Prehospital EMS Triage for Acute Stroke Care

AbstractAcute stroke has had major advances over the last two decades due to the introduction of pharmacologic and endovascular revascularization, which can improve functional outcome. Stroke systems of care have been developed to provide faster, more efficient care for stroke patients. A major part of these care pathways is prehospital care, when patients are triaged to appropriate levels of care. It is essential that prehospital scales are used accurately and effectively by emergency medical services to assist them with the triage process. New technologies including mobile stroke units, telemedicine, and wearable technology have been introduced as options for optimization of this emergent process.

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Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽

10.1161/str.52.suppl_1.p278 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Marco A Gonzalez Castellon ◽

James A BOBENHOUSE ◽

David Franco ◽

Beth L Malina ◽

Mindy Cook ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Advisory Council ◽

Management Tool ◽

Acute Stroke Care ◽

Stroke Systems Of Care ◽

Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

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Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers

Stroke ◽

10.1161/str.47.suppl_1.tp244 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Shelley Nichols ◽

Debbie Camp ◽

McCord Smith ◽

Chris Threlkeld ◽

James Lugtu ◽

...

Keyword(s):

Acute Stroke ◽

Systems Of Care ◽

Standard Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Registry ◽

Remote Treatment ◽

Stroke Systems Of Care ◽

Stroke Center ◽

Iv Tpa

Background: As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve. Methods: As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center. Results: Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308. Conclusion: A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.

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Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000121 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Evan Kolesnick ◽

Alfredo Munoz ◽

Kaiz Asif ◽

Santiago Ortega‐Gutierrez ◽

...

Keyword(s):

United States ◽

Acute Stroke ◽

Clinical Outcomes ◽

Healthcare Disparities ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Time Dependent ◽

Stroke Systems Of Care ◽

Stroke Center

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

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Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

European Neurology ◽

10.1159/000518428 ◽

2021 ◽

pp. 1-11

Author(s):

Anna Alegiani ◽

Michael Rosenkranz ◽

Leonie Schmitz ◽

Susanne Lezius ◽

Günter Seidel ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Metropolitan Area ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Over Time

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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Effects of centralizing acute stroke services

Neurology ◽

10.1212/wnl.0000000000005822 ◽

2018 ◽

Vol 91 (3) ◽

pp. e236-e248 ◽

Cited By ~ 6

Author(s):

Sidsel Hastrup ◽

Soren P. Johnsen ◽

Thorkild Terkelsen ◽

Heidi H. Hundborg ◽

Paul von Weitzel-Mudersbach ◽

...

Keyword(s):

Hospital Stay ◽

Acute Stroke ◽

Stroke Care ◽

Acute Hospital ◽

Acute Stroke Care ◽

Difference In Differences ◽

Stroke Units ◽

Before And After ◽

Stroke Services

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

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Abstract TP246: Emergency Medical Services Survey of a Low-cost, Ambulance-based System for Mobile Neurological Assessment: The iTREAT Study

Stroke ◽

10.1161/str.48.suppl_1.tp246 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

