1. Stroke Center Designation: Impact on EM E. Bradshaw Bunney, MD, FACEP

2. E. Bradshaw Bunney, MD, FACEP Associate Professor Department of Emergency Medicine University of Illinois at Chicago Our Lady of the Resurrection Hospital E. Bradshaw Bunney, MD, FACEP

3. Global Objectives Improve patient outcome for both hemorrhagic and ischemic stroke EM participation in protocol development Hospital financial interest Community education

4. E. Bradshaw Bunney, MD, FACEP Session Objectives Stroke management from community to the ED and beyond The history of Stroke Center designation EM role in protocol development and Stroke Center designation

5. E. Bradshaw Bunney, MD, FACEP Clinical History A 911 call was taken by the Chicago Fire Department dispatch service at 2:25 pm. The caller stated, “My husband is having a stroke and he can not move the left side of his body”. An ALS ambulance arrived at 2:34 pm and found the 67-year-old patient to be sitting in a chair with a BP 140/85, pulse 96, respiratory rate 16 and the inability to move his left arm or leg. His wife also noticed the left side of his face was “flat”. He was able to speak and denied headache, chest pain or shortness of breath.

6. E. Bradshaw Bunney, MD, FACEP Clinical History He had a history of hypertension, was on Labetalol and Lasix, with no allergies. The paramedics noted the time of onset for the symptoms to be 2:15 pm., which was agreed to by both the patient and his wife. The patient was placed on a cart, an IV was established, oxygen was applied, and glucose was 98. The paramedics called into the base station at 2:48 pm, stating, “We have a probable stroke, with two out of three abnormal on the Cincy scale” and arrived in the ED at 2:52 pm.

7. E. Bradshaw Bunney, MD, FACEP Key Clinical Questions Who, What, Why of Stroke Center designation? Does my hospital need to become a Stroke Center? Does a Stroke Team improve ED care of stoke patients? Can an ED use thrombolytics if it is not a Stroke Center? What is EMS role in the process? What are the EM controversies in the care of stroke patients?

8. Stroke in Perspective: An Overview E. Bradshaw Bunney, MD, FACEP

9. Disability Due to Stroke, 1999* †‡ Centers for Disease Control (CDC). MMWR. 2001;50:120-125. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5007a3.htm. Accessed December 4, 2003. * Noninstitutionalized people ≥18 years old. † Total number of people with disabilities=41,168,000. ‡ Numbers may not add up due to rounding.

10. E. Bradshaw Bunney, MD, FACEP Age-Adjusted Stroke Death Rates by Age and Gender, 2001 National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03husupdated.pdf. Accessed January 12, 2004. * Age-adjusted rate calculated using the year 2000 standard population.

11. E. Bradshaw Bunney, MD, FACEP Age-Adjusted Stroke Death Rates by State, 2001 Arias E, et al. Natl Vital Stat Rep. 2003;52:1-116. Available at: http://www.cdc.gov/nchs/fastats/stroke.htm. Accessed December 4, 2003.

12. E. Bradshaw Bunney, MD, FACEP Age-Adjusted Stroke Death Rates by Race and Gender, 2001 National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03husupdated.pdf. Accessed January 12, 2004.

13. E. Bradshaw Bunney, MD, FACEP Estimated Direct and Indirect Costs of Stroke, 2003 American Heart Association (AHA). Heart Disease and Stroke Statistics — 2003 Update. 2003. Available at: http://www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookR EV7-03.pdf. Accessed October 13, 2003.

14. E. Bradshaw Bunney, MD, FACEP Major Causes of Death in the United States, 2001 Arias E, et al. Natl Vital Stat Rep. 2003;52:1-116. Available at: http://www.cdc.gov/nchs/fastats/stroke.htm. Accessed December 4, 2003. COPD=chronic obstructive pulmonary disease.

15. E. Bradshaw Bunney, MD, FACEP Age-Adjusted Death Rates From Stroke: 1950-2001* † * Age-adjusted rates are calculated using the year 2000 standard population. † Data prior to 1970 includes deaths of persons not residents of the 50 states and the District of Columbia. National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/ 03husupdated.pdf. Accessed January 12, 2004.

