Emergency Medical Services
Emergency Medical Services (EMS) operators and dispatchers play a critical role in recognizing stroke and determining the timing and type of the EMS response to stroke.
But it is a complex process that involves interaction among the public, EMS programs and the appropriate hospital Emergency Department (ED).
A systems approach that enables rapid identification of stroke and the appropriate response of EMS operators and dispatchers can have a significant impact on improving stroke outcomes.
The system can greatly benefit from:
- The public’s ability to recognize a stroke
- Rapid response to stroke calls through EMS operators
- Implementation of measures that decrease call time and increase appropriate response
- Establishment of programs for ongoing education and stroke-specific training of EMS personnel
- Establishment of standard stroke protocols
- Coordination of air transport options with EMS
Potential obstacles to an effective EMS system are many, including: costs, geopolitical lines of service, legal and political issues.
The VSS Task Force has been implemented to address these and other issues and identify ways to bridge gaps in the existing system to allow for a complete and effective system throughout the continuum of care.
The Task Force makes the following recommendations in the context of notification and response of EMS for stroke:
- A stroke system should include processes that provide rapid access to EMS for patients with acute stroke and that dispatch EMS in the shortest time possible, given local resource availability.
- A stroke system should promote the use of diagnostic algorithms and protocols by EMS dispatchers that reflect the most current stroke treatment recommendations and should dispatch EMS responders for suspected strokes with the most rapid emergency response and within the same time limits/goals established for other acute events (eg, myocardial infarction [heart attack] and trauma).
- A stroke system should ensure the direct involvement of emergency physicians and stroke experts in the development of stroke education materials, communications and field assessment protocols, treatment protocols, and transport protocols for EMS providers. Such training and protocols should focus on stroke recognition, triage/transport decisions, and early notification to the receiving hospital.
- A stroke system should ensure that all patients having signs or symptoms of stroke be transported to the nearest primary stroke center or hospital with an equivalent designation, given the available acute therapeutic interventions. Air transport should be considered to shorten the time to treatment, if appropriate.
- Stroke patients who are not candidates for hyperacute interventions should be evaluated at the closest hospital and considered for transfer, if appropriate, to a primary stroke center or other facility through established referral processes.
- A stroke system should ensure that EMS personnel perform and document agreed-upon stroke patient assessments and screening of candidates for thrombolysis or other hyperacute interventions, as such interventions become available.
Virginia Stroke Systems Task Force (VSSTF)
Acute Stroke Transport/Triage t-PA Guidance Statement
Acute stroke is a time critical illness with optimal patient outcomes achieved by rapid assessment, management, and intervention. The sooner an acute stroke is treated, the better the potential outcome. We endorse a pre-and inter-hospital triage plan to promote rapid access for stroke victims to appropriate organized stroke care within three hours of symptom onset. In general this would involve transport to a JC Certified Stroke Center, although consideration may be given to transport to a closer facility, given that facility has a protocol in place for administration of IV t-PA. Determinations of transport priority should be made regionally, with consideration given to availability of appropriate facilities, patient transport times, and patient and/or family choice.
It is important to note that the continuing evolution of scientific evidence indicates successful management of stroke outside the three-hour time window using various modalities. System strategies should be implemented that facilitate expeditious patient evaluation, transport directly to stroke centers, and transfer from non-stroke centers to stroke centers for selected patients with stroke symptoms beyond three hours. The VSSTF endorses currently published national guidelines regarding the treatment of acute stroke patients, including recommendations for the administration of t-PA.
References:
Adams HP, del Zoppo G, Alberts MJ et al. Guidelines for the early Management of Adults with Ischemic Stroke: A Guidline from the American Heart Association / American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovscular Radiology and Intervention Council, and the Athersclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke 2007;38:1655-1711.
Del Zoppo GJ, Saver JL, Jauch EC et al. Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator : A Scientific Advisory From the American Heart Association. Stroke;40:2945-2948.
EMS State Stroke Triage Plan Draft
Click below to download the DRAFT EMS state stroke triage plan, approved by the VSS Task Force on Wednesday Jan 20, 2010.
The OEMS Medical Direction Committee has also indicated support for the plan, and it will be moving forward to the Advisory Board in February for their input.
This PDF can serve as a general guide, with these important caveats:
· The OEMS Advisory Board has yet to review and approve, and there could be changes to it in that process.
· This remains officially DRAFT until after OEMS Advisory BOARD approval.