REGIONAL STROKE TRIAGE PLAN

Transcription

1 REGIONAL STROKE TRIAGE PLAN Rappahannock EMS Council 435 Hunter Street Fredericksburg, VA Phone: (540) Fax: (540) Board of Directors Approved: December 17, 2015

2 TABLE OF CONTENTS Executive Summary 3 Field Stroke Triage Decision Scheme 4 Guidance Materials 5 REMS Regional Patient Care Overview 6 Patient Transport Considerations 8 Designated Stroke Centers 9 Stroke Triage Quality Monitoring 10 Stroke Related Resources -- Appendix A EMS Stroke Alert Checklist 12

3 EXECUTIVE SUMMARY Under the Code of Virginia , the Office of Emergency Medical Services, acting on behalf of the Virginia Department of Health has been charged with the responsibility of maintaining a Statewide Stroke Triage Plan. The Rappahannock EMS Council, Inc. (REMS) is responsible for establishing a strategy based on the state plan, incorporating the regions geographic variations, variances within out-of-hospital provider s capabilities and acute stroke care capabilities and resources including hospital capabilities and the capacity to transfer patients between community hospitals and tertiary care centers, such as certified Stroke Centers. This guidance is ultimately derived from guidelines issued by the American Heart Association / American Stroke Association with recommendations from the Brain Attack Coalition and the Virginia Stroke Systems Task Force. The primary goal of the Rappahannock EMS Council Regional Stroke Plan is to develop a Stroke Emergency Care System that, when implemented, will result in decreased stroke mortality and morbidity within the REMS Region. In order to accomplish this, a number of specific processes are essential. These are: 1. The ability to rapidly and accurately identify patients suffering from Stroke-like presentation; 2. Transport these Stroke patients to a Stroke Center (PSC); 3. Provide quality EMS and patient care to these stroke patients; 4. Track patient care statistics to provide feedback to EMS agencies; and, 5. Continuously evaluate the EMS System based on established EMS performance measures for Stroke. SUMMARY OF THE 2015 CHANGES The American Heart Association has issued updated guidelines regarding the treatment of Stroke patients. The major areas are: Changing the treatment window start time from onset of symptoms to the Last Known Well Time. This change is significant. There are occasions when symptom onset time and Last Known Well Times coincide; but there are many scenarios when they are not. An example would be when a patient lays down for a nap with no stroke symptoms and then wakes up symptomatic. When did the symptoms begin when the patient woke up or during the nap? There is no way to know, so the treatment clock now begins with the last time the patient was seen not displaying any stroke symptoms, or the Last Known Well Time. Modifying the triage plan to transport all stroke patients, regardless of their Last Known Well Time, to a Stroke Center (PSC). This deviates slightly from the State Stroke Triage Plan, but is based on guidance from the Co-Chair of the Virginia Stroke Systems Task Force which provides input to the State Stroke Triage Plan (last published in 2010). Removing material from the 2013 plan that conflicts with the above two items. EMS providers must make every effort to determine the Last Known Well Time so the physician can make informed treatment decisions; and providers must alert the hospital that a stroke patient is en route. 3

4 Stroke Definition. A stroke is defined as any patient suspected of having a cerebral ischemic event, with a presentation and symptoms defined in the Cincinnati Pre-Hospital Stroke Scale or FAST exam. An acute stroke is defined as any patient having a stroke with a Last Known Well Time of 4.5 hours. For EMS providers, there is no difference in transport decisions between the two; all stroke patients are transported to the nearest Stroke Center (PSC). When in doubt EMS providers may always consult with on-line medical control. Cincinnati Pre-hospital Stroke Scale (CPSS / FAST). All patients suspected of having a stroke should undergo a formal screening algorithm such as the CPSS/FAST. Use of stroke algorithms has been shown to improve identification of acute strokes by EMS providers up to as much as 30%, with an accuracy rate of 85%. Results of the CPSS/FAST should be called in as a bedside pre-alert, during the HEAR report, and noted on the pre-hospital medical record. ANY abnormal (positive) finding which is suspected or known to be acute in onset is considered an indicator of potential acute stroke. F = Face A = Arm S = Speech T = Time FACIAL DROOP: Have patient smile or show teeth. (Look for facial asymmetry) Normal: Both sides of the face move equally or not at all. Abnormal: One side of the patient s face droops or does not move. MOTOR WEAKNESS: Arm drift (Have patient close eyes, extend arms, palms up for 10 seconds; if only leg is involved, have patient hold leg off floor for 5 seconds) Normal: Remain extended equally, drifts equally, or does not move at all. Abnormal: One arm drifts down when compared with the other. Have the patient repeat, You can t teach an old dog new tricks (repeat phrase) Normal: Phrase is repeated clearly and correctly. Abnormal: Words are slurred (dysarthria) or abnormal (dysphasia) or none (aphasia). LAST KNOWN WELL TIME This is the last time the patient was seen well and symptom free. This is not always the time of onset of symptoms. The only time this would coincide with onset of symptoms is when it is a witnessed event. The intervention clock begins with the time the patient was last known well. Results of the CPSS/FAST should be reported during the pre-alert, given during the normal HEAR report, and documented on the patient s pre-hospital medical record. 4