16. E. Bradshaw Bunney, MD, FACEP Different Types of Stroke, 2000 American Heart Association (AHA). Heart Disease and Stroke Statistics — 2003 Update. 2003. Available at: http://www.americanheart.org/downloadable/heart/ 10590179711482003HDSStatsBookREV7-03.pdf. Accessed October 13, 2003. TIA=transient ischemic attack. Ischemic Stroke 88% Cerebral Thrombosis 61% TIA 3% Cerebral Embolus 24% Intracerebral Hemorrhage 9% Subarachnoid Hemorrhage 3% Hemorrhagic Stroke 12%

17. E. Bradshaw Bunney, MD, FACEP HISTORY 1995- NINDS- TPA therapy for ischemic stroke 1996- EM controversy over use of TPA in stroke 1997- Brain Attack Coalition (BAC) formed 2000- Primary Stroke Center criteria published ?- Comprehensive Stroke Center criteria published

18. Stroke-site.org

19. E. Bradshaw Bunney, MD, FACEP BAC Members NINDS American Academy of Neurology American College of Emergency Physicians American Assn of Neurological Surgeons American Stroke Association National Stroke Association Am Soc of Intervent and Therapy Neuroradiology American Society of Neuroradiology Congress of Neurological Surgeons Stroke Belt Consortium Veterans Administration National Association of EMS Physicians Centers for Disease Control and Prevention American Assn of Neuroscience Nurses

20. E. Bradshaw Bunney, MD, FACEP Brain Attack Coalition Stroke scales Guidelines Pathways North Carolina Stanford Thomas Jefferson www.stroke-site.org

21. Strokeassociation.org

22. E. Bradshaw Bunney, MD, FACEP American Stroke Association Acute Stroke Treatment ProgramAcute Stroke Treatment Program Operation StrokeOperation Stroke Get with the Guidelines-StrokeGet with the Guidelines-Stroke Stroke Center CertificationStroke Center Certification www.strokeassociation.orgwww.strokeassociation.org

23. Stroke.org

24. E. Bradshaw Bunney, MD, FACEP National Stroke Association Public Health Stoke Summit CDC sponsored Increase public awareness Develop state programs to decrease the incidence and death rate National Tutorial on Stroke

25. Why Were Stroke Centers Developed? E. Bradshaw Bunney, MD, FACEP

26. TIME IS BRAIN E. Bradshaw Bunney, MD, FACEP

27. Time is Brain Narrow therapeutic window t-PA within three hours of symptom onset Rapid identification, transport, diagnosis and treatment Stroke “chain of survival” (AHA)

28. E. Bradshaw Bunney, MD, FACEP Trauma Center Model Military experience with rapid evacuation 1966: Accidental Death and Disability: The neglected disease of modern society National Academy of Sciences document Strong government leadership proposed Called for improved training, education, and research Role of prehospital care emphasized Radio communication EMS training Categorize hospital capabilities: 4 categories Resulted in the National Highway Safety Act

29. E. Bradshaw Bunney, MD, FACEP Trauma Center Model 1993 report: 20 states had trauma systems with legal authority 5 States had full implementation: many states failed to enforce limitations on the number of centers based on need (due to political obstacles Financial Crisis: decreased federal support, managed care, DRGs, staff retention Trauma center implementation has provided an infrastructure for the provision of emergency care

30. E. Bradshaw Bunney, MD, FACEP Who is Designating Stroke Centers? American Stroke Association Joint Commission

31. E. Bradshaw Bunney, MD, FACEP ASA GWTG Measures Acute Stroke Treatment: Time of symptom onset Time from EMS receiving call to EMS arrival Time patient arrived at Emergency Department (ED) Time of CT/MRI Scan Time of thrombolytic therapy Ischemic Stroke Prevention: Smoking Cessation Counseling Lipid Lowering Therapy Blood Pressure Treatment Weight and Exercise Management Diabetes Management Atrial Fibrillation Management Focus is quality of care

32. E. Bradshaw Bunney, MD, FACEP Disease Specific Care Certification Premise is that certification process will drive quality measures and improve outcomes No emergency medicine society has endorsed this initiative t-PA controversy Overcrowding Medical legal implications JCAHO

