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Five Steps to Better Stroke Outcomes
When you talk about improving outcomes for stroke victims, you’re usually talking about changing entire systems of care, including patient education, EMS, emergency departments, radiology, intensive care, rehabilitation and more.1 Sound overwhelming? It may be. But keeping your local protocols in mind, here are five steps you may be able to take right now to advance the stroke systems of care in which you work and thus improve the care you give to patients.
1) Determine “time last seen normal”—As opposed to determining the time of symptom onset (which may only tell you when someone first noticed signs and symptoms), one of the easiest things EMS providers can do is determine the time at which the patient was last seen by a reliable witness to be asymptomatic or normal. Clot-busting tPA can only be administered within 3–4.5 hours of the beginning of a stroke.2 Because of this, it is vital to establish exactly when a stroke began. EMS is key in determining when a patient was last asymptomatic or normal through assessment and interviews with caregivers, family, bystanders and, of course, the victim him- or herself.
2) Use a validated stroke scale—You may believe you can spot a stroke from a mile away, but what about those strokes that don’t seem like strokes?3–7 Use of validated tools such as the Cincinnati Prehospital Stroke Scale,8 Los Angeles Prehospital Stroke Screen9 and Melbourne Ambulance Stroke Screen10,11 by EMS has been shown to improve its identification of stroke. They also help facilitate your handoff report as well as assessment of your stroke patient at the hospital.
3) Triage to an appropriate stroke center—For some EMS providers, this may be as simple as transporting to their only hospital. For others the choice is determined by protocol. However, many EMS providers have a choice of destinations for their stroke patients. In that case, keep in mind a variety of factors:12
• Can the patient be transported to the nearest designated stroke center in less than 4.5 hours since they were last seen normal?
• What is the transport time to the nearest primary stroke center or acute stroke-ready hospital, and how does that compare to with the time to the nearest non-stroke-designated emergency department?
• What are your ground vs. air transport options?
• Are there any special considerations for this case (e.g., pediatric patient, bariatric patient, high probability of acute hemorrhagic stroke)?
4) Early notification of the destination stroke center—Whether your transport time is 2 minutes or 2 hours, early notification of the destination hospital is pivotal in allowing it to ready its stroke-care resources or prepare to stabilize the patient and rapidly ship them to a specialty stroke-care facility.13,14 As with prehospital 12-lead ECGs for cardiac patients, some EMS services even use video telemetry to allow in-hospital specialists to evaluate and consult with EMTs and paramedics on care of their stroke patients.15,16 While full telemetry systems cost thousands of dollars, one recent study has proposed the feasibility of using basic smart-phone videoconferencing to bring the expertise of specialist staff into the back of the ambulance.17
5) Handoff report—In the best of circumstances, a good handoff report for a stroke patient will facilitate their movement through the continuum of care. A great handoff report will follow a defined process and report key factors including the patient’s time last seen normal, stroke scale(s) and any contraindications to tPA or special considerations. Ideally this report will be to a nurse or physician who is a member of the stroke team. Even if that is not the case, an efficient handoff report will still help ensure your patient receives the right care from the right team at the right time.18
References
1. Acker JE 3rd, Pancioli AM, et al. Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association expert panel on emergency medical services systems and the Stroke Council. Stroke 2007 Nov; 38(11): 3,097–115.
2. Huisa BN, Raman R, et al. Alberta stroke program early CT score (ASPECTS) in patients with wake-up stroke. J Stroke Cerebrovasc Dis 2010 Nov–Dec; 19(6): 475–9.
3. Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. An interventional study to improve paramedic diagnosis of stroke. Prehosp Emerg Care 2005 Jul–Sep; 9(3): 297–302.
4. Lever NM, Nystrom KV, et al. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs 2012 May 25 (e-pub ahead of print).
5. Ramanujam P, Guluma KZ, et al. Accuracy of stroke recognition by emergency medical dispatchers and paramedics—San Diego experience. Prehosp Emerg Care 1998 Jul–Sep; 12(3): 307–13.
6. Smith WS, Corry MD, et al. Improved paramedic sensitivity in identifying stroke victims in the prehospital setting. Prehosp Emerg Care 1999 Jul–Sep; 3(3): 207–10.
7. Tirschwell DL, Longstreth WT Jr., et al. Shortening the NIH stroke scale for use in the prehospital setting. Stroke 2002 Dec; 33(12): 2,801–6.
8. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med 1999 Apr; 33(4): 373–8.
9. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000 Jan; 31(1): 71–6.
10. Bray JE, Coughlan K, Barger B, Bladin C. Paramedic diagnosis of stroke: examining long-term use of the Melbourne ambulance stroke screen (MASS) in the field. Stroke 2010 Jul; 41(7): 1,363–6.
11. Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. Paramedic identification of stroke: community validation of the Melbourne ambulance stroke screen. Cerebrovasc Dis 2005; 20(1): 28–33.
12. Crocco TJ, Grotta JC, Jauch EC, et al. EMS management of acute stroke—prehospital triage (resource document to NAEMSP position statement). Prehosp Emerg Care 2007 Jul–Sep; 11(3): 313–7.
13. Abdullah AR, Smith EE, Biddinger PD, Kalenderian D, Schwamm LH. Advance hospital notification by EMS in acute stroke is associated with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator. Prehosp Emerg Care 2008 Oct–Dec; 12(4): 426–31.
14. Patel MD, Rose KM, O’Brien EC, Rosamond WD. Prehospital notification by emergency medical services reduces delays in stroke evaluation: findings from the North Carolina stroke care collaborative. Stroke 2011 Aug; 42(8): 2,263–8.
15. LaMonte MP, Xiao Y, Hu PF, et al. Shortening time to stroke treatment using ambulance telemedicine: TeleBAT. J Stroke Cerebrovasc Dis 2004 Jul–Aug; 13(4): 148–54.
16. Schwamm LH, Holloway RG, Amarenco P, et al. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009 Jul; 40(7): 2,616–34.
17. Gonzalez MA, Hanna N, Rodrigo ME, Satler LF, Waksman R. Reliability of prehospital real-time cellular video phone in assessing the simplified National Institutes of Health stroke scale in patients with acute stroke: a novel telemedicine strategy. Stroke 2011 Jun; 42(6): 1,522–7.
18. Nolte CH, Malzahn U, et al. Improvement of door-to-imaging time in acute stroke patients by implementation of an all-points alarm. J Stroke Cerebrovasc Dis 2011 Sep 7.
Rommie L. Duckworth, LP, has more than 20 years of experience working in career and volunteer fire departments, public and private emergency services and hospital-based healthcare systems. He is a frequent speaker at national conferences and a regular contributor to research programs, magazines, textbooks and new media on topics of field operations, leadership, education and career development in emergency services.
