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A Rapid Ambulance Protocol for Acute Stroke

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

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  1. A Rapid Ambulance Protocol for Acute Stroke Prof Gary Ford Freeman Hospital Stroke Service Newcastle Upon Tyne

  2. 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

  3. 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

  4. 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

  5. Aspirin in Acute Ischaemic Stroke IST / CAST Lancet 1997

  6. 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

  7. STROKE SYMPTOMS 999 Primary Care Physician Paramedic Ambulance Assessment Transport A&E Medical/Neurology Stroke Unit Wards

  8. 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

  9. 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

  10. Acute Stroke General Practitioner 999 Accident & Emergency Dept Acute Stroke Unit General Medical Wards Freeman Hospital RVI

  11. 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

  12. 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

  13. Acute Stroke 999 General Practitioner Rapid Ambulance A & E Dept Protocol Acute Stroke Unit General Medical Wards Freeman Hospital RVI

  14. 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

  15. 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

  16. Rapid Ambulance Protocol Directive City wide Letter to Letter to Training East End Crews Protocol Crews Crews Programme Monthly Ambulance Stroke Unit Admissions

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. FAST assessment Face Arm Speech Test Facial Palsy affected side Arm Weakness affected side Speech Impairment

  26. FAST Assessment

  27. Paramedic Training Package • Lecture notes • Handout • Overheads / slides • Video • MCQ test

  28. 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

  29. 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

  30. Acute Stroke 999 A&E Dept General Practitioner NGH (Hospital Direct) Rapid Ambulance Protocol Acute Stroke Unit Medical Wards FRH - - - - - - - (single Trust) - - - - - - - - RVI

  31. Rapid Ambulance Protocol Directive City wide Letters to Training A&E East End Crews Protocol Crews Programme Reconfig Monthly Ambulance Stroke Unit Admissions

  32. Rapid Ambulance Protocol

  33. 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%

  34. Paramedic Stroke Detection 1 Feb – 31 May 2000 129 stroke patients initial contact 999 97 admitted directly via RAP 75% detection 80% accuracy

  35. 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)

  36. Hospital Assessment • Emergency Room staff • Acute medical team • On call Acute Stroke Team nurse / stroke doctor

  37. SWAT Team • Stroke Watch Action Team • St Luke’s Hospital, Kansas City • SWAT beeper • Nurses trained to identify stroke and summon doctor

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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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