33. E. Bradshaw Bunney, MD, FACEP Accreditation Surveys are organization-based, focused on quality and safe care processes and functions Traditional JCAHO evaluation product 50 years establishing expertise in evaluating health care organizations Certification Reviews are service-based, focused on quality, safety, and outcomes of improving clinical care Voluntary—not an add-on to accreditation Accreditation vs. Certification JCAHO

34. Brain Attack Coalition E. Bradshaw Bunney, MD, FACEP Recommendations for Developing Primary Stroke Centers

35. E. Bradshaw Bunney, MD, FACEP Major Elements Patient care areas Acute stroke teams Written care protocols Emergency medical services Emergency department Stroke unit Neurosurgical services Support services Stroke center director Neuroimaging services Laboratory services Outcome and quality improvement activities Continuing medical education Alberts MJ, et al. JAMA. 2000;283:3102-3109. of a Primary Stroke Center

36. E. Bradshaw Bunney, MD, FACEP Anticipated Benefits Increased patient-care efficiency Fewer peristroke complications Increased use of therapies for acute stroke Decreased morbidity and mortality Improved long-term outcomes Decreased costs to the healthcare system Improved patient satisfaction Alberts MJ, et al. JAMA. 2000;283:3102-3109. of a Primary Stroke Center

37. E. Bradshaw Bunney, MD, FACEP Acute Stroke Team Personnel with expertise in diagnosing and treating cerebrovascular disease (may include neurologist or neurosurgeon) 1 Minimum team would include a physician and another healthcare provider (nurse, physician’s assistant, nurse practitioner) 1 National Stroke Association (NSA) organizational recommendations 2 Stroke center team should include a specialist and support in: Neurology, neurological surgery, neuroradiology, as well as emergency medicine and rehabilitation medicine Stroke center team should include, on an as-needed basis, a specialist and support in: Cardiology, critical care, gastroenterology, hematology, infectious disease, internal medicine, pathology, primary care, and vascular surgery 1. Alberts MJ, et al. JAMA. 2000;283:3102-3109. 2. Furlan AJ, et al, 1997. Available at http://199.239.30.192/NR/rdonlyres/exkgdlqimjxtunrlwtsd7tpge3i23nwqm5r5uxw3cby4zk6fe3t3ubvt ek2kpnp5ocmymjutwyyofb/StrokeCenterRecommendatio.pdf.

38. E. Bradshaw Bunney, MD, FACEP Acute Stroke Team (cont’d) Someone from the team should be available 24/7 Need system for quick notification and activation of the team One member of the team should see patient within 15 minutes Written document should be developed to provide information on stroke team guidelines Logbook should be established to document call and response times, diagnoses, treatments, and outcomes Alberts MJ, et al. JAMA. 2000;283:3102-3109.

39. E. Bradshaw Bunney, MD, FACEP Written Care Protocols Reduce tPA–related complications Protocols should include Emergency care of ischemic and hemorrhagic strokes Stabilization of vital functions Initial diagnostic tests Initial use of medications Protocols should be available any place where patients with stroke may be evaluated or treated Should be reviewed and updated once per year Alberts MJ, et al. JAMA. 2000;283:3102-3109.

40. E. Bradshaw Bunney, MD, FACEP Emergency Medical Services Assigned a high priority EMS should be integrated with the stroke center During transportation, EMS and the stroke center need to communicate Quickly triage patients with a stroke upon arrival Educational activities should include stroke center and EMS staff and occur at least twice a year Alberts MJ, et al. JAMA. 2000;283:3102-3109.

41. E. Bradshaw Bunney, MD, FACEP Emergency Department ED personnel should be trained to diagnose and treat all types of acute strokes ED staff should access the stroke team Communicate with EMS and be prepared for arrival of stroke patients Written protocols for stroke management and triage Educational activities should occur at least twice a year to reinforce stroke diagnosis and treatment Alberts MJ, et al. JAMA. 2000;283:3102-3109.

42. E. Bradshaw Bunney, MD, FACEP Additional Hospital Units and Services Stroke Unit Does not need to be a distinct unit in the hospital Personnel should have expertise in managing cerebrovascular disease Additional infrastructure includes: continuous telemetry, written care protocols, and ability to continuously, noninvasively monitor blood pressure Alberts MJ, et al. JAMA. 2000;283:3102-3109.

