1. The Role of EMS in Emergency Cardiac & Stroke Care
Name, Date
County, Agency
Heart attack, cardiac arrest, and strokes are medical emergencies that are some of the top killers of Americans and leading causes of long-term disability. Today’s training is essential to EMS providers providing quality care to emergency cardiac and stroke patients in the field no matter where they are in the state of Washington. The system and the protocols and tools discussed in this training are the result of years of work by scores of volunteers from state agencies, EMS agencies, hospitals, dispatch agencies, and consumer organizations.

2. Objectives
Introduce Washington’s new Emergency Cardiac and Stroke System
Review cardiac & stroke protocol guidelines
Review cardiac & stroke triage tools
Administer stroke F.A.S.T. assessment
Apply triage tools
Discuss cardiac & stroke quality improvement opportunities
Through the course of this training we’ll meet the following objectives:
Introduce Washington’s new emergency cardiac & stroke system
Review cardiac & stroke protocol guidelines based on statewide standard protocols
Review the new statewide cardiac & stroke triage tools
Learn to correctly administer stroke FAST assessment and use the findings to triage patients and report the findings to the destination hospital
Learn to apply the triage tools in our community; and,
Discuss cardiac & stroke quality improvement opportunities

3. Emergency Cardiac & Stroke System
Why do we need a system?
What are the components?
How will it work in Washington?
First, we’ll discuss Washington’s new emergency cardiac and stroke system—why a system is necessary, what the components are, and what the overall structure is in Washington.

4. Why do we need a system?
Systems minimize delays in the chain of survival
Deliver the right patient,
to the right place,
in the right amount of time.
Just like Washington’s trauma system, the goals of the emergency cardiac and stroke system are to minimize delays in the chain of survival by standardizing care to follow evidence-based guidelines. Having a system that spans from patient to dispatch to EMS to treatment in an appropriate hospital will ensure that we deliver the right patient to the right place in the right amount of time.

5. Why do we need a system? People aren’t getting proven treatments
Only 3% strokes get t-PA
Only 35 of 95 hospital administered t-PA
Estimated 39% of heart attacks get PCI
Only 55% of hospitals give lytics under 30 min
OHCA survival rates very low
Variation in care and outcomes across the state
Population at greatest risk increasing rapidly
Time to treatment makes big difference in outcomes
Because we can do better
In 2006 the EMS and Trauma Care Steering Committee with help of the Washington State Department of Health formed an Emergency Cardiac and Stroke Work Group to assess whether people in Washington were getting the treatments proven to save lives. The findings of the work group were published in a report in 2008 and revealed that less than 40% of heart attacks were receiving percutaneous coronary intervention (PCI), land less than 3% of ischemic strokes were getting tPA to break up the blood clot (while 10-20% are eligible), despite these being the recommended treatments. Less than half of our hospitals were administering tPA. We also know that only 55% of hospitals that rely on lytics for heart attack give it within the recommended 30 minutes of arrival time. The study also found that there was wide variation in care and outcomes across the state.
These findings are particularly alarming since the population at highest risk of cardiovascular emergencies is increasing rapidly.
Despite these challenges, we know that reducing time to evidence-based treatment makes a big difference in patient outcomes. Thus, the report also identified recommendations to make the needed improvements through a syste approach.

6. The benefits of early defibrillation and treatment for cardiac arrest are well known. Clearly minutes also matter when it comes to other cardiac emergencies, especially ST-segment elevation myocardial infarctions (STEMIs). TIME IS MUSCLE. This graph shows a dramatic increase in mortality for patients that had longer hospital door to balloon (or PCI) times. One of the well documented strategies for helping hospitals reduce door to balloon times is through early activation by EMS.

7. D2N and Mortality
Similarly, data shows that longer door to tPA times increase the risk of stroke mortality. Faster is better—TIME is BRAIN. Circulation journal report: Researchers' analysis found that every 15-minute reduction in tPA administration time was associated with a 5 percent lower risk of in-hospital mortality, even with extensive risk adjustment for all types of stroke patients.
McNamara, et al.; American Journal of Cardiology

8. In 2004 the American Stroke Association put together a writing group and published a paper recommending establishing a system of care for stroke patients, spanning from community education, to pre-hospital providers, to hospital and rehabilitation. In 2007 a writing group called for a similar system approach to STEMI care, followed by recommendations for systems of care for cardiac arrest in 2010.

9. Systems Work! National momentum Examples
American Heart Association/American Stroke Association
American College of Cardiology
Centers for Disease Control - CARES
Society for Chest Pain Centers
CMS
Examples
North Carolina RACE
Los Angeles
Minnesota Cardiac Level 1
Spokane and North Puget Sound Cardiac Level 1
Cascade HeartRescue
The published papers laid a foundation for nation-wide momentum to approach care from a more holistic viewpoint. The American Heart Association and American Stroke Association launched initiatives for stroke and STEMI systems, as well as an initiative to decrease door to needle times. American College of Cardiology worked with hospitals to reduce door to balloon times. The CDC provided funding to heart disease and stroke prevention programs to create cardiac and stroke systems. The Society for Chest Pain Centers began certifying Chest Pain Centers and Center for Medicare Services is monitoring quality of cardiac and stroke care.
Many regions of the country have established systems that are working. North Carolina has a statewide system for STEMI care, Los Angeles and the surrounding areas determined which hospitals are STEMI receiving centers and which are referral centers and are using those designations for triage, and Minnesota established a cardiac system to quickly transfer patients for PCI. The Minnesota model was adopted by the greater Spokane and North Puget Sound areas. Stroke systems have been established in many states, including Massachusetts, Florida, Arizona, Montana, among others.
Add notes on Cascade HeartRescue and WA CARES

