Building a Bridge: EMS Relations as a Foundation for Rapid Stroke Care

During a stroke, “time lost is brain lost”, according to the American Stroke Association.¹ As the focus in the healthcare field shifts to more fully address stroke as a disease process, no longer does treatment revolve around rehabilitation and supportive care, which has been the mainstay for decades. With the development and refinement of computed tomography (CT) in the 1970’s and 80’s (allowing us to notice the difference between ischemic and hemorrhagic stroke), and with FDA approval of tissue plasminogen activator (tPA) in 1996, changes in stroke care have been in the works for decades. 

We now know that rapid diagnosis of stroke is crucial for immediate and definitive treatment. The narrow window of three hours between onset of symptoms and successful drug administration makes stroke treatment a true emergency, which has only in recent years been given the full import it deserves. As a result, hospitals on the forefront of this shifting paradigm have created stroke programs and/or teams to facilitate rapid patient assessment and diagnosis.²

The focus on quickly treating stroke has intensified, with over 1,500 hospitals in the country to date becoming primary stroke-certified. Stroke certification through the use of guidelines published by the American Heart Association/American Stroke Association (AHA/ASA) recognizes hospitals that meet standards to support better outcomes for stroke care.³ A recent study showed that certified primary stroke centers had a 0.3% lower mortality at one day, 1.3% lower mortality at seven days, 2.5% lower mortality at 30 days, and 3% lower mortality at one year, resulting in 16,000-24,000 fewer deaths per year.⁴ Corazon believes these results to be highly significant, and indicative of how quicker, more streamlined stroke care can vastly improve outcomes and the overall patient experience before, during, and after stroke.

In order to achieve better patient outcomes, certified hospitals are streamlining their processes and reducing time-to-diagnosis by focusing on:

• Emergency department (ED) physician evaluation within 10 minutes of patient arrival, inclusive of validated tools that evaluate patient deficits (NIHSS Stroke Scale) as well as contraindications to tPA;
• CT scan performed within 25 minutes of patient arrival;
• CT scan interpreted within 45 minutes of patient arrival; and
• Decision for tPA within 60 minutes of patient arrival.

The ability to acutely treat a stroke patient with the intent of resolving or minimizing their neurologic deficits with tPA hinges on the “last-known well time” being less than three hours. Indeed, EMS providers play a pivotal role in initial patient triage and entry into the healthcare system, as most strokes occur in the home, with EMS providing the first medical contact for more than half of all patients.⁵ Corazon recommends building strong relationships with EMS providers as an initial step in establishing processes for this critical first contact with stroke patients (or those with suspected stroke). Stroke teams can be mobilized from the field with notification from EMS, with triage poised and ready for patient arrival in the ED. From there, the time to treatment can be shortened, thereby improving results.

Primary stroke-certified hospitals meeting and exceeding the above timestamps have positively impacted stroke patients eligible for tPA administration who have entered their hopital. However, they are missing the majority of patients — the 50-75% who do not arrive within the ideal three-hour treatment window.⁵ Studies have found that the biggest delay between the onset of symptoms and emergency treatment is the time it takes for a patient to recognize that they are experiencing a stroke and decide to seek medical care. Patient education and outreach can work to eliminate these delays. Helping the community recognize the signs and symptoms of stroke, and also understand the correct course of action when stroke is suspected, can decrease these percentages.

Unfortunately, delays in treatment are also the result of poor recognition of signs of stroke by emergency dispatchers and/or a misdiagnosis of stroke by EMS providers.⁵ In order to reach more stroke patients in a timely manner, proactive hospitals have integrated EMS providers into the development of their stroke program, as mentioned above. EMS providers initiating a “Stroke Alert” prior to arrival at the hospital enables the Stroke Alert Team to mobilize and prepare for the patient. Studies at organizations with pre-arrival stroke notification have reduced their door-to-CT times by up to 26% with resultant door-to-tPA median times of 40 minutes.⁶ 

In order to pre-notify hospitals of stroke patients, EMS providers must ascertain “last-known well” or “symptom onset” times. They are in a unique position of having family, friends, or bystanders immediately available for questioning regarding historic details, pattern of events, and even the patient’s baseline neurologic function. They must also accurately identify stroke vs common stroke-mimic pathologies such as hypoglycemia, alcohol intoxication/drug overdose, seizures, or metabolic disorders. A validated stroke screening tool can be used in less than one minute, with studies demonstrating paramedic sensitivity for identifying stroke patients at 86-97% as compared to 61-66% without stroke assessment training.⁷ 

In order to facilitate rapid communication and understanding of patient status, the same screening tool should be used by both EMS and the team at hospital. Further, Corazon recommends that the verbal report to the hospital always include the stroke scale assessment. The most commonly used assessments include the Cincinnati Prehospital Stroke Scale (adapted from the NIHSS scale), the Los Angeles Prehospital Stroke Scale, and the Miami Emergency Neurological Deficit Scale (MENDS). Some stroke programs are asking EMS providers to quickly assess for possible fibrinolytic therapy exclusion criteria through discussions with the patient and if the patient is unable to respond, discussions with the family at the home. A sample report sheet incorporating these assessments can expedite the EMS-to-hospital handoff (Figure 1). This reduces the time spent attempting to ascertain information from a frightened and often neurologically-compromised patient.⁸