43. E. Bradshaw Bunney, MD, FACEP Neurosurgical Services Neurosurgical care should be available within 2 hours of determination that surgery is necessary (patients can be transferred) Hospitals providing the neurosurgical care should have 24-hour–staffed operating room Alberts MJ, et al. JAMA. 2000;283:3102-3109. Additional Hospital Units and Services

44. E. Bradshaw Bunney, MD, FACEP Additional Hospital Units and Services Neuroimaging (CT or MRI) Imaging within 25 minutes Image evaluation within 20 minutes Standard laboratory tests should be available 24/7 Alberts MJ, et al. JAMA. 2000;283:3102-3109.

45. E. Bradshaw Bunney, MD, FACEP Outcomes and Quality Improvement Database or registry of all stroke patients Benchmarks for comparison Can be selected from treatment guidelines Each year, at least two patient-care issues Pre-specified committees meet at least three times a year to review and modify practice patterns Alberts MJ, et al. JAMA. 2000;283:3102-3109.

46. E. Bradshaw Bunney, MD, FACEP Educational Programming Stroke center staff should earn at least 8 hours of CME credit per year related to cerebrovascular disease The stroke center should hold at least two programs per year to educate the public Prevention and recognition of stroke symptoms Availability of acute treatments Alberts MJ, et al. JAMA. 2000;283:3102-3109.

47. E. Bradshaw Bunney, MD, FACEP Stroke Center Certification Certification review will assess Compliance with consensus-based national standards Effective use of primary stroke center recommendations and clinical practice guidelines to manage and optimize care Performance measurement and improvement activities Certification for a 1-year period A 1-year extension is available Joint Commission Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Disease-Specific Care: Update [JCAHO Web site]. Issue 1, June 2004. Available at: http://www.jcaho.org/dscc/dsc/dsc+update/dsc_update.htm. Accessed September 15, 2004. JCAHO

48. Does my Hospital Have to Become a Stroke Center? E. Bradshaw Bunney, MD, FACEP

49. Opportunity Exists

50. E. Bradshaw Bunney, MD, FACEP Hospitals That are Stroke Centers Approximately 5,000 hospitals in the US As of Feb. 2005 there are 88 certified Stroke Centers 50 more in the pipeline California, Florida, Ohio and Pennsylvania each have 7 State certification in Massachusetts and New York

51. Do Stroke Teams Improve Outcomes? E. Bradshaw Bunney, MD, FACEP

52. Stroke Team vs Stroke Center E. Bradshaw Bunney, MD, FACEP

53. TIME IS BRAIN E. Bradshaw Bunney, MD, FACEP

54. Importance of Rapid Identification and Triage Intervention in acute ischemic stroke requires the rapid and careful Assessment Selection Treatment Within 3 hours of symptom onset Multiple disciplines and departments Pre-hospital responders and in-hospital care providers Perceptions, attitudes, and behavior of the public Warning signs of stroke Need for rapid and immediate action of Emergency Stroke Patients

55. E. Bradshaw Bunney, MD, FACEP Factors Potentially Delaying Response Times in Stroke Inadequate public/patient awareness of signs and symptoms and need to call EMS early Strokes don’t cause pain The need for time urgency for emergency stroke patients by prehospital and healthcare professionals Modification of existing EMS programs for rapid identification, triage, treatment, and transport of emergency stroke patients EMS=emergency medical services.

56. E. Bradshaw Bunney, MD, FACEP Primary Stroke Center Team Improves Time to Treatment Variable Before Stroke Center Team 24-Hour Stroke Team Established Time until notification of stroke team (min) 2410 Time for stroke team arrival (min) 286 Time from triage to CT scan (min) 5242 Lattimore SU, et al. Stroke. 2003;34:e55-e57.

57. E. Bradshaw Bunney, MD, FACEP Stroke Teams and Establishment of Acute Stroke Pathways One ED’s 2-year experience St. Joseph’s Hospital A 467-bed institution located in Phoenix, Arizona Includes a neurologic institute and level I trauma center Before a stroke team was established, stroke patients: Waited an average of 33 minutes for a physician examination CT scan took an average of 55 minutes to be completed An additional 10 to 15 minutes passed until the CT scan was interpreted Jahnke HK, et al. J Emerg Nurs. 2003;29:133-139.

