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A Rapid Ambulance Protocol for Acute Stroke. Prof Gary Ford Freeman Hospital Stroke Service Newcastle Upon Tyne. Assessment of Suspected Acute Stroke by Stroke Teams.

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A rapid ambulance protocol for acute stroke l.jpg

A Rapid Ambulance Protocol for Acute Stroke

Prof Gary Ford

Freeman Hospital Stroke Service

Newcastle Upon Tyne


Assessment of suspected acute stroke by stroke teams l.jpg
Assessment of Suspected Acute Stroke by Stroke Teams

  • Accurate early diagnosis and initiation treatment non-stroke present in 20% suspected acute stroke - Subdural haematoma, epilepsy, cerebral tumour

  • Initiation early rehabilitation

  • Early interventions – thrombolysis, aspirin

  • Improved early management stroke - carotid dissection, cerebral venous thrombosis, ic haemorrhage, diagnosis TIA complications – dysphagia, DVT, fluids, BP


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Advances in Stroke Care

  • Intravenous thrombolysis with alteplase in selected patients with acute ischaemic stroke within first 3 hours

  • Aspirin in patients with cerebral infarction within first 48 hours

  • Benefits of organised Acute Stroke Unit care

  • Increasing evidence of the benefits of interventions to correct disturbed physiology (hypoxia, dehydration, fever, hyperglycaemia) early stages of stroke

  • Possible extension thrombolysis time window and use neuroprotective agents within 5 hours


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NINDS rt-PA STROKE TRIAL:RESULTS - PART 23-Month Outcome on Four Stroke Scales

Minimal/No Disability Moderate Disability Severe Disability Death

NIHSS

rt-PA

Placebo

Barthel Index

rt-PA

Placebo

Modified Rankin

rt-PA

Placebo

Glasgow Outcome

rt-PA

Placebo

% of patients

31 30 22 17

20 32 27 21

% of patients

50 16 17 17

38 23 19 21

% of patients

39 21 23 17

26 25 27 21

% of patients

44 17 22 17

32 22 26 21


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Aspirin in Acute Ischaemic Stroke

IST / CAST

Lancet 1997


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Requirements for Early Assessment of Stroke Patients

  • Awareness of signs/symptoms of stroke in community

  • Rapid Admission to Hospital

  • Rapid Assessment at Hospital

  • Imaging when required

  • Skills to administer interventions


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STROKE SYMPTOMS

999 Primary Care Physician

Paramedic Ambulance

Assessment Transport

A&E

Medical/Neurology Stroke Unit

Wards


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Delays in Presentation

  • Stroke admissions in Oxford 6 month period

  • Prospective data collection 183 patients

  • Uncertain onset time 55% (waking 28%)

  • 55% arrived within 3 hr, 76% within 6 hr

  • 24/86 GP cases initially managed at home

  • Symptom recognition to admission within 3 hr GP 31% Ambulance 90%

  • Admission to assessment - 69 min

Reynolds et al, 1999


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Delays in Admission

  • 15 Swedish Hospitals

  • 329 patients stroke/TIA

  • Hospital admission 4.8/4.0 hr

  • Factors associated with delayed admission infarct, gradual onset, mild symptoms, not using ambulance, visiting GP

  • Factors associated with delayed CT/Stroke unit admission large catchment area, mild/moderate deficit waiting for ER physician

Wester et al,1999


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Acute Stroke

General Practitioner 999

Accident &

Emergency Dept

Acute Stroke Unit General Medical Wards

Freeman Hospital RVI


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Freeman Hospital Stroke Service

  • Established Apr 1993

  • First comprehensive stroke service UK

  • Accepts all suspected acute stroke patients

  • 10 acute stroke beds within General Medical Ward

  • 10-14 Stroke rehabilitation beds non-acute hospital

  • Multi disciplinary team both units

  • Initially only GP referrals


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Freeman Hospital Stroke Service

  • 1993 Stroke Discharge Team

  • 1994 Commenced hyper-acute assessment stroke trials

  • 1994 Multidisciplinary stroke review clinics

  • 1997 Establishment cross city stroke rehabilitation ward (20 beds)

  • 1997 Rapid Ambulance Protocol

  • 1998 IV thrombolysis protocol Second stroke consultant

  • 1999 14 bed Acute Stroke Unit

  • 2000 City wide triage of stroke to unit 30 bed Acute Stroke Unit Third Stroke consultant appointed


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Acute Stroke

999 General Practitioner

Rapid Ambulance A & E Dept

Protocol

Acute Stroke Unit General Medical Wards

Freeman Hospital RVI


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Rapid Ambulance Protocol

Acute Stroke Symptoms

Ambulance Control

Paramedical team

Paramedical Assessment

radio control

notify unit

Suspected Stroke Non-stroke

Stroke Unit A & E Dept


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Rapid Ambulance Protocol

  • All 999 patient with suspected stroke not in coma GCS >6 to be taken to FRH Emergency Admission Suite

  • EAS to be informed of pre-arrival information

  • FAST assessment to be used to identify and assess suspected stroke cases


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Rapid Ambulance Protocol

Directive City wide Letter to Letter to Training

East End Crews Protocol Crews Crews Programme

Monthly

Ambulance

Stroke Unit

Admissions


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Rapid Ambulance ProtocolMay 97 -Jul 98

123 Patients

102 Confirmed acute stroke/TIA

21 Non-stroke

5 acute confusional state

5 collapse secondary to vascular instability

3 fall/old CVA

3 cerebral neoplasm

3 collapse secondary to other cause

1 seizure

1 normal pressure hydrocephalus


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Rapid Ambulance Protocol Symptom onset to admission

Median (range)