10. System Components Dispatch 911 Neurology / Cardiology
Complete systems should include all of the following components working consistently and cooperatively:
Patients and the public need to be educated to recognize the signs and symptoms and to quickly call 911
Dispatch operators need to have quick procedures to recognize potential cardiac and stroke emergencies and dispatch appropriate personnel as quickly as possible
Prehospital personnel should have standard assessment, treatment, and triage procedures to appropriate hospitals
Emergency rooms should also have standard assessment, treatment, and triage procedures for walk-in patients
Neurology or cardiology should find ways to reduce time to treatment by activating stroke or cardiac teams based on prehospital or ER notification.

11. Washington’s Approach
Emergency Cardiac & Stroke Technical Advisory Committee made recommendations on:
Dispatch guidelines
Standardized EMS protocol guidelines
Standardized EMS triage tools
Voluntary hospital categorization
Quality improvement & data collection
Public education
The report and recommendations from the Emergency Cardiac & Stroke workgroup laid the foundation for a system approach in Washington and led to the formation of the Emergency Cardiac and Stroke Technical Advisory Committee (ECS TAC) to work on implementation. This one of the TAC’s under the EMS/Trauma Care Steering Committee. The committee has taken many of their cues for system creation from Washington’s trauma system, as well as from national papers, and existing systems in Washington or around the country.
Although recommendations from the committee touch on public education, most of the work has been on prehospital and hospital aspects of emergency cardiac and stroke care. The committee developed cardiac & stroke dispatch guidelines, standardized EMS protocol guidelines, standardized EMS triage tools, voluntary hospital categorization levels, and a set of recommendations for data collection.
The EMS protocol guidelines, EMS triage tools, and hospital categorization levels have been approved by the Governor’s Steering Committee from EMS and Trauma as the state standard. Today, we’ll examine those tools to ensure that we are using them most effectively in our communities.

12. SSHB 2396 Passed in 2010
In addition to the recommendations in the report and the work done by the ECS TAC, The Legislature recognized the need for an emergency cardiac and stroke system like our Trauma System. In 2010, they passed SSHB This law requires the Department of Health to:
Support an Emergency Cardiac and Stroke System.
Adopt cardiac and stroke PCPs, protocol guidelines, triage and transport procedures for EMS
Encourage hospitals to voluntarily participate in the system by self-certifying they meet criteria
Require participating hospitals to participate in quality improvement activities
Expand the scope of regional quality assurance programs to include evaluation of emergency cardiac and stroke care delivery.
In a nutshell, the law requires EMS to take heart attack, CPA-ROSC, and stroke patients to specified hospitals based on transport times – to get the right patient to the right place in time for treatments to work. By doing so, we’ll improve care and outcomes.

13. Here’s a basic schematic of Washington’s system and goals.

14. Emergency Cardiac Care
Partially blocked artery
Emergency Cardiac Care
Prehospital protocol guidelines
Triage tool
Hospital levels
Completely blocked artery
Now we’ll look specifically at the process of caring for emergency cardiac patients. In this case, emergency "Cardiac" means acute coronary syndrome, an umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia, which is chest discomfort or other symptoms due to insufficient blood supply to the heart muscle resulting from coronary artery disease. This includes both STEMIs (completely blocked arteries) and NSTEMIs (partially blocked arteries). Emergency "Cardiac" also includes out-of-hospital cardiac arrest, which is the cessation of mechanical heart activity as assessed by emergency medical services personnel, or other acute heart conditions.
We’ll review the protocol guidelines for treatment in the field, the standard triage tool, and briefly look at the hospital categorization levels.

15. Prehospital Protocols
NOTE: Insert your DOH approved local protocols if different from but consistent with the ACS protocol guidelines that follow this slide. You might also want to insert your CPA-ROSC protocols and any other cardiac protocols you have since the triage and destination procedure includes CPA-ROSC.

16. ACS BLS Protocol
I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABC’s B) Be prepared to provide CPR/defibrillation
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
It’s important during the patient survey to determine whether or not the patient fits into the ACS triage protocol. (Next slide emphasizes signs and symptoms)
If ACS is suspected, BLS providers should request ALS response or arrange for rendezvous if it’s available. It’s important to remember that time is of the essence, so scene time should be limited as much as possible.

17. ACS BLS Protocol (cont.)
II. Focused History and Physical Exam
A) Assess patient for signs and symptoms of Acute Coronary Syndrome (ACS)
Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.
Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.
Shortness of breath with or without chest discomfort.
Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.
(Discuss things to look for in assessing the patient, emphasizing that it’s not all about chest pain.)

