Implementation Strategies for Implementation Strategies for Emergency Medical Services Emergency Medical Services

Within Stroke Systems of CareWithin Stroke Systems of Care

Acker JE., et al., Implementation strategies for emergency medical services within Acker JE., et al., Implementation strategies for emergency medical services within stroke systems of care: A policy statement from the American Heart stroke systems of care: A policy statement from the American Heart

Association/American Stroke Association expert panel on emergency medical services Association/American Stroke Association expert panel on emergency medical services systems and the Stroke Councilsystems and the Stroke Council

StrokeStroke. 2007; 38(11):3097. 2007; 38(11):3097

Background & ImportanceBackground & Importance

• Stroke remains the third leading cause of Stroke remains the third leading cause of death and a leading cause of long-term death and a leading cause of long-term disability among Americans.disability among Americans.

• Approximately 700,000 individuals suffer a Approximately 700,000 individuals suffer a new or recurrent stroke each year.new or recurrent stroke each year.

Important Role of EMS & EMSS Important Role of EMS & EMSS in optimizing stroke carein optimizing stroke care• EMS - Emergency Medical ServicesEMS - Emergency Medical Services

– Full scope of pre-hospital services, including:Full scope of pre-hospital services, including: 9-1-1 activation and dispatch9-1-1 activation and dispatch emergency medical responseemergency medical response triage & stabilization in the fieldtriage & stabilization in the field transport by ground or air ambulance to a hospital or transport by ground or air ambulance to a hospital or

between facilities. between facilities.

• EMSS - Emergency Medical Service SystemsEMSS - Emergency Medical Service Systems– Delivery systems organized on a local, regional, statewide, or Delivery systems organized on a local, regional, statewide, or

nationwide basis using public or private resources. nationwide basis using public or private resources. – The successful integration of one (and often multiple) EMSS is The successful integration of one (and often multiple) EMSS is

critical to ensuring the effectiveness of a stroke system of care. critical to ensuring the effectiveness of a stroke system of care.

Significance of the StatementSignificance of the Statement

• This paper expands on the four This paper expands on the four categories of recommendations that categories of recommendations that were part of the original 2005 Stroke were part of the original 2005 Stroke Systems Task Force white paper* and Systems Task Force white paper* and defines specific and expansive defines specific and expansive recommendations, resources and recommendations, resources and measurement parameters for each. measurement parameters for each.

*Schwamm LH., et al. Recommendations for the establishment of stroke *Schwamm LH., et al. Recommendations for the establishment of stroke systems of care. systems of care. Stroke.Stroke. 2005;36:690. 2005;36:690.

Translating the Science into PolicyTranslating the Science into Policy

• The recommendations can serve as the The recommendations can serve as the basis for state-level model legislation. basis for state-level model legislation.

• At the federal level, the STOP Stroke Act, At the federal level, the STOP Stroke Act, if passed and appropriated, would if passed and appropriated, would provide resources and leadership to provide resources and leadership to states for implementing many of these states for implementing many of these recommendations and measurement recommendations and measurement parameters.parameters.

Recommendation OneRecommendation One• Stroke Systems should Require Stroke Systems should Require

Appropriate Processes that ensure Rapid Appropriate Processes that ensure Rapid access to EMS for Acute Stroke Patientsaccess to EMS for Acute Stroke Patients

Ensure:Ensure:– Access to enhanced landline & wireless 9-1-1 (W-E911). Access to enhanced landline & wireless 9-1-1 (W-E911). – EMS communicators recognize stroke signs & symptoms EMS communicators recognize stroke signs & symptoms

reported by callers.reported by callers.– Stroke patients are dispatched at the highest level of care Stroke patients are dispatched at the highest level of care

available in the shortest time possible.available in the shortest time possible. ensuring use of emergency medical dispatch guidelines reflecting ensuring use of emergency medical dispatch guidelines reflecting

the current ASA/AHA guidelines.the current ASA/AHA guidelines.

Potential Solution Samples Potential Solution Samples • Advocate for funding and legislation at the Advocate for funding and legislation at the

federal, state, & local levels to provide universal federal, state, & local levels to provide universal availability of W-E911 capabilities.availability of W-E911 capabilities.

• Identify political leaders or champions for rural Identify political leaders or champions for rural areas & advocate for funding on behalf of 9-1-1 areas & advocate for funding on behalf of 9-1-1 call centers & wireless carriers that serve rural call centers & wireless carriers that serve rural areas.areas.

