REGIONAL STROKE SYSTEM PLAN

Transcription

1 Attachmet REGIONAL STROKE SYSTEM PLAN OPERATION STROKE TASK FORCE BIRMINGHAM METRO AMERICAN HEART ASSOCIATION Revised 02/2010

2 TABLE OF CONTENTS Attachmet BACKGROUND 3 STROKE SYSTEM GOALS... 7 STROKE SYSTEM BRIEF OVERVIEW... 8 COMPONENTS AND ORGANIZATION Pre-hospital Compoet... Hospital Compoet... Commuicatios Compoet... Commuicatios Ceter... Stroke Resources Display... Data/QI Compoet... Hospital Dataset.... Quality Improvemet Program... Stroke Implemetatio Committee... Stroke Operatios Committee... STROKE SYSTEM FUNCTION System Etry Criteria... Commuicatios... System Operatios... Hospital Destiatio... Pre-hospital System Activities... Hospital System Activities... System Compliace Evaluatio ad Actio... Appedix A Stroke Ceter Stadards Appedix B Data Poits 31 Appedix C Cotiuous Quality Improvemet 33 Appedix D Stroke Implemetatio Committee. 37 Nomiatio Form Appedix E Stroke Operatios Committee.. 38 Nomiatio Form

3 STROKE PLAN Attachmet BACKGROUND Stroke is a serious ad commo illess. Data o the icidece of stroke, collected by the America Heart Associatio, idicated that i the Uited States there is a stroke about every miute ad a perso dies of stroke about every 3 ½ miutes. At the momet, there are 3 to 4 millio Americas who had a stroke yet are still alive. The death rate is approximately 30% of all stroke victims. This rate has declied sigificatly over the last several decades, ot due to therapy for stroke, but due to excellet treatmet of the complicatios that occur after a stroke. We ca put the stroke problem ito perspective by comparig it to other eurological illesses. For example, Parkiso s disease affects about 50,000 ew patiets every year, ad there are ow at least 350,000 Americas with Parkiso s disease. Every year about 400,000 ew cases of Alzheimer s disease are diagosed; there are about 1 millio people alive with the disease. About 125,000 ew cases of epilepsy occur each year ad about 2 millio Americas are curretly affected. Traumatic brai ijury affects 300,000 cases each year; ew brai tumors are foud i 25,000 people each year. Clearly, stroke affects more people every year tha ay of these other illesses, with Alzheimer s disease comig closest - about 400,000 ew cases compared to 500,000 ew cases of stroke. Ad i terms of survivors - patiets who require care ad patiets who require resources - the 3 to 4 millio stroke patiets far ad away preset the biggest problem. What happes to stroke survivors? Recet studies of acute stroke usig the modified Raki disability scale, i which the worst outcome is death (a Raki score of 5), show that the percetage of patiets who die is betwee 16% ad 23% i the first 3 moths. O the Raki scale, a score of 0 or 1 idicates a good outcome, or ormal recovery, after stroke. I these studies, oly 25% of patiets recover fully. Cosiderig the 20% who die, this leaves approximately 55% of stroke patiets (those with a Raki score of 2,3, or 4) with varyig degrees of disability at 3 moths after stroke. These umbers are approximately the same at 1 year after the stroke. It is this group that creates a ogoig burde to society, to the patiet, ad to their families. These patiets are impaired i basic activities of daily livig such as feedig, bathig, ad groomig. What other limitatios do hadicapped stroke survivors face? The most iterestig fidig is that 40% of hadicapped survivors feel they ca o loger visit people. Other sigificat hadicaps iclude impairmets i walkig, helpig aroud the house, doig dishes, ad cookig. Almost 70% of hadicapped stroke survivors report that they ca t read. Life for stroke survivors ca be bleak: they are o loger as mobile as they oce were; they ca t read books or the ewspaper; they ca t ejoy hobbies as they oce did; they ca t help with the shoppig or the gardeig. Almost 100% ca t help out with the housework. The magitude of the problem to the idividual is eormous. Stroke ca result from several differet diseases. Of the 500,000 strokes that occur each year, 400,000 are caused by ifarctios (most are first-time strokes, some are secod time strokes), ad 100,000 are hemorrhagic, either itracerebral or subarachoid. A hemorrhagic stroke ca be

4 Attachmet a hematoma, a disease that occurs i the same age group ad is associated with the same risk factors as ifarctio. But ulike patiets with ifarctios, about 60% of patiets with a hematoma die. Ad most of the survivors are left gravely disabled. Subarachoid hemorrhage is a disease of youg ad middle-aged adults. There are about 30,000 of these cases every year: 80% of them are due to a ruptured berry aeurysm, 50% of which are fatal, ad half of the survivors are left disabled. These patiets, sice they are oly 30 or 40 years old at the time of the stroke, require the same services as older stroke patiets but for a much loger period of time. Serious complicatios of subarachoid hemorrhage iclude vasospasm, which ca be treated. Stroke is a very expesive disease. Of the first-year costs, 50% accrue durig ipatiet hospitalizatio. The distributio of costs amog patiets, though, is skewed: 10% of people accout for about 30% of the total cost. Ad although 80% of strokes are from ifarctios, oly half of the costs are due to ifarctio, idicatig that hemorrhages accout for a disproportioate share of the cost of stroke. Medical costs for a patiet with a mild stroke are approximately $8,000. For patiets with more severe strokes, icludig patiets with itracerebral hemorrhage, the cost is approximately $15,000 for a admissio for the first year. For patiets with subarachoid hemorrhage, the cost is almost $30,000. These patiets are more seriously ill. They sped more time i itesive care uits ad require more care after discharge from the hospital. Dyig from a stroke does t save moey. If a patiet dies of a stroke, the cost is approximately the same as the cost of carig for a stroke ipatiet. A TIA costs about $4,000, o average, for a ipatiet. A fatal itracerebral hemorrhage is slightly less expesive tha a stroke, ad a fatal subarachoid hemorrhage is about $10,000 less. Refereces 1. Aderso CS, Lito J, ad Stewart-Wye EG. A populatio-based assessmet of the impact ad burde of caregivig for log-term stroke survivors. Stroke 1995;26: Solomo NA, Glick HA, Russo CJ, et al. Patiet prefereces for stroke outcomes. Stroke 1994;25: The Natioal Istitute of Neurological Disorders ad Stroke rt-pa Stroke Study Group. Tissue plasmioge activator for acute ischemic stroke. N Egl J Med 1995;333: The aoucemet, i late 1995, that acute ischemic stroke ca be successfully treated with thrombolytic agets created the eed for a atioal pla o how to make this treatmet available to eligible patiets as rapidly as possible. While thrombolytic therapy of ischemic stroke with t- PA was the impetus for care chages, it was recogized from the outset that the successful treatmet of ay type of stroke will require rapid respose to all stroke types. Specifically: Prehospital emergecy respose systems must trai persoel to correctly idetify potetial cadidates for treatmet ad work closely with hospital emergecy departmets to trasport these patiets rapidly to appropriate stroke ceters. Thrombolytic therapy for ischemic stroke requires a especially rapid respose i the first few miutes after a patiet arrives at a hospital.