18. ACS BLS Protocol (cont.)
Other symptoms may include sweating, nausea, vomiting, or dizziness and weakness.
Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

19. ACS BLS Protocol (cont.)
B) If possible ACS patient – request ALS response or arrange ALS rendezvous. Optional in areas without ALS or 12-lead capable ILS: Perform 12-lead ECG according to local operating procedures, and alert receiving facility with results; repeat ECG if signs or symptoms change. C) Limit scene time with goal of ≤ 15 minutes

20. ACS BLS Protocol (cont.)
III. Management
A) Administer oxygen per protocol
B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history)
C) Assist patient with own nitro
Contraindications:
SBP <90 mm Hg.
Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min)
Erectile dysfunction drugs taken within 48 hours.
Cautions:
Borderline hypotension (SBP 90 to 100 mm Hg)
Borderline bradycardia (HR<60/min)
Extreme caution in patients who may have RV infarction
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
If a patient has prescribe nitroglycerin you may assist them with it. However, when unsure about the listed contraindications or cautions it’s prudent to err on the side of caution.
Oxygen: changing standards for how much oxygen to administer to ACS patients, suggest using “per protocol” phrase since

21. ACS BLS Protocol (cont.)
IV. Ongoing Assessment
V. Transport
Follow State Prehospital Cardiac Triage Destination Procedure
Note: If 12 lead ECG and interpretation (by crew or machine) can be obtained in the field—obtain as soon as possible and alert receiving facility with results
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
Later in the training we’ll go step by step through the triage/destination procedures.
(Remove information on 12-lead if not available to your BLS providers)
Some areas of the country are piloting the use of 12 lead ECG acquisition and computer interpretation by BLS providers. In areas that have no or limited ALS coverage this strategy may improve prompt identification and triage of STEMI patients.

22. ACS ILS Protocol I. Scene Size-Up/Initial Patient Assessment
A) Monitor/support ABCs
B) Be prepared to provide CPR/Defibrillation
II. Focused History and Physical Exam
Assess patient for signs and symptoms of Acute Coronary Syndrome (same as in BLS)
Encourage ILS 12-lead ECG in the field and alert receiving facility with results
C) If possible ACS patient – request ALS response
1) Alternative: Arrange ALS rendezvous
D) Limit scene time with goal of ≤ 15 minutes
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing assessing for signs of ACS and differences between ILS and BLS protocol. Differences are noted by underlined text)
Applicability for triage:
≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease:
Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.
Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.
Shortness of breath with or without chest discomfort.
Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.
Other symptoms may include sweating, nausea, vomiting.
Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

23. ACS ILS Protocol (cont.)
III. Management
A) Administer oxygen per protocol
B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history)
C) Administer nitro
Contraindications:
SBP <90 mm Hg.
Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min)
Erectile dysfunction drugs taken within 48 hours.
Cautions:
Borderline hypotension (SBP 90 to 100 mm Hg)
Borderline bradycardia (HR<60/min)
Extreme caution in patients who may have RV infarction
D) IV access (do not delay transport to gain IV access)
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing differences between ILS and BLS protocol. Differences are noted by underlined text)
If you are unsure about possible cautions or contraindications to nitroglycerin use, err on the side of caution and do not administer it. If there is difficulty obtaining IV access, do not delay transport.

24. ACS ILS Protocol (cont.)
IV. Ongoing Assessment
V. Transport
A) Follow State Prehospital Cardiac Triage Destination Procedure
B) IV, NTG
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing differences between ILS and BLS protocol. Differences are noted by underlined text)
Later in the training we’ll go step by step through the triage/destination procedures.

25. ACS ALS Protocol I. Scene Size-Up/Initial Patient Assessment
A) Monitor/support ABCs
B) Be prepared to provide CPR/Defibrillation
II. Focused History and Physical Exam
Assess patient for signs and symptoms of Acute Coronary Syndrome (same as BLS and ILS)
12-lead ECG (repeat ECG if signs or symptoms change)
Limit scene time with goal of ≤ 15 minutes
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing differences between ALS and ILS protocol. Differences are noted by underlined text. Once again emphasize the signs of ACS above and beyond classic chest pain)
Acquiring and interpreting (computer or otherwise) the 12-lead ECG is an important aspect of ensuring the prompt and appropriate triaging of patients. Acquiring and/or repeating the ECG may be done in transit as needed to ensure that scene time is limited.
Applicability for triage:
≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease:
Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.
Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.
Shortness of breath with or without chest discomfort.
Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.
Other symptoms may include sweating, nausea, vomiting.
Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

26. ACS ALS Protocol (cont.)
III. Management
A) Notify receiving hospital with transmission and/or interpretation of ECG
B) Administer oxygen
C) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history)
D) Administer nitro
Contraindications:
SBP <90 mm Hg.
Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min)
Erectile dysfunction drugs taken within 48 hours.
Cautions:
Borderline hypotension (SBP 90 to 100 mm Hg)
Borderline bradycardia (HR<60/min)
Extreme caution in patients who may have RV infarction
E) IV access
F) Administer opiates as needed for pain control
G) Complete fibrinolytic checklist (recommended)
H) Consider field fibrinolysis if transport time ≥ 60 minutes and acute symptom onset < 3 hours
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing differences between ALS and ILS protocol. Differences are noted by underlined text.)
If the ECG indicates that the patient is having a STEMI, it’s important to specifically state that when notifying the receiving hospital so that the hospital may activate the appropriate protocols and personnel.
Completing a fibrinolytic checklist is primarily important if the triage tool would normally direct you to a non-PCI (Level 2) hospital as the destination. If the patient is ineligible for fibrinolytics, talk to medical control about alternative options to ensure the patient can receive appropriate therapies.
To complete the fibrinolytic checklist examine the following contraindications. If the answer is YES to any of these, fibrinolysis MAY be contraindicated:
Does the patient have severe heart failure or cardiogenic shock such that PCI is preferable?
Systolic BP greater than 180 mm Hg
Diastolic BP greater than 110 mm Hg
Right vs. left arm systolic BP difference greater than 15 mm Hg
History of structural central nervous system disease
Significant closed head/facial trauma within the previous three months
Recent (within six weeks) major trauma, surgery (including laser eye surgery), GI/GU bleed
Bleeding or clotting problem or on blood thinners
CPR greater than 10 minutes
Pregnant female
Serious systemic disease (e.g., advanced/terminal cancer, severe liver or kidney disease)
(Discuss field fibrinolysis as applicable and included in county protocols)