As EMS providers are rapidly diagnosing the patient with a stroke and supporting the patient’s ABCs (airway, breathing, and circulation), the clock is ticking with the goal of EMS on-scene treatment time of <15 minutes. Performing a serum blood glucose to rule out the differential diagnosis of hyper or hypoglycemia is part of many ALS (advanced life support) protocols in situations of neurologic dysfunction. So as not to delay transport, EMS providers can place an IV line or two to facilitate potential tPA administration. Also when en route, EMS should obtain blood specimens that can immediately be taken to the lab for processing to rapidly rule out bleeding disorders and other exclusions to tPA.⁸ 

State stroke legislation often includes directives for EMS providers to bypass the nearest hospital when transporting stroke patients if there is a designated stroke center nearby. If such a hospital is not readily available, then a stroke-capable hospital — one with a stroke team, care protocols, and treatment with IV tPA — should be utilized, as many hospitals are in the process of being certified. The goal for this directed transfer is definitive stroke treatment on a 24/7 basis.³

Corazon believes that a successful partnership between a primary stroke center and EMS should consist of a multidisciplinary quality improvement committee to review stroke care quality indicators, evidence-based practices, and patient outcomes. Key EMS-related metrics that we advise our clients to include in QI processes are as follows:

• % of time a pre-hospital stroke screen was completed;
• % of pre-arrival notifications;
• % of stroke team activation prior to EMS arrival;
• Patient last known well time – % documented;
• % of patients with last known well time <3 hours;
• Door-to-tPA administration time (with and without EMS pre-arrival notification);
• On-scene time for all cases with symptom onset <3 hours;
• % of correct stoke diagnosis by EMS; and 
• % missed diagnosis by EMS.

Aggregated quality information as well as feedback on individual patients transported by EMS will assist in enhancing the accuracy of a stroke diagnosis, increasing the number of patients eligible for tPA with <3 hour last-known well times, and reducing door-to-tPA administration time to <60 minutes. 

EMS must be aware that their initial response to a stroke call impacts patient outcomes, as with every 15-minute reduction of door-to-needle time, there is a 5% lower odds of in-hospital mortality.⁹ When first collaborating with an EMS provider, err on the side of stroke over-identification, with the goal of over-triage of 30%, in order to minimize missing patients and delaying their time-sensitive treatment. Over time, and with consistent education and feedback to the EMS provider, the accuracy of EMS-initiated stroke alert calls should improve. As part of the quality process, the stroke alert patients should be compared to their discharge diagnosis, as well as those patients with the discharge of stroke that were initially missed (under-triaged).³ Tracking this data and then using the information for QI can highlight successes, while also pinpointing the areas where process improvement, staff education, or other adjustments are needed. 

Based on identified areas of improvement through the QI process as well as key clinical topics, the goal of hospital and EMS education should be to increase the number of patients treated for stroke as well maximize their quality of care. From stroke symptoms, differential diagnosis, and initial assessment, to evidence-based treatment according to the AHA/ASA guidelines, hospital staff, EMS dispatchers (who begin the stroke identification process), and paramedics can learn together. For every eight patients treated with tPA, one patient returns to living a normal life.¹⁰ What about the others who don’t receive that chance?

References

1. The American Stroke Association. Available online at www.americanstrokeassociation.org. Accessed May 23, 2016.
2. NINDS Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995 Dec 14. 333(24): 1581-1587.
3. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar; 44(3): 870-947. doi: 10.1161/STR.0b013e318284056a.
4. Baney J. Primary stroke centers — does Joint Commission certification improve patient outcomes? Neurology Reviews 2011; 19(5): 11-12.
5. Williams I, Mears G, Raisor C, Wilson J. An emergency medical services toolkit for improving systems of care for stroke in North Carolina. Prev Chronic Dis. 2009 Apr; 6(2): A67.
6. VonCannon, S. Porcelli, T. Abstract TMP81: Stroke systems of care: EMS partnership and feedback. Stroke. 2016; 47: ATMP81. 
7. Maggiore WAW.‘Time is brain’ in prehospital stroke treatment. Journal of Emergency Medical Services. 2012 June 4. Available online at https://www.jems.com/articles/print/volume-37/issue-6/patient-care/time-brain-prehospital-stroke-treatment.html. Accessed May 23, 2016.
8. Acker JE 3rd, Pancioli AM, Crocco TJ, Eckstein MK, Jauch EC, Larrabee H, et al; American Heart Association; American Stroke Association Expert Panel on Emergency Medical Services Systems, Stroke Council. Implementation strategies for emergency medical services within stroke systems of care. Stroke. 2007 Nov; 38(11): 3097-3115.
9. Fonarow GC, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Grau-Sepulveda MV, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011 Feb 22; 123(7):750-758. doi: 10.1161/CIRCULATIONAHA.110.974675.
10. American Heart Association, Stroke Fact Sheet. Available online at: www.heart.org/ic/groups/heart-public/@wcm/@private/@hcm/@gwtg/documents/downloadable/ucm_310976.pdf. Accessed May 14, 2016.

Kathy Brown is a Vice President at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email kbrown@corazoninc.com.