5 Attachmet Emergecy departmets must have specialized protocols i place for idetifyig cadidates for therapy ad treatig those that require therapy withi a arrow therapeutic time widow. Hospitals must develop comprehesive acute stroke plas that defie the specialized roles of ursig staffs, diagostic uits, stroke teams, ad other treatmet services such as pharmacy ad rehabilitatio. To take full advatage of effective stroke treatmet, all health care systems ivolved i maagig eligible patiets must be carefully itegrated, takig ito cosideratio the wide diversity of health care that exists throughout the Uited States, from rural settigs with miimal access to specialized care to urba settigs with a high volume of emergecy patiets. Public educatio is critically importat i esurig that all of the efforts cited above are successful. The public must lear that a brai attack is a medical emergecy, that a treatmet is ow available for some stroke patiets, ad that this treatmet is oly effective whe give withi a few hours of the oset of symptoms. Prehospital Emergecy Medical Care Systems: EMS persoel must be traied to treat stroke as a time-depedet, urget medical emergecy, similar to acute myocardial ifarctio. A Chai of Recovery - begiig with the idetificatio (either by the patiet or a olooker) of a possible stroke i progress ad edig with a rehabilitatio pla - must be established i every commuity of the coutry. New educatioal iitiatives must be developed ad implemeted for all medical persoel i the Chai of Recovery, icludig 911 dispatchers, EMS techicias, ad air medical trasport persoel. This will require the creatio of task forces to develop model educatioal iitiatives, ad stadardized data sets to help esure effective research ad outcomes aalyses. Emergecy Departmet: Acute stroke patiets should be classified as quickly as possible to idetify those eligible for thrombolytic therapy. Although this classificatio will ofte be doe by physicias i emergecy departmets, it may also be accomplished by others, e.g., prehospital care providers, triage urses, or other idividuals competet to apply categorizatio criteria. Patiets deemed ieligible for thrombolytic therapy will udergo a differet rapid categorizatio to establish what treatmet they should receive. Respose systems, icludig optimal time frames, must be established, maitaied, ad moitored i all emergecy departmets. The goal should be to (a) perform a iitial patiet evaluatio withi 10 miutes of arrival i the emergecy departmet, (b) otify the stroke

6 Attachmet team withi 15 miutes of arrival, (c) iitiate a CT sca withi 25 miutes of arrival, (d) Iterpret the CT sca withi 45 miutes of arrival, ad (f) trasfer the patiet to a ipatiet settig withi 3 hours of arrival. Although medical maagemet of blood pressure remais a cotroversial ad complex topic, geeral guidelies were outlied at the Symposium. For example, for acute stroke patiets who are cadidates for thrombolytic therapy, atihypertesive treatmet should ot be give if systolic blood pressure is less tha 185 mm Hg or diastolic pressure is less tha 105 mm Hg or diastolic pressure is less tha 105 mm Hg. Acute stroke patiets with a diastolic pressure greater tha 140 mm Hg or a systolic pressure greater tha 220 mm Hg o two readigs are geerally ot cadidates for thrombolytic therapy, although atihypertesive treatmet should be give. Acute Hospital Care: Every hospital providig care to stroke patiets should develop a Stroke Pla that defies the optimal treatmet pathways appropriate for that particular istitutio. Patiets who meet thrombolytic treatmet criteria should have access to stroke expertise withi 15 miutes of hospital arrival ad eurosurgical expertise withi 2 hours of hospital arrival. Other timeframe recommedatios are outlied above uder Emergecy Departmet. A Stroke Toolbox cotaiig guidelies, algorithms, critical pathways, NIH Stroke Scale traiig tapes, ad other stroke templates should be created, updated, ad made easily available through the NINDS. Health professioal traiig programs should be modified to iclude stadards of acute stroke care ad the Acute Health Care Pael edorsed specialty-specific cotiuig medical educatio related to acute stroke. Criteria for primary, itermediate, ad comprehesive stroke ceters should be established. Commuities should be ecouraged to create local ad regioal stroke etworks ecompassig all levels of acute stroke care. Health Care Systems: Creatig a efficiet stroke care delivery system should start with idetifyig committed prehospital ad hospital leaders who will act as champios. The task of these champios will be to develop ad sustai teams for maagig stroke patiets through the various phases of care. Champios should use flow-chartig techiques to help them uderstad the curret compoets of care, decide o ecessary modificatios, ad implemet these modificatios.