27. ACS ALS Protocol (cont.)
IV. Ongoing Assessment
A) Cardiac Bio Markers (optional)
B) Repeat ECG every 15 minutes
V. Transport
A) Follow State Prehospital Cardiac Triage Destination Procedure
B) IV, NTG
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol, emphasizing differences between ALS and ILS protocol. Differences are noted by underlined text.)
Cardiac biomarker testing may be done if it’s part of your county protocols, but are optional. Biomarker testing and repeating ECGs should not delay transport.

28. Triaging to “the right place”
Level One
Level Two
Perform PCI 24/7 within 90 minutes
Interventional cardiologists and cath lab team available within 30 minutes 24/7
Cardiac surgery onsite or transfer agreements
Administer fibrinolytics 24/7 within 30 minutes
ACLS trained providers
Next we’ll review the Prehospital Cardiac Triage Procedure, commonly called the cardiac triage tool. The purpose of the tool is to identify ACS patients in the field and ensure they are transported to the most appropriate hospital – to “get the right patient to the right place at the right time.” Faster times to reperfusion can reduce death and disability in ACS patients. An organized response system that includes standardized protocols, triage, and transport procedures reduces time to treatment. ACS patients meeting the triage criteria should be transported directly to a hospital that performs primary percutaneous coronary intervention (PCI) when available within specified timeframes. This may include patients with unstable angina and non-ST elevation acute coronary syndromes (UA/NSTE), as well as those that are resuscitated after a cardiac arrest. These patients have an equally significant prognosis and merit comprehensive treatment in specialized cardiac centers.
There are 2 levels for cardiac care:
Level I hospitals must be able to perform Percutaneous Coronary Intervention (PCI aka angioplasty) within 90 minutes of the patient’s arrival 24 hours a day and 7 days a week. They must also have interventional cardiologists and a cath lab team available within 30 minutes. Some level 1 hospitals will have cardiac surgery available onsite. If they do not, then they will have transfer agreements in place with a hospital that does.
Level II hospitals are able to administer fibrinolytics to break up the clot within 30 minutes of arrival on a 24/7 basis. They also have trained ACLS providers and may or may not have cardiologists on staff. These hospitals would also have agreements in place with Level One facilities. Many will assess a patient and immediately transfer to a level I for PCI or other specialized cardiac care.

29. Cardiac Triage Tool
Assess Applicability for Triage
Post cardiac arrest with ROSC
-OR-
≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease:
Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.
Pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.
Shortness of breath with or without chest discomfort.
Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.
Other symptoms may include sweating, nausea/vomiting, lightheadedness.
NOTE: Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.
Transport per regional patient care procedures
YES
If ALS has not been dispatched, upgrade if available. NO
Assess Immediate Criteria
Post cardiac arrest with return of spontaneous circulation
Hypotension or pulmonary edema
EKG positive for STEMI (if available)
Assess applicability for triage –The purpose of this first level of assessment is two-fold: rule-out those that are not ACS, and rule-in those that are ACS but whose symptoms don’t fit the classic chest pain/discomfort. Women, diabetics, and geriatric patients often have symptoms other than chest pain/discomfort.

30. Cardiac Triage Tool (cont.)
Assess Immediate Criteria
Post cardiac arrest with return of spontaneous circulation
Hypotension or pulmonary edema
EKG positive for STEMI (if available)
YES
If ALS has not been dispatched, upgrade if available.
Assess High Risk Criteria
In addition to symptoms in Box 1, pt has 4 or more of the following:
Age ≥ 55
3 or more CAD risk factors:
 family hx
 BP
 cholesterol
 Diabetes
 current smoker
Aspirin use in last 7 days
≥2 anginal events in last 24 hours, including current episode
Known coronary disease
ST deviation ≥ 0.5 (if available)
Elevated cardiac markers
(if available) NO
YES NO
Assess immediate criteria – A positive finding in any of these more definitive criteria means it is highly likely the patient is experiencing an acute coronary event. Point of care biomarkers may be used to augment triage decisions at the discretion of the medical program director; they are not required. Only definitely positive results (high probability) should be used as immediate criteria for triage.
Assess high risk criteria – The high risk criteria box attempts to identify patients experiencing acute coronary syndrome who are not identified by the “immediate criteria,” or for whom a 12-lead EKG is not available (in the case of BLS not equipped with EKG equipment).
YES
If EMS personnel still suspect ACS, contact medical control for destination. If not, transport per regional patient care procedures.

