1. County of Kern EMERGENCY MEDICAL SERVICES Kern County Stroke Center Policies – Implementation Training October 2008 Policies Effective – November 1, 2008 “Time is Brain”

2. County of Kern EMERGENCY MEDICAL SERVICES Objectives of the Policy Provide rapid evaluation and appropriate treatment for all eligible stroke cases in the shortest time possible. In addition, a stroke center must have a component that addresses comprehensive post treatment management/rehabilitation, and involvement in pre-hospital personnel training. The EMS system objective is to transport qualifying stroke patients to a designated stroke center.”

3. County of Kern EMERGENCY MEDICAL SERVICES Target for Training –Pre-hospital EMT-1, Paramedic & Flight Nurse transport personnel –All base & receiving hospital emergency department personnel –Emergency Medical Dispatchers (EMD) Purpose: –To implement Kern County Stroke Center Policies Countywide

4. County of Kern EMERGENCY MEDICAL SERVICES Presentation Overview 1.Policies 2.Designated stroke center(s) 3.Stroke center activation protocol (CPSS- based) 4.Ambulance transport destination policy changes 5.Interfacility transfer of stroke cases 6.Frequently asked questions and answers 7.Further information resources

5. County of Kern EMERGENCY MEDICAL SERVICES Policy Contents Effective November 1, 2008 at 0800 hours. Contains the following main topics: –Application criteria –Designation and re-designation process –Stroke center performance requirements –Quality improvement –Stroke center activation protocol –Pre-hospital transport destination directions –On Internet at EMS Department’s website

6. County of Kern EMERGENCY MEDICAL SERVICES Hospital Standards Any paramedic base hospital in Kern is eligible to apply to EMS for designation. Must be Joint Commission of Accreditation of Healthcare (JCAH) certified as a stroke center. Must maintain compliance with JCAH stroke center requirements and guidelines. Must maintain the following: –Core Stroke Team available 24/7 –2 CT scanners –Immediate access to neurologist, if needed –2 hour time standard for neurosurgeon, if needed

7. County of Kern EMERGENCY MEDICAL SERVICES Hospital Standards Extensive stroke center data reporting requirements to JCAH ALL types of acute stroke are included; not just cases that are fibrinolysis (tPA) eligible. Each stroke center is obligated to accept an interfacility transfer from a Kern County hospital of any stroke case meeting the stroke center activation protocol criteria.

8. County of Kern EMERGENCY MEDICAL SERVICES Hospital Standards Re-designation every two years through JCAH As of August 15, 2011, there are four EMS designated stroke centers in Kern County: –San Joaquin Community Hospital – Bakersfield –Bakersfield Memorial Hospital –Mercy Hospital –Mercy Southwest Hospital Other hospitals are eligible to become stroke center designated in the future.

9. County of Kern EMERGENCY MEDICAL SERVICES

10. County of Kern EMERGENCY MEDICAL SERVICES SIGNS/SYMPTOMS OF CEREBRAL VASCULAR ACCIDENT RULE OUT HYPOGLYCEMIA AND NARCOSIS AS APPROPRIATE ASSESS ONSET OF SIGNS OR SYMPTOMS Examples: Facial Droop One Sided Weakness One Sided Paralysis Sensory Dysfunction Altered Mental Status Unconscious Examples: Glucose Analysis Hypoglycemia Signs or Symptoms Opiate Intoxication Signs or Symptoms Total Time Since Onset of Signs or Symptoms: Within 3 Hours Over 3 Hours Validity of Information?