5 FIELD STROKE TRIAGE DECISION SCHEME Dispatcher suspects Acute Stroke (*) YES Attendant-in-Charge suspects Acute Stroke based on history and physical exam YES Assess blood glucose. Is Glucose greater than 60? NO Treat hypoglycemia YES Evaluate Cincinnati Pre-hospital Stroke Scale/FAST for acute onset of ONE or more positive findings upon exam YES Determine Last Known Well Time; Make bed-side pre-alert to the PSC 1 Rapidly initiate transport to Designated Stroke Center Make effort to bring witness or other individual able to legally provide consent for treatment to hospital, or at a minimum, a phone number for the witness/consenting individual Provide a HEAR report en route Provide care during transport as directed by Protocols or on-line medical control; complete a thrombolytic checklist if time permits NOTE 1 The bedside pre-alert does not replace the HEAR report given en route. It simply provides the hospital with enough early information to know whether to activate the stroke team. The key components of this pre-alert are the results of the FAST screening and the Last Known Well Time. 5

6 Patient Care Guidelines Current Virginia OEMS policy prohibits the creation of a Protocol title by the EMS Regions that has not been approved by OEMS. Stroke is not one of the OEMS identified protocol titles. In lieu of a Stroke Protocol, these guidelines are provided: EMS patient care protocols for a patient suspected of having an acute stroke should include: Complete an initial/primary assessment; Complete a focused assessment, including: o Blood glucose level, if authorized to perform skill; o Cincinnati Prehospital Stroke Scale / FAST assessment; o Documentation of the Last Known Well Time; o Conduct a SAMPLE history; o Attempt to rule out stroke mimicking conditions (i.e. seizures, migraines, hypo/hyperglycemia, and others as deemed appropriate); o Document potential thrombolytic exclusions (i.e. pregnancy, seizure at onset, terminal illness, and others as deemed appropriate as on check sheet); Treat hypoglycemia, if appropriate and if authorized to perform that skill; Initiate IV access and cardiac monitoring if available and if authorized to perform those skills; Reassess neurologic status and reassess stroke scale; Contact with medical control and/or the receiving hospital to advise them that you are transporting a potential acute stroke patient; and, Transport to a designated Stroke Center (PSC). Consult with on-line medical control as needed, especially if you cannot transport to a Stroke Center. 6

7 PATIENT TRANSPORT CONSIDERATIONS Stroke is a time-critical event. Therefore EMS providers should initiate a rapid-transport for all stroke patients to the closest Stroke Center (PSC), whenever possible. EMS providers may deviate as needed from this requirement and transport to the closest hospital emergency department when the patient s condition is such that they will not survive the trip to the Stroke Center; e.g., compromised airway, impending circulatory collapse, cardiac arrest, etc. A rapid-transport does not relieve the operator of the vehicle from exercising due regard, and should not automatically be interpreted as requiring the use of red-lights and siren. Rather it is a reminder to reduce on-scene time to minimize out of hospital time. When ground transport time to a Stroke Center (PSC) exceeds 30 minutes, consideration should be given to using a Helicopter EMS service (HEMS). While there are many factors in this decision tree, the following time-based guidelines are provided to assist in the determination of whether ground EMS or helicopter EMS is faster and more beneficial to the patient: Overhead time + flight time = total air transport time minutes minimum of overhead (5 minutes to start up and lift, 5 minutes for scene LZ size up and landing, 5-10 minutes for patient handoff and take-off, and 5 minutes for landing at the hospital LZ and patient movement to ER); plus, 0.5 minutes for every nautical mile flown from the air transport base to the scene LZ, and then from the scene LZ to the PCI capable hospital LZ. Transport of a stroke patient to a non-stroke certified hospitals other than for those life-saving conditions described above may occur in unusual circumstances. When these situations occur, and whenever possible, consultation with on-line medical control is preferred in making this decision. 7