31. Assess High Risk Criteria (4 or more)
3 or more CAD (coronary artery disease) risk factors:
Age ≥ 55 (epidemiological data in WA State show that incidence of heart attack increases at this age)
Family history: father or brother with heart disease before 55, or mother or sister before 65
High blood pressure: ≥140/90, or patient/family report, or on blood pressure medication
High cholesterol: patient/family report or on cholesterol medication
Diabetes: patient family report
Current smoker: patient family report
Aspirin use in last 7 days: any aspirin use in last 7 days
≥2 anginal events in last 24 hours: 2 episodes of symptoms described in first box of the triage tool, including the current event
Known coronary disease: history of angina, heart attack, cardiac arrest, congestive heart failure, balloon angioplasty, stent, or bypass surgery
ST deviation ≥ 0.5 mm (if available): ST depression ≥ 0.5 mm is significant; transient ST elevation ≥ 0.5 mm for < 20 minutes is treated as ST-segment depression and is high risk; ST elevation >1 mm for more than 20 minutes places these patients in the STEMI treatment category
Elevated cardiac markers (if available) CK-MB or Troponin I in the "high probability" range of the device used. Only definitely positive results should be used in triage decisions.
When Assessing the High Risk Criteria—please remember that the patient has to be positive for 4 or more criteria.

32. No High Risk Criteria—but EMS still suspects ACS Patient
Even if patient does not meet High Risk Criteria (i.e. only 3 boxes positive), EMS crew may still have high index of suspicion that patient is a high risk ACS patient (i.e. patient has had 4 stents and states “this feels just like last heart attack”)
Contact medical control and consult with physician or RN for appropriate patient destination.
When contacting medical control, be as descriptive as possible in “painting picture” of patient presentation.

33. Cardiac Triage Tool (cont.)
Go to Level I Cardiac Hospital and alert destination hospital en route ASAP
Assess Transport Time and Determine Destination by Level of Prehospital Care*
Level I Cardiac Hospital w/in 30 minutes
Level I Cardiac Hospital w/in 60 minutes
Level II Cardiac Hospital 60 minutes closer than Level I?
Level II Cardiac Hospital 30 minutes closer than Level I?
Go to Level I Cardiac Hospital and alert destination hospital en route ASAP
Go to closest Level II Cardiac Hospital and alert destination hospital en route ASAP
YES
Unstable patients with life-threatening arrhythmias, severe respiratory distress, or shock unresponsive to EMS treatment should be taken to the closest hospital. NO
BLS/ILS
ALS
YES
Determine destination and alert hospital pre-arrival – The general guideline is take a patient experiencing ACS directly to a Level 1 cardiac hospital if there is one within 30 minutes transport time for BLS and 60 minutes for ALS. However, slight modifications to the 30/60 minute timeframe may be made where a Level 1 cardiac hospital is not much farther than a Level 2. The benefits of faster reperfusion with angioplasty at a Level 1 can outweigh the additional transport time. Modifications must be consistent with regional patient care procedures. Air transport may be factored in.
If there are two or more Level I (or level II) facilities in close proximity (no more than 15 minutes difference in transport time), patient preference, physician practice patterns, and local rotation agreements may be considered in determining destination.

34. Asses Transport Time & Determine Destination by Level of Prehospital Care
Slight modifications to the transport times may be made in county operating procedures.
Consider ALS and air transport for all transports greater than 30 minutes.
If there are two or more Level I facilities to choose from within the transport timeframe, patient preference, insurance coverage, physician practice patterns, and local rotation agreements may be considered in determining destination. This also applies if there are two or more Level II facilities to choose from.

35. Determine Destination
The general guideline is to take a patient meeting the triage criteria directly to a Level I cardiac (24/7 Cardiac Cath Lab) hospital within reasonable transport times. For BLS, this is generally within 30 minutes transport time, and for ALS, generally 60 minutes transport time (see next section for further guidance).
Inform the hospital en route so staff can activate the cath lab and call in staff if necessary.
From the prehospital standpoint, the major difference between a Cardiac Level I and Cardiac Level II, is that the Level I has a 24/7 available cath lab to use PCI for STEMI patients, whereas the Level II can only use fibrolynitics (i.e. TPA).

36. Cardiac Destination Examples
Insert examples from your area
BLS examples:
A) minutes to Level 1 – minutes to Level 2 = 29: go to Level 1
B) Minutes to Level 1 – minutes to Level 2 = 35: go to Level 2
ALS examples:
A) minutes to Level 1 – minutes to Level 2 = 45: go to Level 1
B) Minutes to Level 1 – minutes to Level 2 = 68: go to Level 2
If ineligible for fibrinolytics, transport to closest Level 1 hospital even if greater than 60 minutes or rendezvous with air transport.
EMS must inform the hospital en route so staff can initiate cardiac protocols and call in staff if necessary.
To determine whether to transport beyond the 30 or 60 minutes, figure the difference in transport time between the Level 1 cardiac hospital and the Level 2 cardiac hospital. For BLS, if the difference is greater than 30 minutes, go to the Level 2 cardiac hospital. For ALS, if the difference is greater than 60 minutes, go to the Level 2 cardiac hospital.
Consider ALS using fibrinolytic checklist to determine if patient is ineligible for fibrinolysis. If ineligible, transport to closest Level 1 hospital even if greater than 60 minutes or rendezvous with air transport.
For both Level 1 and Level 2, EMS must inform the hospital en route so staff can initiate cardiac protocols and call in staff if
necessary.

