1. Stroke Care is a Team Sport
Jay MacNeal, DO, MPH, NREMT-P
EMS Medical Director
Nichelle Jensen, BSN, RN, CCRN
Stroke Program Coordinator
Mercy Health System
Janesville, WI

2. Rock County Population: 160,000
2 Municipal fire based paramedic services
Remainder of EMS at EMT level
Emergency Medical Dispatch
1 Primary Stroke Center

3. Objectives Highlight current EMS guidelines and recommendations
Discuss EMS protocols and education in Rock Co.
Identify barriers of stroke care from field to hospital

4. AHA/ASA Guideline
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Published January, 2013

5. Stroke Chain of Survival
Detection – recognition of s/s
Dispatch – immediate activation of 911
Delivery – transport to PSC/pre-hospital notification
Door – immediate ED triage
Data – stroke team activation, lab, rad
Decision – Diagnose and determine therapy
Drug – administration of appropriate therapy
Disposition – admit to stroke unit or transfer
Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

6. AHA/ASA Guideline
Educational programs for physicians, hospital staff, and EMS are recommended to increase quality of care
Dispatchers should make stroke a priority dispatch
Pre-hospital stroke assessment tools should be utilized
Cincinnati Stroke Scale
Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

7. AHA/ASA Guideline
EMS should begin initial management of stroke in field
ABC’s
cardiac monitoring
02 to maintain sat>94%
establish IV
BGM and treat accordingly
determine onset of symptoms
Triage to nearest stroke hospital (PSC or CSC)
Notify hospital of pending stroke patient (initiate code stroke)
Guidelines for Early Management of Patients With Acute Ischemic Stroke. Stroke, 2013

8. EMS Care in Rock Co. Neuro Exam – (code stroke if indicated)
Blood sugar
12 lead EKG
IV and blood draw
If transferring:
“Drip and ship” protocol
Continuous monitoring
Aggressive BP control

9. EMS Education Initial training Refresher training Run reviews QA
Medical Director on scene
Feedback from stroke program

10. EMS Education Simulation lab ICU and ED clinical rotations
Standardized patients
Lab draw and high pressure tubing
New protocol education

11. Community Education Radio TV Billboards – F.A.S.T. Social Media
Community Events
Rock County Fair
Walk and Talk

12. EMS Opportunities Improves stroke screening
Improve communications of apparent stroke to ED
Increase critical care capability to transport “drip and ship” stroke patients

13. ED Care Rapid assessment immediately upon EMS arrival - <10 min
STAT labs – POCT
STAT Head CT
NIH scoring after CT
12 lead EKG after CT
Immediate discussion with reading radiologist and neurologist

14. ED Care Continuous re-assessment and telemetry
TPA indications/contraindications and discussion with family
If not stroke center, arrange for transfer
“drip and ship” or “send and pray”

15. Neurology Care Notified after CT scan results if pt is tPA candidate
If in-house they respond to ED
Phone consultation available 24/7 with video conferencing
Joint decision between neurology, ED physician and pt/family to give tPA

16. Neurology Care Continue to coordinate care with ICU physician
Available on consult after transfer to floor
Follow-up care after discharge

17. Hospital Care Admit to Stroke unit Imaging/Testing
ICU post tPA, SCU, Ortho/neuro
Imaging/Testing
MRI, echo, carotid duplex
Cardiac, BP, blood glucose monitoring

18. Hospital Care Core/quality measures DVT prophylaxis Rehab consults
LDL monitoring
Dysphagia screening
Discharge teaching and medications

19. Case 1
EMS and MD-1 dispatched to scene for 85 y.o. female with stroke symptoms who pushed Lifealert. Pt with left sided weakness and slurred speech starting approximately 15 prior to EMS arrival.
Pt initally requested to go to community hospital, MD on scene able to council on importance of primary stroke center.

20. MD-1

21. Case 1 EMS care: ABC’s assessed and intact
positive CSS, NIHSS 8 at scene
last well know time determined to be within 15 min
BGM 99
IV started and blood drawn for labs
Code Stroke called to Mercy ED
Patient rapidly transported with MD in ambulance

22. Case 1 Hospital Care: Code stroke called 6 minutes PTA
Door to CT time 16 minutes
Negative for bleed
Initial BP >200 mmHg
Labetolol given x 2 with BP lowered to <180
Door to Needle time > 60 minutes
Pt developed N/V and lethargy in ICU
CT showed ICH
Pt admitted to Inpatient Rehab

23. Case 2
52 y.o. Female brought to critical access hospital ED with left sided weakness. Pt sent to CT and decision made to transport to PSC for tPA. MD felt the delay in preparing tPA and calling for critical care transport would be longer then sending the pt without tPA administration.

24. Case 2
Hospital Care: Code Stroke was called en route to Mercy, CT/lab results were viewed through Epic prior to arrival. tPA was administered with 12 minutes.
No acute findings during stroke work-up.
No deficits at discharge.
Diagnosis: complicated migraine

25. Case 3
EMS dispatched and arrived to find 62 y.o. male with slurred speech, L facial droop and extremity weakness. Pt stated that he had similar symptoms a week ago and was diagnosed with a TIA in Dubuque, IA but these had resolved. Current symptoms started appox. 5 minutes prior to EMS arrival.

26. Case 3 EMS care: ABC’s assessed and intact positive CSS
last well know time determined to be 5 min PTA
BGM 102
IV started and blood drawn for labs
Code Stroke called to Mercy ED
Patient rapidly transported

27. Case 3 Hospital Care: Code Stroke initiated 5 min prior to pt arrival
Door to CT time – 7 minutes
NIHSS 4 on arrival
Symptoms waxed and waned during ED course
When symptoms worsened again tPA started
Door to Needle – 64 minutes
Pt admitted to ICU and discharged home with no deficits within 2 days

28. Future of Stroke Care Better trained communities Better trained EMS
Better trained hospitals
Better systems of care
Better patient outcomes

29. Questions