7 Attachmet All compoets of the stroke care delivery system must be itegrated fuctioally, fiacially, ad legally so they work together seamlessly. Those who activate the acute stroke treatmet system should work with the approach that oe call does it all, with everyoe o the team liked with pagers or cellular phoes. Key idicators for acceptable outcomes of acute stroke care must be idetified. Idicators should be established for the prehospital settig, the emergecy departmet, ad the acute stroke care uit withi the hospital, as well as for the variety of discharge settigs, icludig rehabilitatio facilities. Public Educatio: Behavior chage is achievable, as demostrated by may past public educatio successes. But chage occurs slowly, so those implemetig public educatio campaigs must be persistet ad patiet. Big, comprehesive programs that employ may commuicatios vehicles are the most effective. Motivatio to chage occurs whe the public perceives that the beefits of chage exceed the cost of chage. The messages about seekig prompt health care after a stroke must be simple, clear, ad repeated ofte. We must uderstad our audiece, which is comprised of may subgroups with differet backgrouds ad differet methods of learig. Messages must be tailored to these various groups. Success is most likely if public educators follow a Madiso Aveue approach to deliverig messages. I this approach, strategy always precedes executio, ad the best strategy tool to use is the creative brief, a documet that defies the target audiece, idetifies the desired actios to be take by that audiece, presets curret cosumer beliefs ad barriers to takig actio, ad establishes log-term goals. GOALS The primary goal of this Regioal Stroke System Pla is: To develop a Stroke Emergecy Care System that, whe implemeted, will result i decreased stroke mortality ad morbidity i the regio. I order to accomplish this the Committee idetified a umber of specific processes deemed essetial. These are: 1. The ability to rapidly ad accurately idetify stroke patiets.

8 Attachmet Patiets who have sustaied or are likely to sustai a stroke must receive care i a hospital that has a stroke treatmet program i place (i.e. a Stroke Ceter) which is capable of providig immediate ad comprehesive assessmet, resuscitatio, ad defiitive care, plus establishig rehabilitatio access whe eeded. 3. There must be cotiuous ad effective regio-wide coordiatio of pre-hospital ad hospital care resources, so that stroke patiets will be most expeditiously trasported to the closest stroke ceter, so their care ca be provided i a maer that is both appropriate ad timely, while establishig ad maitaiig cotiuity. To accomplish this process there must be a method of trackig the care of stroke patiets. 4. The program must provide all hospitals i the regio the opportuity to participate i the system (a iclusive system), ad to receive stroke patiets if they are willig to meet the system ad operatioal criteria, as established by this task force. 5. The system must have a ogoig ad effective QI Program, i order to assure cotiuig appropriate fuctio i providig the highly specialized care ecessary i the maagemet of stroke. This program will iclude evaluatio of pre-hospital maagemet, hospital maagemet, ad overall system fuctio. A stadard pre-hospital dataset ad hospital dataset will be required of all system participats, allowig uiform system evaluatio to documet the effectiveess of the fuctio of the stroke system. REGIONAL STROKE SYSTEM OVERVIEW The Task Force has developed a pla for a Regioal Stroke System that meets the goals set forth i the previous sectio. A system is a group of idividual compoets brought together to fuctio i a uified maer to achieve a specific ed result. I this case, the ed result is improvemet i stroke survival ad outcome i our regio. The compoets to some degree have separate ad idividual idetities ad fuctios, however, there should be a uderstadig, a desire, ad willigess to work together i a uified effort to reach the ed result. Sice there is o legally sactioed madate for developmet ad implemetatio of a Regioal Stroke System, the oly optio the Task Force had was to develop a volutary system. A volutary system requires a uiquely strog commitmet to stroke. The Regioal State System is costituted by the hospitals desigated as Stroke Ceters ad the protocols to be implemeted for pre-hospital ad hospital treatmet of patiets that have a stroke or a high probability for stroke. These patiets will be selected based upo primary triage criteria (system etry criteria) icluded i the Regioal Stroke Pla. If patiets meet the primary triage criteria for system etry, the system fuctio protocols ad specialized stroke care resources at the Stroke Ceters will be implemeted for their care. Patiets who do ot meet the primary triage protocols for etry ito the system will ot be Stroke System patiets ad ay referece to Stroke System Patiets i this documet does ot pertai to this group of patiets. Systems require oversight of project cocept, overall resposibility, developmetal aspects, implemetatio, ad evaluatio of cotiuig activities. Such a etity is commoly referred to as a lead agecy ad, i this program, the proposed lead agecy is the Birmigham