William M Clark ◽

Nicole A Chiota-McCollum ◽

Jack Cote ◽

Brett J Schneider ◽

Haydon Pitchford ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Low Cost ◽

Prehospital Care ◽

Stroke Care ◽

Neurological Assessment ◽

Acute Stroke Care ◽

Prehospital Diagnosis ◽

Technical Challenges ◽

Survey Responses

Introduction: Modern advances in acute stroke care place an added emphasis on accurate prehospital diagnosis and triage. As part of the Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine (iTREAT) study, we assessed the EMS provider experience with a novel system for mobile telestroke assessment. Methods: We developed a 12-question survey with input from local participants in an EMS Council serving rural counties in central Virginia. Providers rated the iTREAT system on feasibility for acute stroke triage, potential effectiveness in prehospital neurological assessment, and interactions with prehospital care. All survey responses were voluntary and anonymous. Results: Since initiation of live patient enrollment, we have completed 34 ambulance-based telestroke encounters with the iTREAT system. Among 7 participating agencies, 19 EMS providers have served as tele-presenters during the telestroke assessment, and 17 EMS providers completed the voluntary survey. Of the respondents, 71% were certified EMS providers for over 5 years. Regarding technical feasibility, 69% experienced issues related to maintaining a video connection, 41% with logging in to the videoconferencing application, and 18% powering on the tablet. Of technical challenges, 41% of providers resolved the issue on their own, 18% with guidance from study staff, and 24% could not resolve the issue. Concerning patient care, 23% felt the system interfered, 35% were neutral, and 41% felt there was no interference. The majority of respondents (71%) agreed that the iTREAT system is feasible for acute stroke triage, and an effective tool (59%) for prehospital neurological assessment. In commentary, EMS participants emphasized the system’s utility in rural areas. Conclusion: This survey of the EMS experience with a low-cost, ambulance-based system for prehospital telestroke assessment reveals both technical challenges and clinical promise. Importantly, technical issues are mostly solvable in real time and correctable for further system refinement. As a novel tool for prehospital neurological assessment and acute stroke triage, the initial EMS evaluation supports further investigation of clinical efficacy, particularly in rural and underserved areas.

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Abstract T P206: An Executable Graphical Model for In Silico Prototyping of Processes for Acute Stroke Care

Stroke ◽

10.1161/str.46.suppl_1.tp206 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

David Norris ◽

Drew G Levy

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

In Silico ◽

Graphical Model ◽

Systems Of Care ◽

Stroke Care ◽

Care Process ◽

Quality Improvement Initiative ◽

Acute Stroke Care ◽

Neurologic Outcomes

Background: Strong evidence shows neurologic outcomes in acute ischemic stroke (AIS) worsen with delay from symptom onset to thrombolytic therapy. Yet this onset-to-treatment (OTT) time has not decreased in most systems of care over the past decade. Even the in-hospital, “door-to-needle” (DTN) component of this delay is unimproved, notwithstanding exceptions in institutions where innovative quality improvement efforts have borne fruit. Objective: Provide a basis for visualizing, communicating, and simulating stroke care system configuration and performance to facilitate the quality improvement efforts necessary for reducing DTN and OTT times in AIS. Methods: We developed an executable, graphical model of acute stroke care, employing the hierarchical colored Petri net (CPN) formalism. The top level of the hierarchy sets the epidemiologic context, including demographics and background processes like stroke prevention and onset. At deeper levels, we elaborate time-critical processes that contribute to OTT: stroke recognition, EMS activation and transport, and many emergency department (ED) processes. Key ED innovations described in the literature were modeled: EMS prenotification, a direct-to-imaging transport strategy, process parallelism, and telestroke capability. Results: Our CPN model has provided a platform for detailed, realistic prototyping and simulation of acute stroke care processes. The performance characteristics of process configurations with multiple, interacting innovations were evaluated and compared. Conclusions: In silico care process prototyping permits evaluation of proposed innovations in simulated settings. Using an intensively graphical simulation modeling methodology adds value by promoting “visual consensus” regarding care process structure and function, among stakeholders in a quality improvement initiative.

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Abstract W P286: Assessing Wisconsin Hospitals’ Capacity to Treat Acute Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp286 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Julie E Baumann

Keyword(s):

