Presentation on theme: "Stroke Care is a Team Sport"— Presentation transcript:
1 Stroke Care is a Team Sport Jay MacNeal, DO, MPH, NREMT-PEMS Medical DirectorNichelle Jensen, BSN, RN, CCRNStroke Program CoordinatorMercy Health SystemJanesville, WI
2 Rock County Population: 160,000 2 Municipal fire based paramedic servicesRemainder of EMS at EMT levelEmergency Medical Dispatch1 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 GuidelineGuidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationPublished January, 2013
5 Stroke Chain of Survival Detection – recognition of s/sDispatch – immediate activation of 911Delivery – transport to PSC/pre-hospital notificationDoor – immediate ED triageData – stroke team activation, lab, radDecision – Diagnose and determine therapyDrug – administration of appropriate therapyDisposition – admit to stroke unit or transferGuidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013
6 AHA/ASA GuidelineEducational programs for physicians, hospital staff, and EMS are recommended to increase quality of careDispatchers should make stroke a priority dispatchPre-hospital stroke assessment tools should be utilizedCincinnati Stroke ScaleGuidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013
7 AHA/ASA GuidelineEMS should begin initial management of stroke in fieldABC’scardiac monitoring02 to maintain sat>94%establish IVBGM and treat accordinglydetermine onset of symptomsTriage 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 EMS Care in Rock Co. Neuro Exam – (code stroke if indicated) Blood sugar12 lead EKGIV and blood drawIf transferring:“Drip and ship” protocolContinuous monitoringAggressive BP control
9 EMS Education Initial training Refresher training Run reviews QA Medical Director on sceneFeedback from stroke program
10 EMS Education Simulation lab ICU and ED clinical rotations Standardized patientsLab draw and high pressure tubingNew protocol education
11 Community Education Radio TV Billboards – F.A.S.T. Social Media Community EventsRock County FairWalk and Talk
12 EMS Opportunities Improves stroke screening Improve communications of apparent stroke to EDIncrease critical care capability to transport “drip and ship” stroke patients
13 ED Care Rapid assessment immediately upon EMS arrival - <10 min STAT labs – POCTSTAT Head CTNIH scoring after CT12 lead EKG after CTImmediate discussion with reading radiologist and neurologist
14 ED Care Continuous re-assessment and telemetry TPA indications/contraindications and discussion with familyIf 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 EDPhone consultation available 24/7 with video conferencingJoint 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 floorFollow-up care after discharge
17 Hospital Care Admit to Stroke unit Imaging/Testing ICU post tPA, SCU, Ortho/neuroImaging/TestingMRI, echo, carotid duplexCardiac, BP, blood glucose monitoring
18 Hospital Care Core/quality measures DVT prophylaxis Rehab consults LDL monitoringDysphagia screeningDischarge teaching and medications
19 Case 1EMS 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.
21 Case 1 EMS care: ABC’s assessed and intact positive CSS, NIHSS 8 at scenelast well know time determined to be within 15 minBGM 99IV started and blood drawn for labsCode Stroke called to Mercy EDPatient rapidly transported with MD in ambulance
22 Case 1 Hospital Care: Code stroke called 6 minutes PTA Door to CT time 16 minutesNegative for bleedInitial BP >200 mmHgLabetolol given x 2 with BP lowered to <180Door to Needle time > 60 minutesPt developed N/V and lethargy in ICUCT showed ICHPt admitted to Inpatient Rehab
23 Case 252 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 2Hospital 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 3EMS 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 PTABGM 102IV started and blood drawn for labsCode Stroke called to Mercy EDPatient rapidly transported
27 Case 3 Hospital Care: Code Stroke initiated 5 min prior to pt arrival Door to CT time – 7 minutesNIHSS 4 on arrivalSymptoms waxed and waned during ED courseWhen symptoms worsened again tPA startedDoor to Needle – 64 minutesPt 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 hospitalsBetter systems of careBetter patient outcomes
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