9 Attachmet Regioal Emergecy Medical Services System (BREMSS). This body has the resposibility for coordiatig pre-hospital EMS ad hospital Emergecy Departmet activities i our regio. The authority of this agecy is derived from specific activity goals ad plas approved by the ADPH/EMS office ad the State Board of Health. Also, the willigess of pre-hospital ad hospital healthcare providers i our regio to allow BREMSS to serve as the lead agecy so that stroke care i our regio is systemically improved. The Executive Committee of BREMSS serves as the leadership body for this orgaizatio ad therefore, will serve as the oversight for this program. The Regioal Stroke System basically ivolves the orgaizatio of already existig resources ito a program providig comprehesive care for stroke patiets through all phases of their maagemet from the momet of oset through rehabilitatio. The two basic patiet maagemet compoets of this system are the pre-hospital providers ad idividual hospital orgaizatios (i.e. Stroke Ceters). The system fuctio ivolves the establishmet ad implemetatio of the protocols icluded i this Pla. Based upo eed, modificatios ad additios may be developed by the Stroke Implemetatio Committee ad the Stroke Operatios Committee for system operatios. The etry criteria are iteded to select patiets with actual or a high potetial for havig a stroke. It is estimated that four to five patiets per a 24-hour period will be etered i the system. Upo determiatio that a patiet has had or has a high probability for a stroke ad would beefit from specialized Stroke Ceter maagemet, specific etry ito the Stroke System will be automatically accomplished ad resource availability will be surveyed. Etry ito the system meas that a patiet meets specific triage criteria idicatig a actual or high probability of a stroke ad the specialized Stroke System resources will be used i their care. Protocol directed Stroke Ceter destiatio will be determied ad the care of these patiets will be evaluated through the QI Program. A Stroke System which reports stroke patiets ito a cetralized facility eables the most appropriate resource utilizatio ad the most appropriate care to be provided. Oce a stroke patiet is etered ito the System, the closest system hospital (i.e. Stroke Ceter) with available resources matchig the level of eed ca the be selected as the appropriate destiatio for that patiet, usig the Regioal Stroke Pla criteria ad protocols. Hospitals participatig i this system ad receivig stroke patiets will have orgaized respose systems, icludig 1) equipmet ad facilities 2) traied ad committed persoel 3) orgaized maagemet protocols such as that i the Advaced Cardiac Life Support. A regioal stroke database will be established, which will allow geeratio of overall kowledge of the magitude ad scope of stroke i our regio, determiatio of teachig ad traiig eeds i stroke, ad will be used i cojuctio with other ambulace services ad hospital evaluatios i a cotiuous quality improvemet program to evaluate the stroke care ad be able to documet appropriateess ad quality, with implemetatio of improvemets utilizig this evaluatio process. The Task Force recommeds a specific Stroke Implemetatio Committee to actually establish the program ad the a Stroke Operatios Committee to oversee the program durig its cotiuig fuctio. These committees will be directly resposible to the lead agecy. They will make recommedatios regardig the Stroke System to the lead agecy for actio. The

10 Attachmet Stroke Operatios Committee will specifically review the cotiuig fuctio of the Stroke System ad prepare routie reports regardig system fuctio ad QI review summaries for the lead agecy. Fially, it is importat to emphasize that Stroke is a eurological disease. The Emergecy Departmet plays a critical role i stroke maagemet, but Neurological ad Neurosurgical Care are absolute pivotal services i determiig the survival ad recovery of stroke patiets. Neurological leadership of hospital stroke programs is, therefore, essetial i order for hospitals to participate i the Stroke System. This leadership role must be clearly defied withi the Hospital Stroke Pla alog with specific appropriate authority to carry out that leadership role. Evidece of cotiuig leadership should be demostrated through eurologist s participatio i the Regioal Stroke System activities ad through the idividual hospital QI programs. COMPONENTS AND ORGANIZATION The Regioal Stroke System is comprised of a umber of separate compoets, which are orgaized ad work together as a system. The idividual compoets ad elemets which make up the system will be described i this sectio. I. PRE-HOSPITAL COMPONENT EMS Uits are a itegral part of the Regioal Stroke System. However, their orgaizatio will ot be chaged by the Regioal Stroke System. Coversely, chages i the make up of EMS Uits will ot affect the fuctioal status of the Regioal Stroke System. There is, evertheless, a specific issue regardig the pre-hospital compoet of the Regioal Stroke System: All EMT Itermediates ad Paramedics eed to have a basic kowledge ad awareess of the Regioal Stroke System elemets ad system fuctio. This specifically refers to the etry criteria ad commuicatios. If they are uclear about etry criteria or system fuctio this iformatio ca be easily obtaied o a 24 hour a day basis from the Trauma/Stroke Commuicatios Ceter so that they ca the apply the system stroke protocols i field care situatios. II. HOSPITAL COMPONENT Hospitals will be able to participate i this system o a volutary basis. Stadards have bee developed by the Stroke Task Force. These are preset i Appedix A. Each hospital will be able to determie whether they are o-lie (have adequate resources curretly available ad receive patiets based o system operatios protocols) or are offlie (do ot have adequate resources curretly available ad do ot receive patiets per the Stroke System). The participatig hospitals (i.e. Stroke Ceters) will be able to go o-lie ad off-lie at will.

11 Attachmet Each hospital must have a Neurologist primarily resposible for oversight of the Stroke Program. This resposibility icludes: 1. Workig with admiistratio to maitai the resources ecessary to be a desigated Stroke Ceter. 2. Assurig that call schedules that provide physicia availability are prepared o a mothly basis. 3. Establishig maitaiig basic stroke care protocols for the hospital. 4. Oversight resposibility for the Hospital Stroke QI Program per Pla stadards, ad participatio i Regioal Stroke System admiistrative ad QI activities as per the Regioal Stroke Pla, icludig data collectio ad reportig to BREMSS. Participatio i the Regioal Stroke System is accomplished as follows: 1. The decisio to participate must be made joitly by both Hospital Admiistratio ad Medical Staff, uder the commitmet of huma ad physical resources. 2. A applicatio is obtaied from BREMSS, completed ad retured, documetig the hospital's desire to participate. 3. A o-site orietatio meetig at each applyig facility is to be held to review the system desig ad fuctio, plus the requiremets to assure there is a full ad complete uderstadig o the part of the hospital ad the medical staff. This meetig must be atteded by a miimum of the Neurologist leader of the stroke program i that hospital, the Medical Director of Emergecy Departmet ad the Hospital Admiistrator. 4. The Stroke Operatios Committee will review the applicatio ad o site visit report to documet compliace with requiremets ad kowledge of system desig ad fuctio ad provide a report to the BREMSS Executive Committee. 5. The BREMSS Executive Committee will make the fial decisio regardig hospital participatio as a Stroke Ceter i the System. If approved, the hospital will become part of the System by executig a cotract with BREMSS documetig their willigess to actively participate i the System. Hospitals, therefore, must elect whether or ot to participate i this system based upo their idividual ability to meet the stadards for a Stroke Ceter, the desire of the Medical Staff to participate ad support this program, ad the willigess of the Hospital Admiistratio to support the Regioal Stroke Program. III. COMMUNICATIONS COMPONENT Commuicatios are critical to the fuctio of the Stroke System. Commuicatios provide (1) essetial kowledge of the overall status of pre-hospital stroke activities ad hospital resource availability o a cotiuous basis, (2) access to system orgaizatio ad fuctio protocols wheever such iformatio is requested by pre-hospital persoel or hospital based persoel, (3) a lik betwee the field ad Stroke Ceters for the rapid exchage of iformatio resultig i efficiet pre-hospital care