• Ensure EMSS emergency medical dispatch guide Ensure EMSS emergency medical dispatch guide cards and education resources are stroke-cards and education resources are stroke-specific. specific.

• Establish targets for reducing the time-to-dispatch Establish targets for reducing the time-to-dispatch interval; include as a component of certification and interval; include as a component of certification and proficiency programs for EMS communicators. proficiency programs for EMS communicators.

Measurement Parameters Measurement Parameters Within the stroke system of care:Within the stroke system of care:

• 100% coverage for E911 and W-E911 services 100% coverage for E911 and W-E911 services for all callers in all geographic areas.for all callers in all geographic areas.

• All EMS communicators receive written and in-All EMS communicators receive written and in-person education on recognizing stroke signs person education on recognizing stroke signs and symptoms as reported by callers. and symptoms as reported by callers.

Measurement ParametersMeasurement Parameters (cont.)(cont.)• 100% of 911 call centers use dispatch 100% of 911 call centers use dispatch

guidelines that prioritize stroke patients at the guidelines that prioritize stroke patients at the highest care level available.highest care level available.

• Ensure that the time period between the receipt Ensure that the time period between the receipt of the call and the dispatch of the response of the call and the dispatch of the response team is less than 90 seconds for 90% of calls team is less than 90 seconds for 90% of calls involving stroke. involving stroke.

• EMS communicators correctly identify a max % EMS communicators correctly identify a max % of callers experiencing stroke and dispatch of callers experiencing stroke and dispatch EMS responders at the highest priority for EMS responders at the highest priority for these calls. these calls.

Recommendation TwoRecommendation Two• For EMS responders, EMSS should use For EMS responders, EMSS should use

protocols, tools and training that meet protocols, tools and training that meet current AHA/ASA guidelines for stroke current AHA/ASA guidelines for stroke carecare. .

– Identify acute stroke patients rapidly by ensuring that Identify acute stroke patients rapidly by ensuring that EMS responders use validated screening algorithms EMS responders use validated screening algorithms effectively.effectively.

– Establish goals for the EMSS response time for Establish goals for the EMSS response time for suspected stroke patients. The EMSS response time suspected stroke patients. The EMSS response time comprises the dispatch time, the turnout time, and the comprises the dispatch time, the turnout time, and the travel time. travel time.

Potential Solution SamplesPotential Solution Samples• Include stroke screening tools within the 10 Include stroke screening tools within the 10

core ACLS cases when teaching both pre-core ACLS cases when teaching both pre-hospital and hospital personnel. hospital and hospital personnel.

• Measure and report each component and Measure and report each component and overall EMSS response time and on-scene overall EMSS response time and on-scene time for all stroke patients.time for all stroke patients.

• Work with the National EMS Information Work with the National EMS Information System (NEMSIS) project to recommend that System (NEMSIS) project to recommend that states collect and submit all necessary data states collect and submit all necessary data elements for stroke for inclusion in the elements for stroke for inclusion in the national EMS dataset. national EMS dataset.

Measurement ParametersMeasurement Parameters• Ensure that 100% of EMSS use validated pre-hospital Ensure that 100% of EMSS use validated pre-hospital

stroke screening tools to identify stroke patients.stroke screening tools to identify stroke patients.

• Ensure that when EMS responders screen patients for Ensure that when EMS responders screen patients for stroke, they err on the side of over-identification. stroke, they err on the side of over-identification. Initially, EMSS should establish a goal of over-triage of Initially, EMSS should establish a goal of over-triage of 30% for the pre-hospital assessment of acute stroke. 30% for the pre-hospital assessment of acute stroke.

• As part of the CQI process, EMS responders’ stroke As part of the CQI process, EMS responders’ stroke screening assessment should be compared against final screening assessment should be compared against final patient diagnoses to identify failures to identify patients patient diagnoses to identify failures to identify patients who were experiencing a stroke (under-triage). who were experiencing a stroke (under-triage). – These data should be used to develop and adjust EMS responder These data should be used to develop and adjust EMS responder

training and protocols for the use of stroke screening forms. training and protocols for the use of stroke screening forms.

Measurement ParametersMeasurement Parameters (cont.) (cont.)• Ensure EMSS response time is <9 minutes for at least Ensure EMSS response time is <9 minutes for at least

90% of acute stroke patients. 90% of acute stroke patients. – Response time reflects the amount of time elapsed from the Response time reflects the amount of time elapsed from the

receipt of the call by the dispatch entity to the arrival on the receipt of the call by the dispatch entity to the arrival on the scene of a properly equipped and staffed ambulance.scene of a properly equipped and staffed ambulance.