37. Emergency Cardiac Hospitals
Cardiac team activation policy and criteria based on EMS pre-arrival notification
Cardiac protocols include use of induced hypothermia for post-cardiac arrest patients.
Participate in regional QI program that includes EMS
Provide training for EMS if requested, particularly in reading ECG for STEMI
No divert policy for emergency cardiac cases
All Washington hospitals are encouraged to participate in the cardiac system of care and to identify their hospital’s capabilities. All participating hospitals must, among other things:
Have a cardiac team activation policy and criteria based on EMS prearrival notification
Have established cardiac treatment protocols, including initiation of hypothermia for appropriate patients (not all EMS providers may be familiar with concept)
Participate in a regional quality improvement program that include EMS
Assist with training and clinical education of EMS, particularly in reading ECG for STEMI
Have a no divert policy for emergency cardiac patients

38. Hospital Levels-Emergency Cardiac
Level One
Level Two
Perform PCI 24/7 within 90 minutes
Interventional cardiologists and cath lab team available within 30 minutes 24/7
Cardiac surgery onsite or transfer agreements
Administer fibrinolytics 24/7 within 30 minutes
ACLS trained providers
Just to review…

39. Our Local Cardiac Hospitals
In our area, the following hospitals have identified themselves as
Level One:
Level Two:
Level Ones
Level Twos

40. Insert Local Destination Examples
(insert local destination examples applying the triage tool to the identified hospitals)

41. Acute Stroke Prehospital protocol guidelines Triage tool
Hospital levels
Now we’ll look specifically at the process of caring for acute stroke patients.
Strokes, or brain attacks, are a major cause of death and permanent disability. They occur when blood flow to a region of the brain is obstructed and may result in death of brain tissue. There are two main types of stroke: ischemic and hemorrhagic. Ischemic stroke is the most common and is caused by blockage in an artery that supplies blood to the brain, resulting in a deficiency in blood flow. Hemorrhagic stroke is caused by the bleeding of ruptured blood vessels in the brain. During ischemic stroke, diminished blood flow initiates a series of events that may result in additional, delayed damage to brain cells. Early medical intervention can halt this process and reduce the risk for irreversible complications.
We’ll now review the protocol guidelines for treatment in the field, the standard triage tool, and briefly look at the hospital categorization levels.

42. Signs of a Stroke
To determine if someone might be having a stroke look for any of these five signs:
Talk: Sudden confused speech, slurred speech, inability to talk, or droopy face
Reach: Sudden numbness or weakness in one arm or leg
Feel: Sudden severe headache with no known cause
Walk: Sudden trouble walking, dizziness, balancing or lack of coordination
See: Sudden trouble seeing in one or both eyes

43. Stroke Protocol I. Scene Size-Up/Initial Patient Assessment
A) Support ABCs
B) Check glucose, temperature, SpO2 (if possible)
C) Treat hypoglycemia (if possible)
D) NPO
II. Secondary Survey
A) Perform FAST Assessment (Face/Arms/Speech/Time last normal). If one component is abnormal, high probability of stroke. Refer to stroke destination triage tool. Time from last normal will determine destination.
B) Limit scene time with goal of ≤ 15 minutes.
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
It’s important during the patient survey to determine whether or not the patient fits into the stroke triage protocol.
We’ll review the steps of FAST later…

44. Stroke Protocol (cont.)
III. Transport A) Early hospital notification - specify FAST findings (issue stroke alert & share abnormal physical findings and time last normal). B) Transport according to Washington State Stroke Triage Tool and regional patient care procedures. C) If closest appropriate facility is greater than 30 minutes, consider air transport when appropriate.
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
It’s important when contacting the hospital to tell them that you are bringing in a possible stroke and share both the abnormal findings that you had from the FAST assessment and share the time last normal. This allows the hospital to activate the appropriate protocol internally.

45. Stroke Protocol (cont.)
IV. Management/Ongoing Assessment en route
A) Lay patient flat unless signs of airway compromise, in which case elevate no higher than 20 degrees.
B) IV access (as able)
Ideally, 16 or 18 ga IV in unaffected arm (affected arm is acceptable)
Normal saline (avoid glucose-containing and hypotonic solutions)
3) Optional: Blood draw with IV start
C) 2nd exam/neuro reassessment
D) Optional: initiate tPA checklist
NOTE: If your county MPD has received state approval for altered protocols replace the protocol sections with those.
(Walk through steps of protocol)
Want more information on the tPA checklist with inclusion and exclusion criteria?
Visit

46. Stroke Triage Tool
The purpose of the Stroke Triage Tool is to help identify stroke patients in the field and ensure they are transported to the most appropriate hospital. Stroke treatment is time-critical – the sooner a patient is treated, the better the outcome. For ischemic stroke, clot-busting medication must be administered within 4.5 hours from time of symptom onset. For hemorrhagic stroke, time is also critical. EMS plays a crucial role in reducing time to treatment by identifying likely stroke patients in the field, providing rapid transport to the closest hospital capable of treating stroke, and notifying the hospital prior to arrival.
If any of the following stroke warning signs are reported you should use the stroke triage tool:
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden, severe headache with no known cause
Yes?

47. Stroke Triage Tool
The next step is to perform the FAST assessment, also known as the Cincinnati Stroke Scale. Let’s look at FAST a little more closely…

48. FAST Assessment
The first aspect is facial droop. Ask the patient to show his or her teeth or smile. Watch closely to observe that both sides of the face move equally. If they don’t, or there is facial droop, that is an abnormal finding.