12 Attachmet provisio ad hospitals beig able to best prepare for stroke patiet arrival, (4) collectio of uiform System-wide data for both QI activities ad developmet of a Regioal Stroke database. Providig all of these fuctios to the etire System o a cotiuous basis requires a cetral commuicatios facility with costat commuicatios capabilities to all pre-hospital uits ad participatig hospitals, plus the ability to immediately ad directly lik the pre-hospital providers to the Stroke Ceters. This cetral commuicatios will be the existig Alabama Trauma Commuicatios Ceter (ATCC). This decisio is made because of a already existig fuded ifrastructure which may be utilized. The ATCC is staffed 24 hours a day by persoel who will be provided with specific i-depth kowledge of the Regioal Stroke System desig, fuctio, ad protocols. It will be the primary resposibility of the ATCC to coordiate the Regioal Stroke System activities by maitaiig ad providig iformatio wheever eeded o the field status ad hospital status so this data ca be used by the pre-hospital ad hospital persoel i providig care to patiets meetig system etry criteria. The ATCC, a part of the Regioal Stroke System, will be maaged by BREMSS, ad oversight of the dayto-day operatios of the ATCC are the resposibility of the BREMSS Executive Director. The ATCC will operate through the system operatios protocols. The ATCC will make o primary decisios themselves, but provide iformatio about patiet maagemet ad destiatio as per pre-established protocols for system fuctio. The ATCC will serve as a resource for such protocol iformatio to EMTs that may ot be familiar with the protocols or the ATCC may simply provide the coordiatio of pre-hospital ad hospital resource utilizatio for stroke maagemet. Therefore, the geeral fuctios of the Stroke Commuicatios Ceter are: 1. Assigs uique system I.D. umber for each patiet meetig system etry criteria for trackig throughout the system. 2. Collects brief pre-hospital database? 3. Provides iformatio o system etry criteria based o preset protocols as requested by EMTs whe it is ot clear if a patiet meets Stroke etry criteria. 4. Maitais kowledge of the fuctioal status of all system hospitals at all times. 5. Maitais kowledge of the activity status i the pre-hospital settig at all times. 6. Coordiates patiet destiatio, whe patiet meets system etry criteria, based o preset protocols as to the closest curretly operatioal Regioal Stroke Ceter. 7. Coordiatio for optimal resource utilizatio usig pre-established protocols for system fuctio whe there are multiple simultaeous evets i the regio (which, of course, either EMTs or idividual hospitals could kow about). 8. Establishes automatic commuicatio lik betwee EMS provider ad receivig facility. 9. Records ad eters pre-hospital data for Regioal Stroke database. A Emergecy Resources Display is also part of the commuicatios compoet. The Emergecy Resources Display provides each participatig hospital ad the Stroke

13 Attachmet Commuicatios Ceter with the cotiuous real-time fuctioal status display of all Stroke Ceters. The Emergecy Resources Display is a simple computer system with termials at each participatig facility ad the ATCC. This system will provide a display grid listig each idividual hospital, ad the primary resource compoets idicatig the availability or o-availability of these idividual compoets i each hospital. Therefore, their curret stroke activity status. Each system hospital will maitai the status otatio of the primary stroke resources i that hospital ad therefore, their overall stroke activity level. The Stroke Ceters will be able to chage their resource availability status ad activity level at ay time. A record of stroke hospital activity status for the etire system will be maitaied through the Emergecy Resources Display at the ATCC. Ay chage i hospital status as made by hospital persoel at its ow display termial will be automatically commuicated to the cetral system moitorig statio at the ATCC. The ATCC maitais a cosolidated system wide display status idicatig the idividual resource availability at the Stroke Ceters ad their overall fuctioal status at ay give time. This cosolidated iformatio table will be trasmitted back to hospitals. The system is maitaied automatically by computers with automatic pollig ad display refresh. The cosolidated status display would be similar to the followig example: EMERGENCY RESOURCES DISPLAY T.C./STROKE HOSP. LEVEL E.D.* ANES. O.R. X-RAY ICU* TS SS OS NS CT* NEURO* A 1 Stroke B 3 Stroke C 1 Stroke D 2 Stroke E 3 Stroke F 4 Stroke Numbers are color coded - gree for available, red for ot available Hospital abbreviatios are automatically color coded for o-lie status (gree-active, red-iactive) based o idividual resource availability i the hospital at that time. (See page 27) * Resources available for stroke system patiet The equipmet for the Emergecy Resources Display will cosist of a color video moitor, a computer ad a modem coected to a dedicated lie which does ot eter the facility through the switchboard. The software will allow simple keystroke chage of resource status by the Stroke Ceter persoel ad this chage will be trasmitted to the cetral system moitorig statio at the ATCC with this iformatio the beig immediately updated o all resource display moitors i the system. The cetral moitor statio automatically polls the idividual