8 DESIGNATED STROKE CENTERS The following hospitals have been designated as a Stroke Center (or higher) as provided by the Virginia Stroke System Task Force web page: Geographic Area Hospital Type of Stroke Center Designated Stroke Centers within the REMS Region Fredericksburg Mary Washington Hospital Warrenton Fauquier Hospital Alexandria Charlottesville Stroke Centers Outside the REMS Region Used by REMS Agencies Inova Alexandria Hospital Inova Mount Vernon Hospital Martha Jefferson Hospital University of Virginia Hospital Comprehensive Falls Church Inova Fairfax Hospital Comprehensive Mechanicsville Bon Secours Regional Medical Center Richmond Augusta Medical Center Bon Secours Richmond Community Bon Secours-St. Mary Hospital CJW Hospital Henrico Doctor s Hospital Johnston Willis Hospital Parham Doctors Hospital Retreat Doctors Hospital VCU Health Systems Comprehensive Comprehensive Comprehensive Winchester Winchester Medical Center Comprehensive Woodbridge Sentara Northern VA Medical Center A current list of all Virginia Stroke Centers may be found on the Virginia Stroke System Task Force web page: 8

9 STROKE TRIAGE QUALITY MONITORING The Rappahannock EMS Council will report aggregate acute stroke triage findings on an intermittent basis, but no less than annually, to assist EMS systems and the Virginia Stroke Systems Task Force improve the local, regional and Statewide Stroke Triage Plans. A deidentified version of the report will be available to the regional agencies and will include, minimally, as defined in the statewide plan, and as statistics are available, the frequency of: (i) (ii) (iii) Over- and under- triage to Designated Stroke Centers in comparison to the total number of acute stroke patients delivered to hospitals; Helicopter EMS (HEMS) utilization; EMS Benchmarks as identified annually; The Rappahannock EMS Council Performance Improvement Committee will produce a report which will be used as a guide and resource. This report should consider three primary evaluation areas: timeliness of care, treatment provided, and outcomes of care; depending on availability of appropriate statistics. The fields identified are critical to analyses for the following reason: they allow linking of EMS data and hospital Stroke data, they allow for real time collection of data focused upon process improvement, and they allow for retrospective systemic analyses. The ultimate goal of collecting this data is to provide actionable information, to the REMS Regional Stroke Committee and the REMS Medical Direction Committee, relative to the care processes and outcomes associated with their treatment of Acute Stroke patients as it relates to EMS. STROKE RELATED RESOURCES Virginia Stroke System Web page: Virginia Office of EMS Stroke Web page: Joint Commission: 9

10 APPENDIX A: EMS STROKE ALERT CHECKLIST Date: Last Known Well Time: Witness: Witness Contact #: Family Contact: Family Contact Cell #: SYMPTOMS if Abnormal Initial Reassessment Severe headache with Nero deficit Difficult speaking or understanding Visual impairment (e.g., loss of vision, double vision) Limb weakness or drift Loss of sensation on one side of the body Sudden onset ataxia Does the patient have any of the above symptoms? Deficit is not likely due to head trauma? Blood glucose > 60 mg/dl? Blood Glucose Level: If the answer is YES to all of the above, initiate a pre-alert from the bedside and call a STROKE ALERT, and transport to the nearest Stroke Center. HR: RR: BP: EXAMINATION (Pre-Hospital Stroke Scale) Level of consciousness: A V P U Speech ( You can t teach an old dog new tricks. ) Facial Droop (show teeth or smile) Arm Drift or arm/leg weakness (close eyes and extend arms) if Abnormal Initial Reassessment tpa EXCLUSION CRITERIA (patient may still be a stroke Alert if excluded from tpa) Recent (with 30 days) surgery or biopsy of an organ Recent (with 30 days) trauma with internal injuries or ulcerative wounds Recent (with 90 days) head trauma or prior stroke Any Active or Recent (30 days) hemorrhage Known hereditary or acquired hemorrhagic condition Terminal Illness (such as end-stage cancer, end-stage HIV, or severe Alzheimers) Coma Seizure occurring concurrently with stroke symptoms Patient on anticoagulants (Coumadin, Heperin, Lovenox, etc.) Contact Nearest Stroke Center per this Regional Stroke Triage Plan Patient s Name & Age: EMS Agency & Unit #: Date and Time: 10