58. E. Bradshaw Bunney, MD, FACEP Improved Approach to Assessment St. Joseph’s Hospital developed a stroke team and a written acute stroke pathway The acute stroke pathway included a standardized set of orders and instructions for the management of acute ischemic stroke Acute stroke pathway goals to improve the quality of patient care: Decreased length of stay Increased use of select medications and treatment Improved patient assessment Reduced unnecessary testing Jahnke HK, et al. J Emerg Nurs. 2003;29:133-139. of Stroke Patient

59. E. Bradshaw Bunney, MD, FACEP Acute Stroke Pathway: Triage nurses assign stroke patients to “Stroke Team One” or “Stroke Team Two” Stroke Team One  patients <6 hours since onset of symptoms Stroke Team Two  patients >6 hours since onset of symptoms OR patients whose symptoms have resolved (due to transient ischemic attack) ED nurses perform brief neurologic exams every 15 minutes following patient arrival Orientation, motor skills, sensory abilities, speech, and vision NIHSS score determined by stroke neurologist, neurology resident, or stroke research nurse Jahnke HK, et al. J Emerg Nurs. 2003;29:133-139. A Two-Armed Approach

60. E. Bradshaw Bunney, MD, FACEP Improvement in Patient Care Adapted from Jahnke HK, et al. J Emerg Nurs. 2003;29:133-139. Since Implementation of Stroke Team and Acute Stroke Pathway

61. E. Bradshaw Bunney, MD, FACEP Stroke Units Improve Outcomes Study included 802 patients admitted with a stroke diagnosis to a hospital in Norway Study patients arrived within 24 hours of stroke onset and were at least 60 years old Patients were treated in the stroke unit or in the general medical ward Stroke outcomes were assessed Ronning OM, et al. Stroke. 1998;29:58-62.

62. E. Bradshaw Bunney, MD, FACEP Stroke Units Improve Outcomes in Ischemic Stroke P=0.077 P=0.017 P=0.043 P=0.140 P=0.144 P=0.112 Ronning OM, et al. Stroke. 1998;29:58-62.

63. E. Bradshaw Bunney, MD, FACEP Stroke Units Improve Outcomes in Hemorrhagic Stroke P=0.0291P=0.0041P=0.0143P=0.0104P=0.0205P=0.0217 Ronning OM, et al. Stroke. 1998;29:58-62.

64. “Drip and Ship”? E. Bradshaw Bunney, MD, FACEP Is There a Role for

65. Strict Protocol is the KEY E. Bradshaw Bunney, MD, FACEP

66. Rural Nevada One designated stroke center 8 rural EDs One protocol agreed to by all hospitals Managed through the central stroke team Site visits to confirm protocol adherence and promote team approach

67. Role of Community Education E. Bradshaw Bunney, MD, FACEP

68. Can Community-Based Education Improve Knowledge? Becker KJ, et al. Cerebrovasc Dis. 2001;11:34-43. Objective Assess if the knowledge deficits regarding stroke signs, symptoms, and risk factors could be improved Methods Telephone interviews used to assess effect Several media resources used May to September 1998

69. E. Bradshaw Bunney, MD, FACEP Community-Based Education Improves Knowledge: Results Becker KJ, et al. Cerebrovasc Dis. 2001;11:34-43. What organ is injured during a stroke? Prior to the campaign, 45.2% of respondents knew that the brain was injured, after the campaign, 49.5% Can’t easily teach old dogs new tricks Sustained media education Begin education earlier in life Effect of education campaign Respondents were 52% more likely to know a risk factor of stroke (P=0.005) Respondents were 35% more likely to know a symptom of stroke (P=0.032)

70. E. Bradshaw Bunney, MD, FACEP Community-Based Education Improves Knowledge: Conclusion Becker KJ, et al. Cerebrovasc Dis. 2001;11:34-43. There is a severe knowledge deficit about stroke that is greater in those at a high risk for stroke, including: Elderly Less educated Persons with low income Men Asian Americans Knowledge deficit can be improved through community-based education, particularly through public service announcements on television

71. EMS Front and Center E. Bradshaw Bunney, MD, FACEP

72. Paramedic Quick Screen Focal neurological symptoms including: Unilateral weakness Numbness Blindness Loss of speech Loss of balance Well-established time of onset less than 3 hours Age >18 years Notify Base Station to activate Code Stroke on potential patients during transport 1. Lyden PD, et al. J Stroke Cerebrovasc Dis. 1994;4:106-113. 2. Rapp K, et al. J Neurosci Nurs. 1997;29:361-366.