14 Attachmet moitor statios i the system. If a statio's computer fails to ackowledge the poll, that hospital's iformatio will be blaked out o all resource display moitors i the system. If there is a isolated failure at a resource display at a hospital that will ot cause a total system fault, that hospital will be blacked out ad the ATCC will call requestig the iformatio directly. The system itegrity is ot depedet upo ay sigle statio's operatio. The commuicatios compoet's optios are detailed i Appedix. IV. DATA QUALITY IMPROVEMENT COMPONENT This compoet is absolutely essetial for fuctio of the Regioal Stroke System. I virtually ay serious stroke emergecy, the patiet has a very limited ability to meaigfully select pre-hospital, hospital ad physicia care. The efficacy of the iitial care i these patiets may have a pivotal role i determiig their outcome. Therefore, there is a eed to evaluate the system fuctioig to determie cotiuig effectiveess i the maagemet of stroke. This compoet uses a system-wide stroke database, which would provide a overall look at stroke emergecies, care ad outcomes, provide iformatio for use i determiig ad developig stroke teachig programs, provide iformatio able to be used i potetial stroke studies, ad utilizatio i evaluatio of system fuctio i the QI Program. There are two basic elemets of this compoet. The first is a stadard stroke dataset that will be used to establish a regioal stroke database. The secod elemet is the cotiuous quality improvemet program of the Stroke System. The Stroke QI Dataset is desiged as a small dataset, with oly 10 fields, ad it is iteded to fulfill the goals of this compoet as stated i the previous paragraph. A uique stroke idetificatio umber will allow uitig pre-hospital ad hospital data which will icrease the data usefuless. The data fields are oted i the followig list: 1. Icidet locatio 2. Pre-hospital uit(s) 3. Activity times 4. Receivig hospital 5. Patiet ad system demographics 6. Pre-hospital outcome 7. Hospital status/respose 8. Emergecy Departmet dispositio 9. Iitial (withi the first 24 hours) procedures 10. Fial dispositio A more thorough listig of the Stroke QI Data set is preset i Appedix. The secod etity i this compoet is the quality improvemet (QI) program for the Stroke System. This program is ecessary to the Stroke System to documet cotiuig fuctio ad allows the implemetatio of improvemets i a system where the patiets may ot have the ability to make their ow persoal medical care choices ad

15 Attachmet deped o the system for adequacy ad completeess of care. This program will be system-wide with the idividual agecies basically doig their ow QI evaluatios ad reportig to a regioal oversight committee. The appropriateess, quality ad quatity of all activities i the system must be cotiuously moitored i the areas of pre-hospital care, medical care of the patiets i the hospitals ad overall system fuctio. The basic QI process ivolves specific steps to be performed by each idividual etity. These steps are: 1. Assigmet of a QI maager to oversee the process i the orgaizatio. 2. Develop a writte QI program to evaluate patiet care with regard to appropriateess, quality ad quatity ad as part of that program, patiet care stadards are established for use i the evaluatio process. For prehospital programs this simply may be the regioal pre-hospital protocols. These programs are reviewed ad approved by the Regioal QI Committee ad lead agecy as part of becomig a Stroke System participatig hospital. 3. A method for QI data collectio is established. For Stroke Ceters this must iclude a morbidity ad mortality list. 4. QI evaluatios are udertake by the idividual system participats - EMS providers or Stroke Ceter hospitals. This first ivolves the determiatio of specific audit filters. Madatory Stroke Ceter audit filters iclude major complicatios ad deaths. Other appropriate audit filters are also evaluated. For Stroke Ceters, exteral outcome comparisos are part of the evaluatio process. 5. Determie the presece of QI issues through the data evaluatio process. 6. Discussio of QI issues at the formal QI Coferece of each idividual system participat - EMS provider or Stroke Ceter. 7. Develop a correctio actio pla. I geeral, actio activities ca be placed uder the categories of professioal resolutio or admiistrative resolutio. 8. Re-evaluatio must occur to documet the results ad effectiveess of the corrective actio pla. This is commoly called "closig the loop". Adequate documetatio of these activities is essetial. I Stroke Ceters a multidiscipliary peer review process must occur. I Stroke Ceter QI programs both medical care ad Stroke Ceter fuctio must be evaluated. The Regioal QI Committee has the goal of reviewig the etire Regioal Stroke Program activities for appropriateess, quality, ad quatity of activities. That review is to iclude system admiistratio/orgaizatio activities, pre-hospital care ad hospital care. The Regioal Committee will documet effectiveess of hospital ad EMS Service QI evaluatios through routie reports of these QI activities provided by each participatig etity. The Regioal Committee will perform focused review of specific items as determied appropriate, but these reviews will iclude evaluatio of both prehospital ad hospital activities. It is expected that most issues will be resolved by

16 Attachmet developig a actio pla i cojuctio with the various Stroke System etities. A reevaluatio for results is to be udertake. If it is determied that a chage i system cofiguratio or stadard fuctio should occur, a recommedatio will be set to the Stroke Operatios Committee for evaluatio ad report to the lead agecy. A more detailed outlie of the Regioal Quality Improvemet Program is available i Appedix 13. V. STROKE IMPLEMENTATION COMMITTEE The Stroke Implemetatio Committee (SIC) will be established by the lead agecy for the purpose of implemetatio of the Stroke Pla. This is doe uder the authority of the lead agecy with actio plas developed ad preseted as recommedatios to the lead agecy. As part of the implemetatio pla, operatioal protocols for the Stroke System will be developed ad forwarded to the lead agecy. This committee will fuctio oly durig the implemetatio period. Committee developmet will occur i the followig maer. A. A chairma ad vice-chairma will be chose by the chairma of the Executive Committee from a list of cadidates offered by all hospitals i the regio. The chairma ad vice-chairma of the SIC will be physicias ad they will cotiue o as the iitial chairma ad vice-chairma of the Stroke Operatios Committee i order to maitai cotiuity through iitial system implemetatio ad activity. The hospital ad the cadidate must joitly uderstad that the chairma ad vice-chairma positios will require a estimated four to six hours a week work effort, ad a commitmet to availability for that time must be made by the hospital ad the cadidate. Requiremets for chairma: 1. Neurologist with sigificat past experiece i direct medical maagemet of stroke cases. 2. Kowledge of BREMSS structure ad fuctio. 3. Ability to commit a average of four hours a week to this project. The vice-chairma is to be a Emergecy Medicie physicia. B. Hospitals ad other agecies/groups will provide committee membership omiatios as per the followig groups: 1. Hospitals a. Hospital Admiistratio b. Emergecy Nursig c. Stroke Nursig d. Neurologist (primary stroke call) e. Surgeo, Neurological f. Emergecy Medicie Physicia