Acute Stroke ◽

Technical Assistance ◽

Systems Of Care ◽

Stroke Care ◽

Self Report ◽

The Status ◽

Primary Stroke Center ◽

Stroke Systems Of Care ◽

Stroke Center ◽

Reported Data

Introduction: Establishing regional stroke systems of care can improve timely treatment and survival, and reduce disability and related healthcare costs for persons experiencing acute stroke. A well-functioning stroke system requires seamless coordination between EMS, hospitals and certified stroke centers. Of 127 non-specialty hospitals in Wisconsin, 2% are comprehensive stroke centers and 24% have achieved primary stroke center certification. However, little is known about other hospitals’ capacity to treat acute stroke. The Wisconsin Stroke Coalition (WSC) wanted to better understand the need to improve stroke care capacity among hospitals not certified to treat stroke. The hypothesis was that few non-stroke certified hospitals in Wisconsin have all the criteria in place to treat acute stroke. Methods: WSC developed a short survey based on the Brain Attack Coalition’s recommendations for an acute stroke-ready hospital (ASRH). The tool included a user-friendly checklist that captured the status of each recommendation; in place currently or within six months; could be developed with assistance; or no plan to develop. WSC distributed the survey to 88 non-specialty, non-stroke certified hospitals and requested that each self-report their level of stroke care. Results: Fifty-nine percent of hospitals responded to the survey. Among respondents, 5% reported having all recommendations in place within six months, 53% reported having some of the recommendations in place and 1% reported no plan to develop any of the recommendations. While only a few had implemented every recommendation, the majority either had in place or were receptive to adopting individual suggestions. Nearly half of respondents reported having telestroke in place (either by phone, with video, or both). Conclusions: According to self-reported data, non-specialty, non-stroke certified hospitals in Wisconsin appear well-positioned or receptive to developing basic recommendations for acute stroke-ready hospitals. WSC plans to disseminate findings to Wisconsin hospitals and gather further information about technical assistance that would improve their level of stroke care and coordination with EMS.

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Abstract TP365: Think Big: Weekly Stroke Education for Registered Nurses on the Stroke Unit

Stroke ◽

10.1161/str.44.suppl_1.atp365 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Betty Robertson

Keyword(s):

Systems Of Care ◽

Stroke Care ◽

Interesting Case ◽

Stroke Patients ◽

Stroke Units ◽

Optimal Outcomes ◽

Information Research ◽

Stroke Education ◽

Stroke Systems Of Care ◽

Stroke Center

Background: Nurses play a pivotal role in all phases of care of the stroke patient. Stroke Nurses have responded to the challenge of making stroke systems of care a reality in recent years. We wanted our stroke nurses to use evidence-based practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients. One of the most important components of a Stroke Program is having a designated unit where patients receive specialized stroke care. Nurses who are a part of a stroke center should be trained to recognize medical complications that can arise in someone who has suffered a stroke. One of the most important reasons why primary stroke centers are the premier places for the treatment of strokes is that, by having specialized stroke units, patients have better outcomes. Is weekly stroke education for RNs on the stroke floor helpful to the nurses?<br Does it influence or impact the way they care for their patients? Methods: Since information,research and even nursing staff is always changing, education needs to be provided to nurses taking care of stroke patients so they have the latest and greatest knowledge to share with their patients and loved ones. We asked the staff what topic they wanted to cover and posted a suggestion box on the unit entitled “Ask a Stroke Nurse,” analyzed the attendance and did a survey to get the nurses’ feedback. Collectively we decided the best way to capture all staff on all shifts was to do weekly in-services and education sessions covering everything from Journal articles, updates about the program, interesting case studies, breaking science and even guest speakers from other departments. Conclusion: The survey showed that 96% of RNs on the stroke floor found the weekly education very valuable. 96% found that it positively impacted their practice,additionally, 91% said it greatly increased their knowledge about stroke & TIA. We will continue weekly education and continue to get feedback from the nurses. This endeavor has proven to be a very successful. We were pleased to see the positive comments from the staff about how much they enjoy and look forward to the classes each week.

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Utstein recommendation for emergency stroke care

International Journal of Stroke ◽

10.1177/1747493020915135 ◽

2020 ◽

Vol 15 (5) ◽

pp. 555-564 ◽

Cited By ~ 1

Author(s):

AG Rudd ◽

C Bladin ◽

P Carli ◽

DA De Silva ◽

TS Field ◽

...

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Prehospital Care ◽

Public Awareness ◽

Stroke Care ◽

Successful Implementation ◽

Care Needs ◽

Acute Stroke Care ◽

Implementation Program ◽

Prehospital Triage

Background Recent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient. Aim To develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients. Methods Building on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

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