73. E. Bradshaw Bunney, MD, FACEP University of Cincinnati Prehospital Stroke Scale Facial Droop (Patient shows teeth or smiles): Normal (Both sides of face moves equally well) Abnormal (One side of face doesn’t move as well as other side) Arm drift: Normal (Both arms move the same OR both arms don’t move at all) Abnormal (One arm either doesn’t move OR one arm drifts down compared to the other) Speech (The patient says “The Cubs aren’t going to the playoffs”): Normal (Patient says correct words with no slurring of words) Abnormal (Patient slurs words, says the wrong words, or is unable to speak) Source: Adapted from Kothari R, et al. Acad Emerg Med. 1997;4:986-990

74. E. Bradshaw Bunney, MD, FACEP AHA-Recommended Assessment of a Person With Suspected Stroke by EMS Personnel Assure adequate airway Monitor vital signs Conduct general medical assessment Evidence of trauma to head or neck Cardiovascular abnormalities Ocular signs Conduct neurological examination Prehospital assessment (eg, Cincinnati Prehospital Stroke Scale) Level of consciousness (Glasgow Coma Scale) Pupils: size, equality, reactivity Presence of seizure activity Prearrival notification: estimated time of onset, Glascow Coma Scale score AHA. BLS for Healthcare Providers. 2001:36-47.

75. E. Bradshaw Bunney, MD, FACEP Assessing the Role of Paramedic Diagnosis and ED Efficiency Houston study Performance data from paramedics and 6 hospital EDs Data collected from 446 patients with suspected acute stroke Data were used to assess the effect of: Establishing emergency stroke centers Paramedic education program Target treatment times were based on ASA standards Unenhanced CT scan of the brain within 30 minutes Maximum of 60 minutes for initiation of tPA Wojner AW, et al. Am J Crit Care. 2003;12:411-417. ASA=American Stroke Association.

76. E. Bradshaw Bunney, MD, FACEP Effectiveness of Paramedic Diagnosis and ED Treatment Patterns Stroke diagnosis 321/446 (72%) cases Onset of signs/symptoms 359/446 (80.5%) patients Of these 359 patients, 210 (58.5%) arrived at the ED within 120 minutes of onset There were 319 case report forms submitted with thrombolysis data; 195 of these cases had acute ischemic stroke diagnosed; hospitals 3 and 6 did not administer thrombolytics Wojner AW, et al. Am J Crit Care. 2003;12:411-417.

77. E. Bradshaw Bunney, MD, FACEP EMS and ED Stroke Care Are Improved With Education Houston paramedics are able to diagnose stroke Aggressive stroke education initiative during the NINDS study Close interaction between paramedics and hospital Community awareness of signs/symptoms Allowed >65% of patients with confirmed stroke to arrive in the emergency department within 3 hours ASA standards can promote uniform stroke assessment and treatment processes Wojner AW, et al. Am J Crit Care. 2003;12:411-417.

78. E. Bradshaw Bunney, MD, FACEP ED Stroke Protocol All very similar Specific to nuances within the specific hospital Must be strictly followed Must be implemented in ALL appropriate patients

79. Treatment of Stroke Patients Following Admission to the Hospital E. Bradshaw Bunney, MD, FACEP

80. Admission to the Hospital and Complications Approximately 25% of patients can worsen during first 24 to 48 hours after stroke DVT/PE Pneumonia/aspiration Neurological complications Most to a monitored setting OT/PT are essential Adams HP, et al, a scientific statement from the Stroke Council of the American Stroke Association, approved by the American Heart Association Science Advisory and Coordinating Committee. Stroke. 2003;34:1056-1083.