17 Attachmet g. Aesthesiology 2. No-Hospital Agecies/Group a. EMT - Trasportig/No-trasportig b. Fire Service Admiistratio c. Ambulace Service Admiistratio 3. MCAC Chairma (or desigee) SIC membership omiatio form is Appedix E. C. The SIC chairma ad vice-chairma will select a proposed committee from the omiatios received ecompassig members from the groups. There will be 12 to 16 members o the committee. D. The Chairma of the BREMSS Executive Committee will appoit the SIC membership. E. BREMSS will staff the SIC (iclusive of the Regioal Medical Director). At the iitial meetig the SIC will draw up a implemetatio schedule ad provide that schedule alog with at least mothly progress reports to the BREMSS Executive Committee. VI. STROKE OPERATIONS COMMITTEE (SOC) Moitorig ad primary maagemet of system fuctio durig the cotiuig operatio of the Stroke System will be the resposibility of the Stroke Operatios Committee. This committee will be directly resposible ad report to the lead agecy. The committee will have a specific accoutability for direct ogoig system goverace which will occur by evaluatio of issues/situatios/ideas ad stadard system data regardig operatios ad cofiguratio. Recommedatios for actio will be developed by the committee based o aalysis of data/iformatio evaluated durig committee fuctio. A. Membership 1. The chairma ad vice-chairma shall serve for two year terms. The first chairma ad vice-chairma shall be the chairma ad vice-chairma of the Stroke Implemetatio Committee. Future chairma ad vicechairma of the Stroke Operatios Committee shall be appoited by the Chairma, BREMSS Executive Committee from omiatios provided by hospital, actively participatig i the Stroke System. Requiremets for the chairma of this committee iclude:

18 Attachmet a. Neurologist with sigificat past experiece i direct medical maagemet of stroke patiets. b. Adequate kowledge of BREMSS structure ad fuctio. c. Ability to commit a average of four hours a week to this project. The vice-chairma is to be a Emergecy Medicie Physicia. Nomiees for the chairma ad vice-chairma positios of the Stroke Operatios Committee ad their sposorig istitutios must uderstad the expected 4-6 hours per week time availability for carryig out the duties this positio. Resposibility of the chairma iclude: a. Serve as leader for committee meetigs. b. Resposibility for carryig out the assiged duties of the Stroke Operatios Committee. c. Report to the BREMSS Executive Committee regardig overall system fuctio plus system moitorig activities, suggestios, problems, QI activities, ad other issues as deemed appropriate. The vice-chairma is to actively assist the chairma as appropriate i carryig out the committee resposibilities. 2. Geeral membership will be costituted from the followig groups makig omiatios for specific membership positios (although ot all omiees will ecessarily become committee members). a. Hospitals actively participatig i the Stroke System. 1) Hospital Admiistratio 2) Emergecy Nursig 3) Stroke Nursig 4) Neurologist (primary Stroke call) 5) Surgeo, Neurological 6) Emergecy Medicie Physicia 7) Aesthesiologist 8) Stroke Prevetio persoel 9) Stroke Registry persoel b. Hospital ot directly ivolved i the Stroke System. 1) Physicia - Neurologist/Iteral Medicie or Emergecy Medicie physicia c. Pre-hospital members

19 Attachmet ) EMT-Trasportig or o-trasportig 2) Fire service admiistratio 3) Ambulace service admiistratio d. A commuity member will be requested by the BREMSS Executive Committee to be a member. e. A local govermet official will be requested by the BREMSS Executive Committee to be a member. f. BREMSS will staff the SOC to iclude participatio of the Regioal Medical Director. The geeral membership term is for two years ad the committee will be costructed so there is a oe-half turover each year. There will be 17 to 24 committee members. B. Duties The duties of the Stroke Operatios Committee iclude the review of the overall fuctio of the stroke program icludig hospital ad pre-hospital activities. This icludes review of criteria, data, or reports. This iformatio will be evaluated regardig adequacy of these various activities ad for developmet of system fuctio reports ad recommedatios regardig the hospital or pre-hospital compoets or fuctios, icludig resposibilities, stadards, ad activities. If recommedatios directly ivolve pre-hospital aspects of the stroke program they will be referred to the MCAC for review ad commet ad the re-evaluated by the SOC regardig the MCAC iput ad the, the recommedatio i fial form will be set to the Executive Committee for actio. Areas of resposibilities iclude: 1. Stroke Ceter resource requiremets criteria 2. Stroke Ceter membership i the System 3. Stroke Ceter removal from the System 4. Commuicatios withi the System 5. Pre-hospital ad hospital dataset 6. Pre-hospital ad hospital quality improvemet programs 7. Patiet etry criteria ito the Stroke System 8. Pre-hospital activities i the System 9. Moitorig of ogoig system requiremets/stadards/activities ad use of system fuctio protocols STROKE SYSTEM FUNCTION Geeral fuctio of the System will follow the sceario of:

