EMERGENCY EVALUATION OF THE

ACUTE STROKE PATIENT

Angel Rochester, MD Associate Director of Critical Care & Trauma

Associate Director of Chest Pain

Greenville County EMS

800 Square Miles in Greenville County Busiest EMS organization in South Carolina 62,000 Annual Responses Over 500 Stroke transports per year Strong relationship with County Hospitals

Involvement in Hospital meetings

EMS Stroke Screening

EMS Dispatchers perform a pre-arrival stroke screen over the phone

EMS Providers conduct a Cincinnati Stroke Scale upon arrival

NIH Stroke Scale Pre-hospital Stroke Thrombolytic Check List

Standing Orders EMS Stroke/CVA/TIA

Assessment: 1. Perform patient assessment. 2. Perform both Glasgow Coma Scale and Cincinnati Stroke Scale on patients who

present with signs / symptoms of Acute Stroke. Determine blood glucose level, if hypoglycemic, follow Hypoglycemia Standing Order. Interventions: Follow Airway Management Standing Order. Establish IV at KVO rate – follow Intravenous Infusion Initiation Standing Order. Monitor cardiac rhythm. All patients with new signs and symptoms of a stroke regardless of time onset are to be

transported to a cardiac/stroke center (Greenville Memorial Medical Center or St. Francis Hospital Downtown). Notify the receiving facility as soon as possible of the STROKE ALERT.

If Acute Stroke*, complete Prehospital Stroke Thrombolytic Check List and if time permits an NIH Stroke Scale

If Major Stroke** and the patient meets the criteria, consider Rapid Sequence Intubation Standing Order.

Contact Medical Control: Transport and continue BLS and ALS – follow Standard of Care guidelines. Acute Stroke* = Involves onset of symptoms < 4 ½ hours Major Stroke** = Involves patient with an altered level of consciousness

Cincinnati Stroke Scale

Facial Droop

Normal: Both sides of face move equally Abnormal: One side of face does not move at all

Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other

Speech Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute

Stroke Distribution 8/1/2010- 8/1/2011

GHS Referral Line Transfers

GHS Satellites have a dedicated onsite STEMI/Stroke stretcher and Activation Line

GCEMS has an ambulance stationed at Hillcrest and Greer

Mobile Care Reach® Access to surrounding counties

Greenville Memorial Emergency Department

90,000 Adults/yr

20,000 pediatrics/yr

Acute Stroke Decision Pathway Greenville Memorial Emergency Department

Signs and Symptoms of Acute Stroke? •Sudden numbness or weakness of the face, arm or leg, especially on one side of the body •Sudden confusion, trouble speaking or understanding •Sudden trouble seeing in one or both eyes •Sudden trouble walking, dizziness, loss of balance or coordination

Yes Onset less than 4.5 hr

Triage in room •Print Form M10357, M10108, M10682 •Stroke Alert page to notify neurologist, CT & Lab

• MD assesses patient, NIHSS (full initially) • TPA criteria reviewed (M10357) • Stroke orders started (M10357) • LOD labs (CBC, PT/PTT, INR, BMP) • LOD Head CT • STAT EKG, continuous cardiac & O2 monitoring, CXR,

fingerstick glucose, urine pregnancy, NPO including meds • Register patient in REACH cart (per neurologist request) • Consult neurologist via REACH telemedicine

TPA candidate? YES •Neurologist to

oDiscuss risks/benefits w/ pt/family oMake recommendations for tPA in person or via REACH & give order to ED RN

•RN to oAdminister tPA, complete tPA orders M10682, transfer to GHS via Mobile Care or Med Trans oComplete Dysphagia Screening

NOT TPA candidate

• ED MD to document reason in IBEX Doctor Notes, NIHSS

• Neurologist recommendations in person or per REACH consult

• ED MD calls PCP or neurologist for admission or transfer. (Follow normal admit procedure)

• Complete Dysphagia Screening

No Onset greater than 4.5 hr

Triage

•Stroke orders started • Labs (CBC, PT/PTT, INR,

BMP, fingerstick glucose, Head CT, EKG and continuous monitoring, NPO

• Assess using NIHSS (full initially, focused q 1 hr x 2 and then q2hr)