49. FAST Assessment (cont.)
Ask the patient to close his or her eyes and extend both arms straight out with the palms up and thumbs pointing out for 10 seconds. If one arm drifts down compared to the other or one arm does not move it’s abnormal.

50. FAST Assessment (cont.)
Finally, ask the patient to repeat a simple phrase such as “Firefighters are my friends” or “You can’t teach an old dog new tricks”. If the patient slurs words, says the wrong words, or is unable to speak those are abnormal findings.
If any of those 3 had abnormal findings there is a 72% likelihood that the patient is having a stroke.
In order to proceed with proper triage it’s essential to find out the last time that patient was known to be normal. Ask the patient, the family or bystanders. Without this information doctors can’t administer some of the treatments, such as tPA (clot-busting drug).

51. Destination if YES on F, A, or S
The time windows are important, as different treatments would be applicable. IV-tPA can be given up to 4.5 hours after the time the patient was last known to be normal. IV-tPA can be given at all Acute Stroke level hospitals (Level 1, 2 or 3). Since administering IV-tPA takes about an hour, patients need to be able to arrive at the facility within 3.5 hours of time last normal.
Once a patient is outside of that window there still are other methods that can remove or dissolve the clot that’s causing the blockage. These therapies might include Intra-arterial tPA or the use of devices to remove the clot. These procedures can be done in all Level 1 hospitals (Comprehensive Stroke Centers). Some Level 2 hospitals (Primary Stroke Centers) may also be able to administer Intra-arterial tPA. Patients that are in the 3.5 to 6 hour window should be transported to the nearest acute stroke hospital meeting that criteria.
If time last normal is unknown or is over the 6 hour window, transport the patient to any Level 1, 2, or 3 within 30 minutes per regional patient care procedures and patient/family preference.
To ensure that the destination hospital is set to quickly administer treatment it’s important to alert the hospital en route. You should specifically state that you have a possible stroke with x symptoms (i.e. facial droop, slurred speech).
You may also want to encourage the family to go to hospital to provide medical history, or obtain contact information for someone who can provide a medical history.
“Possible stroke w/ x symptoms”

52. Important Considerations
Report possible tPA contraindications to ED:
Symptom onset more than 180 minutes
Head trauma or seizure at onset
Recent surgery, hemorrhage, or AMI
Any history of intracranial hemorrhage
Minor or resolving stroke
Sustained BP> 185/110 (do not treat!)
Of course, if you are unable to manage the airway you should stop at the nearest facility capable of definitive airway management.
If a stroke center is not available within transport times by ground, consider air transport or contact medical control for destination decision.
If you suspect any of the following contraindications to tPA you should report these to the destination hospital en route as they may be better served at a higher level facility that could use a more advanced therapy.
Symptom onset more than 180 minutes
Head trauma or seizure at on-set
Recent surgery, hemorrhage, or AMI
Any history of intracranial hemorrhage
Minor or resolving stroke
Sustained BP> 185/110 (do not treat!)

53. Hospital Levels-Stroke
Level 1-Comprehensive Stroke Center
Certified Primary Stroke Center that also has:
Neurologist w/in 20 minutes 24/7
Neurosurgeon w/in 30 minutes 24/7
Vascular neurologist and vascular surgeon
Other highly specialized stroke care capabilities
Level 2- Primary Stroke Center
Has the necessary staffing, infrastructure, and programs to stabilize and treat most acute stroke patients.
Some may also have capability to do more advance intra-arterial therapies
Level 3-Acute Stroke Center
Have the infrastructure and capability to care for acute stroke, including administration of IV t-PA
Most stroke patients would be transferred to a Level 1 or 2 post-treatment
All Washington hospitals are encouraged to participate in the stroke system by identifying their stroke capabilities. Our state’s system has three categories of hospitals.
These are some of the major distinctions between the 3 levels:
Level 1-Comprehensive Stroke Center
Certified Primary Stroke Center that also has:
Neurologist w/in 20 minutes 24/7
Neurosurgeon w/in 30 minutes 24/7
Vascular neurologist and vascular surgeon
Other highly specialized stroke care capabilities
Level 2- Primary Stroke Center
Has the necessary staffing, infrastructure, and programs to stabilize and treat most acute stroke patients.
Some may also have capability to do more advance intra-arterial therapies
Level 3-Acute Stroke Center
Have the infrastructure and capability to care for acute stroke, including administration of IV t-PA
Most stroke patients would be transferred to a Level 1 or 2 post-treatment

54. Our Local Stroke Hospitals
In our area the following facilities have identified themselves in these levels:
Level One:
Level Two:
Level Three:

55. Insert Local Destination Examples
(insert local destination examples applying the triage tool to the identified hospitals)

56. Working Systems Data collection Quality improvement Resources & tools
Systems of care require concerted data collection and a continual quality improvement process. The Emergency Cardiac and Stroke Technical Advisory Committee have made recommendations for data that should be monitored and evaluated on a local and systems level. We’ll now look at what those elements are for EMS and discuss ways to collect those. Finally, we’ll outline further resources that may help in your cardiac and stroke work.