20 Attachmet Stroke occurs or warig sigs/symptoms are preset. 2. Field evaluatio doe by EMT who determies if the patiet meets the system criteria (if EMT is usure of etry criteria, that iformatio may be immediately obtaied from the ATCC). 3. Commuicatio is established with the ATCC with brief basic iformatio provided to the ATCC o all stroke patiets trasported to a hospital. 4. The triage status ad the curret Stroke Ceter activity status (from the Emergecy Resources Display) determie hospital destiatio. 5. A direct patched commuicatios lik to the closest active Stroke Ceter is provided by the ATCC to the field EMT. 6. Medical cotrol is established with the receivig Stroke Ceter by the commuicatios lik; orders are provided as eeded. 7. Pre-hospital care is completed ad trasport to the destiatio Stroke Ceter is iitiated. Specific fuctios relative to the Stroke System are described i the followig sectios. I. SYSTEM ENTRY CRITERIA Patiets are to be etered ito the Stroke System followig a stroke icidet based o the followig criteria: If the patiet is uresposive ad there is o history of trauma: A. Glasgow Coma Score B. Ay Evidece of weakess of either side of the body If the patiet is able to respod ad follow commads. A. Facial Droop (have patiet show teeth or smile): Normal - both sides of face move equally well Abormal - oe side of face does ot move as well as the other side B. Arm Drift (patiet closes eyes ad holds both arms out): Normal - both arms move the same or both arms do ot move Abormal - oe arm does ot move or oe arm drifts dow compared with the other C. Speech (have the patiet say "you ca't teach a old dog ew tricks"): Normal - patiet uses correct words with o slurrig Abormal - patiet slurs words, uses iappropriate words, or is uable to speak

21 Attachmet D. EMT Discretio: 1. If the EMT is coviced the patiet is likely to have a stroke, which is ot yet obvious, the patiet may be etered ito the Stroke System. 2. The EMT's suspicio of stroke may be raised by the followig factors (but these situatios aloe do ot costitute reaso for Stroke System etry): a. Symptoms of stroke occurred ad disappeared withi a few miutes, eve if the patiet is presetly ormal. b. Awake patiet with spotaeous iability to remember, to uderstad what is said or to express himself. 3. The EMT is to immediately iform the ATCC whe a decisio is made to eter a patiet ito the Stroke System usig discretio ad iform the ATCC of the reaso for that decisio. 4. It is to be specifically oted i the ru report that EMT discretio is beig used to eter a patiet ito the Stroke System ad the reaso or basis for that decisio is to be writte o the Pre-hospital Patiet Care Report (PHPCR). II. COMMUNICATIONS Maiteace of adequate ad prompt commuicatios are essetial to fuctio of the Stroke System. I all istaces stroke survival or maximum outcome potetial ca oly be achieved with efficiet ad rapid movemet of the patiet through the system of pre-hospital assessmet ad treatmet, trasport, ad hospital resuscitatio, evaluatio ad defiitive care. Commuicatio throughout the system is vital to this activity occurrig i a most efficiet ad complete maer. Kowledge of the system-wide prehospital stroke activities ad the curret (ad possibly chagig) status of the fuctioal capabilities of the various hospitals i the system is importat at all times as it is possible multiple stroke activities are occurrig simultaeously. Commuicatios allow differetial system resource utilizatio whe there are multiple stroke activities ogoig simultaeously. The key to system fuctio is full kowledge of ogoig activities i all parts of the system at all times. I order to maitai the goal of decreased stroke mortality ad morbidity i the regio ad a program havig cotiuous ad effective regio-wide system status, kowledge ad coordiatio of the cotiuous status of stroke activity must be moitored. This is a fuctio of the ATCC. All stroke patiets requirig trasport are to be called i to the ATCC. The ATCC otes the date ad time. The respodig EMT provides the followig data. 1. Age ad sex 2. Etry criteria (sigs/symptoms) 3. Estimated Time of Oset (ETO) 4. Major obvious problems 5. Cofirmatio that the patiet does or does ot meet system etry criteria

22 Level of care provided, that is actually used for this patiet - ALS vs. BLS 7. Hospital destiatio ATCC will ote the closest hospital for the EMT from the database. It is essetial to establish radio commuicatios as soo as possible i patiets meetig system etry criteria to provide a baselie level of the patiet's status. After determiatio that a patiet meets system etry criteria, the highest level EMT should cotact the ATCC at the earliest practical time to eter the patiet ito the system. The reportig EMT should idetify himself/herself ad provide the followig iformatio: 1. Basic patiet data - age, ad sex. 2. Etry criteria (sigs/symptoms). 3. Curret primary survey status - airway, breathig, circulatio, level of cosciousess, ad vital sigs. 4. Icidet locatio. 5. Estimated Time of Oset (ETO). 6. Estimated scee departure time. 7. Proposed mode of trasport; if groud state trasportig uit umber. The ATCC will establish a direct patched commuicatios lik with the receivig Stroke Ceter hospital, ad provide them with the basic iformatio. The field EMT will the be able to commuicate ay additioal pertiet data ad receive medical cotrol while the hospital is simultaeously activatig its stroke respose system. The trasportig EMT will maitai cotact as appropriate with the receivig Stroke Ceter hospital, ad provide iformatio updates if chages i the patiet's status or trasport pla occur. The EMTs are to recofirm Stroke Ceter ETA oce trasport has bee iitiated. If radio failure occurs, direct cotact betwee the EMS uit ad their dispatch should be established with relay of iformatio to the ATCC by phoe. III. SYSTEM OPERATIONS System operatios refers to the activities that occur oce it is determied a patiet meets system etry criteria ad commuicatios has bee established withi the system. These activities iclude Stroke Ceter destiatio determiatio, cotiuig commuicatios, provisio of field care, patiet trasport, ad Stroke Ceter maagemet. 1. Hospital Destiatio Hospital destiatio will be determied by the closest available Stroke Ceter or the patiet choice. The hospital status is traced by the Emergecy Resources Display at the ATCC. That equipmet is described i the Commuicatios Compoet, ad details the status of idividual resources i the hospital ad