GP referrals (n=108) 6.0 (0.5-23.5) hr

Rapid Ambulance Protocol 1.2 (0.5-18.7) hr

Symptom onset to contact emergency service 33 min

Contact to arrival paramedical team 8 min Arrival at home to arrival stroke unit 22 min


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Purpose Paramedic Stroke Instrument

  • Identification stroke - direct to Stroke Unit - rapid transfer - obtain relevant information at scene - administer neuroprotective therapies

  • Identification non-stroke

  • Increase profile stroke


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Cincinnatti Instrument

  • 74 patients treated in thrombolysis trial and 225 non-stroke patients evaluated in ER

  • NIHSS all patients

  • Facial palsy, motor arm and dysarthria identified 100% stroke patients (specificity 92%)

  • Out-of Hospital scale facial palsy, arm weakness, language disturbance

Kothari et al, 1997


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Cinicinnati EMS experience

  • 4413 evaluations

  • Paramedic diagnosis Stroke/TIA 96 2%

  • Confirmed in 62/86 72% 22 paramedic interventions

  • Mean time to scene 3 min after 911 call

  • Earlier arrival with basic units compared to paramedics (40 vs 45 min)

  • Physician assessment (10 vs 20 min) and CT (47 vs 69 min) earlier with paramedics

Kothari et al, 1995


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Los Angeles Instrument

  • Exclude age<45 yrs, seizure, symptoms >24 hr, patient wheelchair bound or bedridden

  • Arm strength, facial smile, grip

  • Evaluated in patients entered 6 hr intervention trials

  • 41 ischaemic stroke by ambulance

  • 93% ‘would’ have been identified

Kidwell et al, 1998


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San Francisco Instrument

  • 4 items

  • Language - 3 step command, name objects, speech fluency

  • Motor - Smile, pronator drift, lift each leg

  • Visual fields - confrontation testing

  • Gait


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San Francisco experience

  • Retrospective review stroke admissions and paramedic evaluations

  • Paramedics identified 49/81patients

  • 15 patients identified by paramedics non-stroke

  • Patients/families waited 2.5hr before calling 911

Smith et al, 1998


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FAST assessment

Face Arm Speech Test

Facial Palsy

affected side

Arm Weakness

affected side

Speech Impairment



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Paramedic Training Package

  • Lecture notes

  • Handout

  • Overheads / slides

  • Video

  • MCQ test


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Paramedic knowledge

  • MCQ assessment before/following training package 57 ambulance staff

  • Score 14.0 before 16.8 following

  • Errors GCS scoring affected side Cerebral haemorrhage commonest cause Headache present >80% patients Depressed conscious level most patients


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Identification non-stroke

  • Male 75 yrs admitted with suspected stroke via General Practitioner, symptoms dizziness

  • Ambulance personnel undertake FAST assessment - negative

  • Examine patient - bradycardic

  • Complete Heart block - pacemaker insertion


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Acute Stroke

999 A&E Dept General Practitioner

NGH (Hospital Direct)

Rapid Ambulance Protocol

Acute Stroke Unit Medical Wards

FRH - - - - - - - (single Trust) - - - - - - - - RVI


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Rapid Ambulance Protocol

Directive City wide Letters to Training A&E

East End Crews Protocol Crews Programme Reconfig

Monthly

Ambulance

Stroke Unit

Admissions



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Diagnostic Accuracy Stroke Referrals1 Feb 00 – 31 May 00

GP A&E Paramedic Total

Stroke/TIA 89 45 95 229

Non-stroke 34 12 24 70

Proportion of referrals 28% 21% 20%


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Paramedic Stroke Detection

1 Feb – 31 May 2000

129 stroke patients initial contact 999

97 admitted directly via RAP

75% detection

80% accuracy


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Stroke Referrals - subtypes

Paramedic GP

(n=84) (n=73)

TACS 37% 10% p<0.001

PACS 37% 34% n.s.

LACS 14% 33% p<0.01

POCS 2% 14% p<0.01

PICH 10% 10% n.s.

4 month period (Feb-May 00)


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Hospital Assessment

  • Emergency Room staff

  • Acute medical team

  • On call Acute Stroke Team nurse / stroke doctor


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SWAT Team

  • Stroke Watch Action Team

  • St Luke’s Hospital, Kansas City

  • SWAT beeper

  • Nurses trained to identify stroke and summon doctor


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Links with Accident & Emergency

  • A&E doctors used to acting quickly

  • Clear protocol - who requests imaging?

  • Need for stroke recognition instrument

  • Support of stroke team

  • Admission to Stroke unit vs A&E


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Freeman Stroke Service

  • Admission suite staff notify stroke nurse

  • Collect data from paramedics

  • Stroke nurse undertakes initial evaluation (SNSS/NIH) takes bloods, speaks to/contact relatives

  • Contacts stroke doctor further neurological evaluation

  • If non-stroke direct further management in discussion with stroke consultant

  • Urgent CT requested if required

  • Thrombolysis/neuroprotectant trials initiated in Admission unit


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Freeman Thrombolysis Experience

  • 17 patients treated in 2 years (2% referrals)

  • 15 admitted via 999 contact

  • Main contraindications, delayed admission and co-morbidities

  • Outcomes similar to NINDS trials

  • 1 symptomatic intracerebral haemorrhage as complication


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Establishing an Ambulance Protocol

  • Go the top

  • Establish agreement colleagues across district

  • Incorporate stroke instrument in patient report form

  • Protocol must be unambiguous and simple

  • Initiate audit and involve ambulance staff

  • Regular feedback to crews on the ground

  • Change takes time


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Acute Stroke Patient Flow

Suspected Acute Stroke Community education

Emergency Services Primary Care Physician

Paramedic Paramedical assessment Professional Education

Training

Acute Stroke Unit Emergency Room

Organised rehabilitation Health Care Purchasers


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