• Ensure that dispatch time is <1 minute, turnout time is <1 Ensure that dispatch time is <1 minute, turnout time is <1 minute, and travel time is equivalent to trauma or acute minute, and travel time is equivalent to trauma or acute myocardial infarction calls.myocardial infarction calls.

• Ensure that the on-scene time is <15 minutes (unless Ensure that the on-scene time is <15 minutes (unless extenuating circumstances or extrication difficulties).extenuating circumstances or extrication difficulties).

• Report all times using the fractile method (e.g. 90th Report all times using the fractile method (e.g. 90th percentile). For accurate data collection, all clocks percentile). For accurate data collection, all clocks capturing these times in the EMSS should be capturing these times in the EMSS should be synchronized. synchronized.

Recommendation ThreeRecommendation Three• Pre-hospital providers, emergency Pre-hospital providers, emergency

physicians, and stroke experts should physicians, and stroke experts should collaborate in the development of EMS collaborate in the development of EMS training, assessment, treatment, and training, assessment, treatment, and transportation protocols for stroketransportation protocols for stroke..

– Develop & implement stroke education activities that Develop & implement stroke education activities that meet current AHA/ASA guidelines. meet current AHA/ASA guidelines.

– Develop stroke system transport protocols.Develop stroke system transport protocols.

– Engage with pre-hospital and hospital programs in Engage with pre-hospital and hospital programs in continuous quality improvement processes for stroke continuous quality improvement processes for stroke patient care while complying with protections for the patient care while complying with protections for the privacy of personal health information. privacy of personal health information.

Potential Solution SamplesPotential Solution Samples• Integrate EMS within ED stroke care & CQI Integrate EMS within ED stroke care & CQI

activities for stroke.activities for stroke.

• Collaborate with state or local coalition of Collaborate with state or local coalition of healthcare providers, experts, and regulators to healthcare providers, experts, and regulators to develop improved EMSS processes & protocol develop improved EMSS processes & protocol enhancements. enhancements.

• Advocate for funding of professional education Advocate for funding of professional education training for pre-hospital providers.training for pre-hospital providers.

• Collaborate with state or local coalition of Collaborate with state or local coalition of healthcare providers, experts, and regulators to healthcare providers, experts, and regulators to develop improved EMSS point-of-entry (transport develop improved EMSS point-of-entry (transport destination) plans. destination) plans.

Measurement ParametersMeasurement Parameters• Ensure pre-arrival notification of hospitals is Ensure pre-arrival notification of hospitals is

provided for all suspected stroke patients.provided for all suspected stroke patients.

• Ensure that 100% of EMS providers complete a Ensure that 100% of EMS providers complete a minimum of 2 hours of instruction on stroke minimum of 2 hours of instruction on stroke assessment and care as part of their required CME assessment and care as part of their required CME for certification and re-licensure. for certification and re-licensure.

• Ensure the total EMSS contact time Ensure the total EMSS contact time (from the receipt (from the receipt of the 9-1-1 call or presentation at a non-stroke center of the 9-1-1 call or presentation at a non-stroke center hospital to arrival at a stroke center)hospital to arrival at a stroke center) is measured for is measured for 100% of stroke patients. EMSS should consistently 100% of stroke patients. EMSS should consistently strive to decrease this time.strive to decrease this time.

Measurement Parameters (cont.)Measurement Parameters (cont.)• Ensure on-scene time is <15 minutes before Ensure on-scene time is <15 minutes before

transport, unless there are extenuating transport, unless there are extenuating circumstances. This also applies to emergent circumstances. This also applies to emergent interfacility transportation of stroke patients. interfacility transportation of stroke patients. EMSS & hospitals should develop policies & EMSS & hospitals should develop policies & procedures to streamline paperwork and procedures to streamline paperwork and equipment issues.equipment issues.

• Ensure EMS response time to reach a stroke Ensure EMS response time to reach a stroke patient for emergent interfacility transfer is the patient for emergent interfacility transfer is the same as the time from dispatch to transport same as the time from dispatch to transport (less than 9 minutes at least 90% of the time or as (less than 9 minutes at least 90% of the time or as determined appropriate by the local EMSS). determined appropriate by the local EMSS).