57. Data and Quality Improvement
ECS TAC Report: Develop a comprehensive data system to demonstrate the effectiveness of the ECS system and improve performance. Include dispatch, EMS and hospitals, and use existing data systems (WEMSIS!) to avoid duplicate data entry and analysis. EMS/T Strategic Plan: Goal 19, Objective 5: Local Quality Improvement By June 2012 regional cardiac and stroke systems evaluate system performance through a quality improvement process.
The Emergency Cardiac and Stroke Technical advisory group recommends in their report a comprehensive data system that would demonstrate the effectiveness of the ECS system and improve performance. Ideally dispatch, EMS and hospitals would use existing data systems and avoid duplicate data entry and analysis whenever possible. WEMSIS is an existing tool for EMS data collection and can be a great vehicle for collecting, sharing and analyzing cardiac and stroke data points.
Quality improvement is also an important piece of the EMS & Trauma strategic plan. Goal 19, objective 5 aims to improve local quality improvement by asking regional cardiac and stroke systems to evaluate system performance through a quality improvement process.
So, how do we get there? The ECS TAC has outlined key system measures that can help us measure our performance.

58. Key System Measures Time from onset to 911 call
Time from first medical contact (EMS or first ED) to treatment (e.g., balloon or t-PA)
On-scene time
Time from onset to treatment (e.g., balloon or t-PA)
These are they key measures that are related to EMS; there are others that are recommended for hospitals as well.
The key measures are:
Time from onset to 911 call
Time from first medical contact (EMS or first ED) to treatment (balloon or t-PA)
On-scene time
Time from onset to treatment (balloon or t-PA)
Additionally, some measures relate to the patients’ role in the system of care.

59. Key System Measures % of cardiac/stroke patients that arrive by EMS
% of patients EMS notified hospital pre-arrival
Cardiac arrest measures (future)
We know that patient delay in seeking treatment is one of the main reasons for people not getting treatment in time. Average wait times are from 1-6 hours, and sometimes weeks for milder heart attack symptoms. We also know that many patients don’t call 911. But if patients call 911, and if EMS notifies the hospital en route of an incoming stroke or heart attack, a lot of time can be saved. We’re hoping to see an increase over time in the % of patients that arrive by EMS as a result of public education efforts. It would be great to have EMS include education on signs and symptoms of heart attack and stroke and the importance – really the life-saving benefits – of calling 911 instead of having family drive them, or God forbid, driving themselves. You could do this in your community outreach and education about 911 and EMS, through your newsletters, and in conjunction with blood pressure screening if you do this at your firehouses. Participating hospitals will be required to do education around this, too.
Cardiac arrest measures will be included in the future. The ECS system is not limited to heart attack and stroke. It includes cardiac arrest, and will capture other acute cardiac conditions. Cardiac arrest data will be included in the future, in coordination with the cardiac arrest registry project.

60. Some of the Data Elements
Time of symptom onset
PSAP call receipt
Time of dispatch
Time of EMS arrival at patient’s side
Time left scene
Time arrived at hospital
FAST, ECG or other clinical findings
(Resuscitation efforts and outcomes)
Medications administered
To be able to evaluate those key measures, these are the main data elements that need to be collected:
Time of symptom onset
PSAP call receipt
Time of dispatch
Time of EMS arrival at patient’s side
Time left scene
Time arrived at hospital
FAST, ECG or other clinical findings
(Resuscitation efforts and outcomes)
Medications administered

61. Essential from EMS for QI
Patient reports on paper (e.g., run sheets) to the receiving hospital are critical for system evaluation and QI. Data elements to be determined, consistent with NEMSIS.
Those elements are important for EMS to analyze internally, but they must also be shared with the receiving hospital in order to look at some of the measures that span from EMS to the patient outcome. According to WAC a written report must be given to the hospital within 24 hours of patient delivery (add most current requirement here when revised WAC is final).
The handoff of patient reports to the receiving hospital are critical for the immediate care of the patient, as well as overall system evaluation and quality improvement.

62. Quality Improvement
Dispatch, pre-hospital and hospital partners should work together to set goals and ensure they are being met
Washington’s law allows cardiac and stroke cases to be discussed in the regional EMS/Trauma QI forums
Cardiac and stroke should be evaluated just as the trauma system uses the regional EMS & Trauma quality improvement committees to evaluate trauma patients on a regional level. Quality improvement cannot be done in isolation, rather through a collaboration of dispatch, pre-hospital and hospital partners.
Washington’s trauma quality improvement law has now been modified to allow cardiac and stroke cases to be discussed in the regional EMS/Trauma QI forums within discoverability protections. If your area is not yet doing this, this is a great opportunity to build on an existing structure to take a comprehensive approach to cardiac and stroke patient care and overall system improvement.

63. Resources & Tools
Emergency Cardiac and Stroke System
Development of Systems of Care for STEMI Patients: The EMS and ED Perspective;
Implementation Strategies for EMS Within Stroke Systems of Care ow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Implementa tion+strategies&searchid=1&FIRSTINDEX=0&resourcetype=HWCI T&eaf
AHA E-learning: Learn Rapid STEMI ID, Prehospital Stroke alog
Stroke Rapid Response™  Prehospital Education Training ials
Washington Stroke Forum
Please visit the links above for more detailed information on the ECS Report, as well as national papers that were used to form Washington’s approach to cardiac and stroke systems.
Additionally, several links lead you to additional training resources on cardiac and stroke care.