Acute Stroke Care and the Role of EMS Ryan Hakimi, DO, MS April 30, 2015 Assistant Professor Director, Critical Care Neurology Department of Neurology University of Oklahoma Health Sciences Center DISCLOSURES FINANCIAL DISCLOSURE Nothing to disclose UNLABELED/UNAPPROVED USES DISCLOSURE Nothing to disclose Some slides have been adapted from presentation at the 2015 International Stroke Conference, Nashville, TN Learning Objectives At the end of this presentation, participants should be able to improve patient outcomes by being able to: 1. Describe the state of acute stroke care and the change in the standard of care as of February 2015 International Stroke Conference 2. Illustrate the challenge of taking patients to the appropriate stroke center 3. Describe features of stroke patients or suspected stroke patient which should drive you as an EMS provider to take the patient to a comprehensive stroke center 1
Acute Stroke Care Background Stroke Outcome Measures MR CLEAN www.google.com/mrclean accessed 4/8/15 2
MR CLEAN Outcomes Acute Stroke Care Background Advancing Acute Stroke Care 3
Advancing Acute Stroke Care Advancing Acute Stroke Care Advancing Acute Stroke Care 4
The New Standard of Care in Acute Ischemic Stroke Evaluate all acute stroke patients to receive IV tpa (0-4.5 hours) Give IV tpa and determine whether there is a large vessel occlusion (anterior, middle, or posterior cerebral artery or internal carotid artery) Activate Neuro IR suite and perform thrombectomy with or without IA tpa The Next Standard of Care in Acute Ischemic Stroke? Posterior circulation ischemic stroke Give IV tpa (0-4.5 hours) Can perform thrombectomy with or without IA tpa up to 24 hours Where the Patient SHOULD go is Political CSCs PSCs www.google.com/political accessed 4/8/15 5
The Role of EMS Providers EMS providers are usually the first medical professional to have contact with a patient Their initial assessments, treatments, and decisions will have a significant effect on the patient s subsequent care They play a critical role in patient triage, diversion, and routing Types of Stroke Centers Comprehensive Primary Acute Stroke Ready Oklahoma Designations (for now) Level 1 (intra-arterial tpa/thrombectomy) Level 2 (IV tpa and care for the patient) Level 3 (IV tpa and transfer patient out) Distribution of Stroke Centers Amongst Acute Care Hospitals in the US (n=5000) Acute Care Hospitals in US Comprehensive Primary Acute Stroke Ready Other 6
Comprehensive Stroke Center (CSC) Capable of caring for the most complex stroke patients Large ischemic strokes (may need hemicraniectomy, ICP monitoring) Intracranial or subarachnoid hemorrhages Multi-system disease Neurosurgical or endovascular specialists Neurosciences ICU 24/7 365 day per year Currently about 60 CSC CSC as of 4/9/15 Process for Patient Transport Initially taken to PSC, then to CSC 1) Ambulance dispatch to scene 2) Scene to hospital 3) PSC back to base 4) Base back to PSC 5) PSC to CSC 6) CSC back to base Taken to CSC Initially 1) Ambulance dispatch to scene 2) Scene to hospital 3) CSC back to base 7
Inefficiencies Each transfer leg runs 30-40 minutes 3 trips (90-120 minutes) May delay care at least 2-3 hours Need to repeat some or all diagnostic testing Increase stress on family Overall increase cost Transfer Study of 1996 Almost 41,000 patients, of which 1874 were inter-hospital transfers 49% of transfers were very sick vs 35% of direct admits Ratio of in-hospital deaths = 1.99 (transfers vs direct admits) Overall increase in mortality and increased LOS (after adjustment for illness and other factors) Gordon and Rosenthel, Med Care, 1996 When Should a PSC be Bypassed for a CSC? Ryan Hakimi, DO, MS 8
When Should a PSC be Bypassed for a CSC? When Should a PSC be Bypassed for a CSC? 9
The 10-Point Survey What s Next Creating the personalized script Know where the CSCs are in your region If you are CSC and you can t care for a patient who is the CSC you will divert/transfer your patients to (Dr. X on vacation, OU-Texas weekend, spring break week, etc.) If you are a PSC know the CSC that will take your patient Consider taking patient to CSC over a PSC if items in the survey are present and less than 1 hour additional travel time? 10
Thank you! 11