stroke survival: linking ems to hospital in treating acute ...linking ems to hospital in treating...

Linking EMS to Hospital in

Treating Acute Stroke

Elizabeth Perkins, BSN, CNRN

Providence Sacred Heart Medical Center

WA State Stroke Conference

March 11, 2019

Wenatchee, WA

Stroke Survival:

Objectives

• Understand the importance of an integrated

approach to the care the stroke patient.

• Discuss the importance of 2-way data sharing

between the hospital and EMS.

• No disclosures

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Stroke Treatment’s Brief History – 22 Years

• 1996 – FDA approval for IV alteplase

• Catheter-based approaches exist, using intra-arterial lytics

directly at clot

• December 2003 Primary Stroke Center certifications begin

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https://www.brainattackcoalition.org/index.html#BAC_Publications

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The NINDS Trial

TISSUE PLASMINOGEN ACTIVATOR FOR ACUTE ISCHEMIC STROKE. NEJM. Dec 14, 1995 Vol 333, No,24, p1581-1587.

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The NINDS Trial

TISSUE PLASMINOGEN ACTIVATOR FOR ACUTE ISCHEMIC STROKE. NEJM. Dec 14, 1995 Vol 333, No,24, p1581-1587.

Stroke Treatment’s Brief History – 22 Years

• Brain Attack Coalition

• 2005 - Recommendations for Comprehensive Stroke Centers

• 2011- Updated Primary Stroke Center recommendations

• 2013 – Recommendations for Acute Stroke Ready hospitals

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https://www.brainattackcoalition.org/index.html#BAC_Publications

2010 – Target: Stroke

• The benefits of tPA in patients with acute

ischemic stroke are time-dependent

• Guidelines recommend a door-to-needle time

of 60 minutes or less

• Less than 30 percent of U.S. patients were

being treated within this window

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Retrieved 3/9/2019 from: https://www.heart.org/en/professional/quality-improvement/target-stroke/learn-more-about-target-stroke

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DATA: GWTG Stroke

AHA 20th Anniv Report

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2010 – Target: Stroke • Performance goal of 50 percent or more of eligible patients treated with

tPA within 60 minutes of hospital arrival

AHA 20th

Anniv Report

Target: Stroke Data

• An increase in the proportion of patients treated with alteplase

within the 60-minute window, from 29.3 to 53.3 percent

• A fourfold increase in the annual rate of improvement in patients

treated with tPA alteplase within the 60-minute window

• Fewer hospital deaths, reduced symptomatic intracranial

hemorrhage and fewer overall tPA complications with more

patients able to be discharged home

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AHA 20th Anniv Report

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Saver, et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA, June 19, 2013—Vol 309, No. 23

GWTG Data Analysis

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GWTG Data Analysis

Saver, et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA, June 19, 2013—Vol 309, No. 23

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AHA 20th Anniv Report

2014 – Target: Stroke II

• Primary Goal: Achieve door-to-needle times within 60 minutes in 75 percent or more of acute ischemic stroke patients treated with IV tPA.

• Secondary Goal: Achieve door-to-needle times within 45 minutes in 50 percent or more of acute ischemic stroke patients treated with IV tPA.

• Results:

• The median DTN time decreased from 66 minutes to 51 minutes

• The percentage of patients with DTN times less than or equal to 60 minutes increased from 42 percent to 67 percent. 14

Retrieved March 9, 2019 from: https://www.heart.org/en/professional/quality-improvement/target-stroke/introducing-target-stroke-phase-ii

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DATA: GWTG Stroke

AHA 20th Anniv Report

2012 – 2018 A New Era in Acute Stroke Care

• 2012 - Stent retrievers introduce endovascular clot removal

• 2015 – 5 positive clinical trials showing dramatic benefit of clot

retrieval in 1 in ~ 2.2 patients

• 2018 – 2 positive clinical trials for clot retrieval to 16/24 hours

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Target: Stroke III

• Achieve door-to-needle times within 60 minutes for

85 percent or more patients

• Achieve to door-to-device times within 90 minutes

for direct arriving patients and within 60 minutes for

transfer patients in 50 percent or more patients

treated with endovascular therapy.

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Retrieved March 9, 2019 from: https://www.heart.org/en/professional/quality-improvement/target-stroke/introducing-target-stroke-phase-ii

The ACLS Stroke Chain of Survival

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The “D’s of Stroke CareDetection: Rapid Recognition of Symptoms

Dispatch: Immediate Activation of 911

Delivery: Rapid EMS identification, management, and transport

Door: Appropriate Triage to Stroke Center

Data: Rapid triage, evaluation, and management within the ED

Decision: Stroke expertise and therapy selection

Drug: Fibrinolytic therapy, intra-arterial strategies

Disposition: Rapid admission to stroke unit, ICU

AHA ACLS content

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Providence Sacred Heart Medical

Center and EMS

• Hospital pre-notification

• Integration of KPI information into ED patch form

• Vital signs, including intubation

• LKW

• FAST +/-

• Blood Glucose measurement

• LAMS score

• History of anticoagulation use

• Pre-hospital labs 20

Integration of EMS into

Door to CT Process

• Time-out called for initial EMS report to team

• Scene history is an integral part of initial stroke assessment

• If patient is medically stable, EMS goes with the stroke

team to CT

• Receives CT interpretation from neurologist with the

rest of the team

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On the Back End

• Fire sends a list of patients to

data reviewer

• Data reviewer sends back

information on diagnosis,

treatment, and discharge

disposition to Fire

• Fire sends individual case

feedback to paramedics who

responded to that case 24

2019 Goals

• Continue feedback work with Spokane and Spokane Valley Fire

• Integrate ESO into our practice

• Increase outcome feedback to

• AMR

• Life Flight

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Never doubt that a small group of thoughtful,

committed citizens can change the world;

indeed, it's the only thing that ever has.

~ Margaret Mead

The only place success comes before

work is in the dictionary.

~ Vince Lombardi

90-day Modified Rankin calls

~ Beth Perkins

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