Measurement Parameters (cont.)Measurement Parameters (cont.)• Ensure that 100% of stroke patients are included in Ensure that 100% of stroke patients are included in

CQI activities and that EMSS receives feedback CQI activities and that EMSS receives feedback from the hospital on all confirmed & suspected from the hospital on all confirmed & suspected stroke patients they provided pre-arrival hospital stroke patients they provided pre-arrival hospital notification for.notification for.

• Implement continuous monitoring of standard Implement continuous monitoring of standard measures as part of the CQI process including: measures as part of the CQI process including: – stroke history obtainedstroke history obtained– stroke assessment using validated screening toolsstroke assessment using validated screening tools– stroke history checklists that document eligibility for stroke history checklists that document eligibility for

acute therapies properly completedacute therapies properly completed– whether on-scene time was appropriatewhether on-scene time was appropriate– whether the hospital transport destination decision was whether the hospital transport destination decision was

appropriate.appropriate.

Recommendation FourRecommendation Four• Patients should be transported to the Patients should be transported to the

nearest Stroke Center for evaluation & nearest Stroke Center for evaluation & care if located within a reasonable care if located within a reasonable transport distance & transport time. transport distance & transport time. – The determination needs to take into The determination needs to take into

account regional issues such as the account regional issues such as the availability of Stroke Centers & geography availability of Stroke Centers & geography and whether transportation to a Stroke and whether transportation to a Stroke Center is possible within the appropriate Center is possible within the appropriate time for acute therapeutic interventions.time for acute therapeutic interventions.

Recommendation Four (cont.)Recommendation Four (cont.)– Assess stroke patient eligibility for acute Assess stroke patient eligibility for acute

stroke therapies using a stroke history stroke therapies using a stroke history checklist or algorithm consistent with checklist or algorithm consistent with AHA/ASA guidelines.AHA/ASA guidelines.

– Establish EMSS transport destination Establish EMSS transport destination protocols that reflect optimal patient care protocols that reflect optimal patient care with transport to a certified Stroke Center.with transport to a certified Stroke Center.

– Establish protocols for the transfer of Establish protocols for the transfer of stroke patients from non-stroke center stroke patients from non-stroke center hospitals to certified Stroke Centers. hospitals to certified Stroke Centers.

– Transport stroke patients to stroke-ready Transport stroke patients to stroke-ready hospitals regardless of the patients’ hospitals regardless of the patients’ geopolitical location. geopolitical location.

Potential Solution SamplesPotential Solution Samples• Ensure the use of stroke triage & transport protocols Ensure the use of stroke triage & transport protocols

that reflect current recommendations for assessing that reflect current recommendations for assessing stroke patients for eligibility for acute stroke stroke patients for eligibility for acute stroke therapies, including thrombolytic therapy.therapies, including thrombolytic therapy.

• Ensure that EMS responders have adequate education Ensure that EMS responders have adequate education & training to screen patients accurately for acute & training to screen patients accurately for acute therapies.therapies.

• Advocate for a statewide plan for EMS protocols to Advocate for a statewide plan for EMS protocols to ensure stroke patients receive high-priority care at ensure stroke patients receive high-priority care at recognized certified Stroke Centers. recognized certified Stroke Centers.

• Advocate for the development of a public statewide Advocate for the development of a public statewide hospital identification system identifying hospitals hospital identification system identifying hospitals that meet the criteria for Primary or Comprehensive that meet the criteria for Primary or Comprehensive Stroke Centers. Stroke Centers.

Measurement ParametersMeasurement Parameters• Ensure that stroke history checklists are Ensure that stroke history checklists are

completed for at least 90% of all suspected stroke completed for at least 90% of all suspected stroke patients. patients.

• Ensure that the amount of time EMS responders Ensure that the amount of time EMS responders spend collecting the clinical history at the scene spend collecting the clinical history at the scene is is << 10 minutes. Total on-scene time should not 10 minutes. Total on-scene time should not exceed 15 minutes.exceed 15 minutes.

• Work within existing coalitions with Work within existing coalitions with representatives of the emergency medicine, representatives of the emergency medicine, political, and pre-hospital communities.political, and pre-hospital communities.

• Establish model policies & regulations for patient Establish model policies & regulations for patient transportation protocols that are consistent with transportation protocols that are consistent with AHA/ASA guidelines and can be adopted at state, AHA/ASA guidelines and can be adopted at state, regional, & local levels. regional, & local levels.