11. County of Kern EMERGENCY MEDICAL SERVICES ASSESS PATIENT IN ACCORDANCE WITH CINCINNATI PREHOSPITAL STROKE SCALE (CPSS) FACIAL DROOP (Have the Patient Show Teeth or Smile) - Normal: Both Sides of Face Move Equally - Abnormal: One Side of Face does not Move as Well as the Other Side ARM DRIFT (Patient Closes Eyes and Extends Both Arms Straight Out, with Palms Up, for 10 Seconds) - Normal: Both Arms Move the Same or Do Not Move at All - Abnormal: One Arm does Not Move or One Arm Drifts Down Compared to the Other ABNORMAL SPEECH (Have the Patient Say “You can’t teach an old dog new tricks”) - Normal: Patient Uses Correct Words with No Slurring of Words - Abnormal: Patient Slurs Words, Uses Wrong Words, or is Unable to Speak CPSS: Most common stroke scale in use Motor function and speech based May not pick up on sensory loss Does not replace the need for a full neurological exam or further diagnostics if available Drooling from one side of mouth, eye movement dysfunction, tongue dysfunction are other indicators. Indicative of hemiparesis (one-sided weakness) or hemiplegia (one sided paralysis). May also include a stroke patient that is unconscious or unresponsive.

12. County of Kern EMERGENCY MEDICAL SERVICES IF ONE OR MORE ABNORMAL CPSS ARE PRESENT AND ONSET OBSERVED WITHIN 3 HOURS BY VALID HISTORIAN; OR QUESTIONABLE ONSET TIME – EXPEDITE CONTACT WITH DESIGNATED STROKE CENTER BASE HOSPITAL If ANY indicator is abnormal and the onset of signs or symptoms are within 3 hours, the appropriate stroke center is activated by contact of the designated stroke center emergency department. If the history of onset timing is not reliable or not available, the appropriate stroke center should be contacted and activated. The appropriate stroke center may also be contacted for advice as needed.

13. County of Kern EMERGENCY MEDICAL SERVICES EOA #4: West, South, Central Bakersfield EOA #5: East, North, Central Bakersfield EOA #2: Shafter, Buttonwillow EOA #9: Taft, Maricopa, McKittrick EOA #8: Lamont, Arvin, Frazier Park, Tehachapi  In Exclusive Ambulance Operational Areas (EOA) 4, 5, 2, 9, or 8 (excluding the Tehachapi area) where transport to a Bakersfield area hospital is the closest destination, stroke patients that meet the Stroke Center Activation Protocol indications shall be transported to a stroke center. This is applicable to both ALS and BLS level ambulance transports. TRANSPORT AS FOLLOWS

14. County of Kern EMERGENCY MEDICAL SERVICES EOA #1: Wasco, Lost Hills EOA #3: Delano, McFarland. Woody EOA #6: Kern River Valley, Isabella EOA #8: Applicable to Tehachapi area and surrounding communities in the area.  In Exclusive Operational Areas (EOA) 1, 3, 6, or 8 – Tehachapi Area:  ALS Ambulance: A stroke patient that meets Stroke Center Activation Protocol indications shall be transported to a stroke center. A stroke patient from these areas may be transported to the closest hospital emergency department if the patient airway cannot be managed appropriately; or if the patient condition is deteriorating rapidly, at paramedic discretion. BLS Ambulance: A stroke patient that meets Stroke Center Activation Protocol indications shall be transported to the closest hospital emergency department.

15. County of Kern EMERGENCY MEDICAL SERVICES EOA #7: Ridgecrest, Inyokern EOA #11: Mojave, California City, Rosamond, Boron & surrounding communities  In Exclusive Ambulance Operational Areas (EOA) 7 or 11:  ALS Ambulance: ALS Ambulance: A stroke patient that meets Stroke Center Activation Protocol indications shall be transported to the closest hospital emergency department unless air transport is indicated in compliance with EMS Aircraft Dispatch-Response- Utilization Policies and Procedures.  BLS Ambulance: A stroke patient that meets Stroke Center Activation Protocol indications shall be transported to the closest hospital emergency department unless air transport is indicated in compliance with EMS Aircraft Dispatch-Response- Utilization Policies and Procedures.