• Complete Dysphagia Screen

ED MD calls PCP or Hospitalist for admission or transfer (Follow normal admit procedure) •Nurse completes Dysphagia Screen before any PO Intake/Meds

Patient presents to

triage

EMS calls with possible stroke patient

ED Physician

Goal: <10 min

Stroke Alert Page

Goal: <15 min

Labs drawn & testing started - Goal: <15 min

CT complete - Goal: <25 min

CT & labs resulted Goal:< 45 min

tPA initiated Goal: <60 min

Stroke Alert

Process

GMH

Accurate Weights

Acute Stroke Decision Pathway

Greenville Memorial Emergency Department

Signs and Symptoms of Acute Stroke? Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination

Patient

presents to triage

EMS possible stroke patient

Yes

Onset less than 4.5 hr

No

Onset greater than 4.5 hr

Triage in Critical Care Room Print Form M10357, M10108, M10682 Stroke Alert page to notify neurologist, CT & Lab

ED Physician Eval

Goal: <10 min

Triage

To Critical Care

Stroke Alert Page

Goal: <15 min

WEIGH THE PATIENT

CALL THE STROKE ALERT-3-3333

WEIGH THE PATIENT / STRETCHER

Labs drawn & testing started

Goal: <15 min

CT complete

Goal: <25 min

CT & labs reported/resulted

Goal: 45 min

•MD assesses patient •NIHSS (full initially) •TPA criteria reviewed (M10357) •Stroke orders started (M10357) •LOD labs (CBC, PT/PTT, INR, BMP) •LOD Head CT •STAT EKG, continuous cardiac & O2 monitoring, finger stick glucose, urine pregnancy, NPO including meds •Register patient in REACH cart (neurologist request) •NOTIFY CT REACH PATIENT

•Consult neurologist via REACH telemedicine

Code Stroke

Candidate for tPA

TPA candidate? YES •Neurologist to

oDiscuss risks/benefits w/ pt/family oMake recommendations for tPA in person or via REACH & give order

•RN (2 signatures confirm dose ) oAdminister tPA, infuse 50 ML BOLUS NS AT THE END OF TPA TO AT THE SAME RATE AS TPA. Complete tPA orders M10682,

o Complete Dysphagia Screening oVs q 15 minutes oNIHSS Q15, then Q30, then Qhr

tPA initiated

Goal: <60 min

CALL 5-7455 (5-PILL) NOTIFY PHARMACIST

OF LOCATION, PATIENT WEIGHT, SCAN

ORDER WHEN COMPLETED

Observation Unit

Group Time Period Ischemic stroke TIA SAH ICH Stroke

NOS

No stroke related

diagnosis

Blank "Missing

diagnosis" Total

My Hospital

07/01/2010 - 06/30/2011

621 (69.1%)

116 (12.9%)

37 (4.1%)

124 (13.8%)

1 (0.1%)

0 (0%)

0 (0%) 899

All SC Hospitals

07/01/2010 - 06/30/2011

3414 (62.5%)

976 (17.9%)

243 (4.4%)

557 (10.2%)

85 (1.6%)

163 (3%)

26 (0.5%) 5464

JC PSC Hospitals

07/01/2010 - 06/30/2011

144816 (62%)

41588 (17.8%)

10198 (4.4%)

26200 (11.2%)

2947 (1.3%)

5159 (2.2%)

2770 (1.2%) 233678

Total CVA/TIA Pts ALOS

7/2010 13 0.89

8/2010 6 1.21

9/2010 12 1.06

10/2010 8 1.53

11/2010 10 1.11

12/2010 6 1.33

1/2011 9 1.08

2/2011 14 1.06

3/2011 10 1.21

4/2011 11 1.02

5/2011 13 1.12

6/2011 23 1.22

Total 135 (53 – ICD9 435.9)

1.15

• TIA/Stroke Workup as observation status

• Labs, MRI/MRA, Echo, Carotid U/S

• Risk factor identification/reduction

• NP managed with ED physician

• Neurology consult

Observation Unit

• TIA/Stroke Workup as observation status

• Labs, MRI/MRA, Echo, Carotid U/S

• Risk factor identification/reduction

• Neurology Consult

• NP managed with EM Physician

• Work up completed in 24-48 hours, 365 days

Questions?

Thank You