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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