16. County of Kern EMERGENCY MEDICAL SERVICES Based upon Hall Critical Care Transport Medevac-1 from Meadows Field Bakersfield; or Mercy Air Service from Mojave.  Air Transport: Air transport shall be used if an air ambulance is available and the overall time savings will be 10 minutes or more in comparison with ground transport in compliance with EMS Aircraft Dispatch-Response-Utilization Policies and Procedures. Generally, 10 minutes time-savings cannot be attained with ground transport times of 30 minutes or less.  Interfacility Transfer: A patient that meets Stroke Center Activation Protocol indications at a hospital that is not a designated stroke center should be transferred to a designated stroke center by the receiving hospital. If indicated, the receiving hospital shall notify the stroke center emergency department to activate response. A receiving or base hospital emergency department may request interfacility transfer of any stroke case meeting Stroke Center Activation Protocol criteria to a designated stroke center. The designated stroke center cannot refuse to accept an interfacility transfer of a stroke case that meets Stroke Center Activation Protocol criteria. Ground or air transport are at the discretion of the transferring physician. Generally, if a ground ambulance is within 30 minutes driving time from the Stroke Center, there will be no time savings by using an air ambulance.

17. County of Kern EMERGENCY MEDICAL SERVICES Ambulance Transport Destination Decision/Hospital ED Status Policies & Procedures: Stroke Case Specific Added: San Joaquin Community Hospital listed Bakersfield Memorial Hospital listed Mercy Hospital Mercy Southwest Hospital Stroke Only Status Added: Can be authorized by EMS Department staff as indicated Can be deactivated by EMS Department staff or the designated stroke center.

18. County of Kern EMERGENCY MEDICAL SERVICES Frequently Asked Questions Q: If I believe a patient has had an acute stroke, but the CPSS is normal, what should I do? A: Contact a designated stroke center, convey a patient information report, request advice regarding stroke center activation. Q: If I have a patient with an onset of abnormal CPSS findings that were over 3 hours ago, but the history is suspect. What should I do? A: Contact a designated stroke center, convey a patient information report, request advice regarding stroke center activation.

19. County of Kern EMERGENCY MEDICAL SERVICES Frequently Asked Questions Q: I have a critical stroke patient with severe airway problems in the Tehachapi area that cannot be managed. Should I transport to a designated stroke center anyway? A: No. Transport to the closest hospital emergency department in this case to secure the airway, then possibly interfacility transfer the patient to the designated stroke center. Q: I have a patient with a past medical history of stroke 3 years ago reported by an extended care facility. The patient’s current complaint is headache for 2 hours with no other acute signs or symptoms. Should I activate and transport to a designated stroke center? A: Not necessarily. This patient does not meet the Stroke Center Activation Protocol criteria for abnormal CTSS time of onset. This patient can be transported to any appropriate hospital emergency department, including a designated stroke center, according to standard procedures.

20. County of Kern EMERGENCY MEDICAL SERVICES Frequently Asked Questions Q: I have a patient with an abnormal CPSS onset within 1 hour in the Kern Valley area. Kern Valley Hospital is 15 minutes away in transport time. An air ambulance has a 5 minute ETA to my current location. What should I do? A: Have the patient transported by air ambulance. Q: I have a patient with an abnormal CPSS onset within 2 hours in the California City area. AVHMC is 30 minutes away in ground transport time. A designated stroke center is 60 minutes away in ground transport time. An air ambulance has a 30 minute ETA to my current location but has not lifted off yet. I am ready to start transport. What should I do? A: Begin ground transport toward AVHMC. It is important to make forward progress with the transport process. Waiting at an LZ for more than just a few minutes is generally excessive. Remember, time is brain.

21. County of Kern EMERGENCY MEDICAL SERVICES Frequently Asked Questions Q: I am a physician at a receiving hospital emergency department and have an acute stroke patient that meets Stroke Center Activation Protocol indications. Do I have to transfer the patient to a designated stroke center? A: It is recommended to transfer the patient immediately. However, if the responsible physician believes the patient can be managed adequately, that physician can certainly elect to not transfer the patient to a designated stroke center.

22. County of Kern EMERGENCY MEDICAL SERVICES Additional Resources Kern County EMS Website: http://www.co.kern.ca.us/ems Joint Commission of Healthcare (JCAH): http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/ American Stroke Association: http://www.strokeassociation.org The Brain Attack Coalition: http://www.stroke-site.org/index.html Please contact the Kern County EMS Department at 661-868-5201 or send an email to blindr@co.kern.ca.us with any questions regarding the Stroke Center Policies.