81. E. Bradshaw Bunney, MD, FACEP Recommendations for Stroke Care Following Admission to Hospital Admission to a stroke unit with comprehensive rehabilitation for patients Frequent neurological status checks and vital signs during the first 24 hours Early mobilization and measures to prevent stroke complications Aspiration, malnutrition, pneumonia, deep vein thrombosis (DVT), pulmonary embolism, pressure sores, orthopedic complications, and contractures Prophylactic treatment to prevent DVT Treatment of infectious complications with antibiotics Treatment of concurrent medical conditions

82. EM Controversies E. Bradshaw Bunney, MD, FACEP in Stroke Management

83. ACEP.org

84. SAEM.org

85. AAEM.org

86. E. Bradshaw Bunney, MD, FACEP EM Concerns Internal and external validity of the NINDS trial Single trial (two parts) Treated group not as sick as the placebo group Hemorrhage rate Neuroradiology interpretation Infrastructure needed to provide timely care EMS not prepared for their role Hospitals not prepared for their role Medical legal concerns in the emergency medicine and neurology communities Reimbursement issues

87. E. Bradshaw Bunney, MD, FACEP EM Role in the Process and Center A hospital can not embark on becoming a stroke center without EM participation Models exist where EM has taken the lead role in developing the stroke team Conversely, models exist where EM has blocked the initiative

88. E. Bradshaw Bunney, MD, FACEP ACEP and Stroke Centers October 2003: ACEP Council and Board of Directors unanimously adopted a resolution to monitor the progress of any federal stroke legislation and dedicate resources to make members of Congress aware that: Standards of care in stroke treatment remain controversial The designation of stroke centers based on their ability / willingness to adhere to such standards of care may have many unintended negative consequences

89. E. Bradshaw Bunney, MD, FACEP SAEM: MAY 18, 2004 Background Policy statements: Andy Jagoda American Stroke: Ellen Magnis Panel Presentations American Stroke: Mark Alberts ACEP: Brian Hancock SAEM: Jim Adams NAEMSP: Robert O’Connors JACHO: Maureen Connors Potter Panel Discussion

90. E. Bradshaw Bunney, MD, FACEP Where do We go From Here? Work with the Brain Attack Coalition Educational programs Medical students Residents Implementation packets for stroke center certification Pathways, protocols, tools Focus on future therapies and having systems in place to facilitate utilization

91. E. Bradshaw Bunney, MD, FACEP Clinical Course The patient was met by a nurse, a doctor and an EM tech and taken to the resuscitation room. They confirmed the onset time of 2:15pm. Vital signs were BP 142/88, P 98, R 16, T 99.2 F. HEENT: eyes were deviated to the right but came back to midline with command, PERRL, Ears clear, neck supple. Heart, lungs and abdomen were normal. Neurological exam: CN mild left facial droop, strength 5/5 R arm and leg, 1/5 L arm and leg, no light touch or pin prick sensation in the L arm and leg. NIHSS=17-18.

92. E. Bradshaw Bunney, MD, FACEP Clinical Course The stroke team was called at 3:05pm Labs were drawn and sent. The patient went to CT at 3:20 pm and returned at 3: 41pm. The stroke team assessed the patient on return from CT and agreed with the diagnosis of CVA and NIHSS=18. Head CT reading was “negative for bleed, normal brain” at 4:03pm.

93. E. Bradshaw Bunney, MD, FACEP Clinical Course The patient was felt to be a good candidate for thrombolytics. The patient was advised of the risks and benefits. The patient, along with his wife refused thrombolytic therapy, stating “I want nature to take its course”. The patient was given 325 mg. of aspirin and admitted to the hospital. His 24 hour NIHSS=14. On discharge, 5 days later, NIHSS=10.

94. E. Bradshaw Bunney, MD, FACEP Key Learning Points JACHO Stroke Center certification requires multi-disciplinary cooperation with one central champion Strict adherence to stroke protocols improves outcomes in these patients EMS plays a KEY role in maximizing the management of stroke patients The EM community has numerous concerns about the Stroke Center designation concept

95. E. Bradshaw Bunney, MD, FACEP Questions?? www.ferne.org ferne@ferne.org E. Bradshaw Bunney, MD, FACEP Questions?? www.ferne.org ferne@ferne.org E. Bradshaw Bunney, MD, FACEP bbunney@uic.edu 312 413 7484 www.ferne.org formatted_bunney_strokecenter_aaem_2005.ppt 2/11/2005 7:32 PM