred speech, L facial droop and extremity weakness. Pt stated that he had similar symptoms a week ago and was diagnosed with a TIA in Dubuque, IA but these had resolved. Current symptoms started appox. 5 minutes prior to EMS arrival.

26. Case 3 • EMS care: • ABC’s assessed and intact • positive CSS • last well know time determined to be 5 min PTA • BGM 102 • IV started and blood drawn for labs • Code Stroke called to Mercy ED • Patient rapidly transported

27. Case 3 • Hospital Care: • Code Stroke initiated 5 min prior to pt arrival • Door to CT time – 7 minutes • NIHSS 4on arrival • Symptoms waxed and waned during ED course • When symptoms worsened again tPA started • Door to Needle – 64 minutes • Pt admitted to ICU and discharged home with no deficits within 2 days

28. Future of Stroke Care • Better trained communities • Better trained EMS • Better trained hospitals • Better systems of care • Better patient outcomes

29. Questions