EMS & Stroke NECC. Peter Moyer MD,MPH Medical Director Boston EMS, Fire and Police 9/13/06

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1 EMS & Stroke NECC Peter Moyer MD,MPH Medical Director Boston EMS, Fire and Police 9/13/06

2 No financial interests to disclose

3 EMS key and underappreciated role in stroke Stroke recognition by stroke victim and use of EMS <50% Stroke Recognition at dispatch and in field Recognition of hypoglycemia as stroke mimic Thrombolytic contraindication check list Transport by air or ground- within 2 hours of symptom onset to stroke center Pre arrival Notification to hospital

4 EMS-Current State IOM s EMS at the Crossroads (2006) EMS underfunded -after initial start up funds in 70 s little subsequent federal $ -average salaries: EMT $18 K Paramedic $34 K -to date have received 4% of federal public safety (Fire, Police and EMS) antiterrorism $

5 IOM-cont. -EMS has no single national lead agency -variability of structure: 45% are Fire based (in cities its 80%);rest a combination of volunteer, private, hospital based and 3 rd municipal service -variability in training: last national EMT training curriculum standard

6 IOM cont. EMT s considered second class citizens in both public safety and medicine

7 IOM cont. new challenges : -emergency preparedness -emergency department overcrowding, diversions, closings -transport to newly defined specialty centers (stroke and STEMI in addition to trauma)

8 EMT/Paramedics & Stroke priority dispatch medical oversight training monitoring feedback regionalization of care

9 EMT text Brady s Prehospital Emergency Care(2004): -refers to stroke as brain attack -refers to AHA s 7D s noting that first 3-Detection, Dispatch and Delivery- belong to EMS -describes Cincinnati and LA stroke scales noting importance of obtaining a sugar -notes importance of delivering patient to hospital within 2 hours

10 Paramedic text Mosby s paramedic textbook (2005): covers same plus management of -hypertension -seizures -compromised airway

11 Mass stroke Point of Entry Plan EMS operational definition of acute stroke: Presence of symptoms < 2 hr duration (or since last seen at baseline) according to the Boston Stroke Scale (BOSS) or other concerning neurologic signs consistent with stroke. Other neurologic signs include: sudden onset dizziness with inability to walk double vision and eye movement abnormalities weakness affecting the leg 1 Following the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke, establish a diagnosis of possible acute stroke based on BOSS scale (Protocols Appendix Q) 2. Establish time of onset and last time seen at baseline 3. If stroke symptoms present and time from onset of symptoms to hospital arrival will be < 2 hours, transport patient to nearest appropriate IDPH-designated Primary Stroke Service (PSS) 4. Notify receiving facility as early as possible

12 Massachusetts Department of Public Health Office of Emergency Medical Services Stroke Point of Entry

13 Purpose To provide EMTs with the fundamental knowledge needed to recognize and manage potential stroke in the pre-hospital setting and make appropriate transport and hospital notification decisions based on the Stroke POE Plan. Photo source: UMass Memorial LifeFlight

14 Objectives Identify the two major categories of stroke List common signs & symptoms of stroke Provide several risk factors for stroke Explain the importance of rapid stroke therapy Describe pre-hospital assessment and care, including the BOSS and thrombolytic checklist Describe the MA and Regional Stroke POE plan Discuss appropriate treatment and transport modalities Describe detailed stroke documentation

15 Boston EMS Stroke is dispatched as a priority 1, EMT call type APCO(a proprietary dispatch algorthym)- after determining patient is breathing and conscious, caller is asked if patient acting normally; if answer is no, asked if new onset of one sided weakness, paralysis or inability to speak ~ 50% sensitive

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17 RTQI- SYSTEM PERFORMANCE EVALUATIONS/AUDITS September 2005 Boston EMS CASES 43 of 50 cases had B.O.S.S. neuro exam (86%) B.O.S.S. EXAM 21 of 50 had blood glucose Documented (42%) 1 case documented a pre-hospital notification Stroke Symptomology Blood Glucose All but 1 case went to a Boston Stroke Center

18 Monthly Performance Review Act on issues & Implement training Reassess

19 Following up on the September Stroke results, RTQI In service training for October focused on the areas where we saw need for improvement. Documentation of Stroke as an Impression. Obtaining a blood glucose Notification to the E.R. Results in November 2005 Showed improvement In all categories 100% Neuro Glucose Stroke Imp 80% 60% Notify 40% 20% 0% 1 Stroke Imp 82% Neuro 100% Glucose 92% Notify 57%