How to improve stroke patient triage, assessment, care and transport

EMS medical directors discuss innovations and improvements in stroke patient, triage care at Gathering of Eagles

DALLAS — Innovations and improvements in stroke care, from dispatch to tPA administration or catheterization, were discussed by medical directors at the 2016 Gathering of Eagles XVIII EMS State of the Science program.

David Miramontes, MD, NREMT, medical director for the city of San Antonio, opened the session with a discussion of dispatch initiated stroke assessment with a goal to decrease time to patient treatment at a stroke center. In San Antonio, paramedic dispatchers begin patient assessment of stroke by asking a series of questions to the caller or patient using a modified version of the FAST stroke assessment, priming the first on scene and medic units that a stroke is suspected.

The on-scene processing of neurological emergencies was discussed by W. Scott Gilmore, MD, medical director for the city of St. Louis. Gilmore described changing a system from sequential to simultaneous processing of the stroke patient. Process improvements have significantly reduced time intervals for patient delivery straight to CT and tPA administration while in the CT scanner.

Paramedic-trained dispatchers begin a modified FAST assessment for stroke as the ambulance is dispatched.
Paramedic-trained dispatchers begin a modified FAST assessment for stroke as the ambulance is dispatched. (Photo by Greg Friese)

The improvement of triage for stroke patients to determine which patients need delivery to a comprehensive stroke center vs. a primary stroke center was described by Jason McMullan, MD, medical director for the city of Cincinnati.

Peter Antevy, MD, representing the Greater Broward County (Fla.) EMS medical directors association, answered questions about which patients need to go to the cath lab and if a CT scan for stroke, like a 12-lead ECG for STEMI, in a discussion about large vessel occlusions.

The outcomes of EMS triaging and transporting all stroke patients to a comprehensive stroke center was discussed by Christopher Hunter, MD, medical director for Orange County (Fla.). Hunter shared the improvements in time to scan, time to tPA and time to catheterization after the hospital became a comprehensive stroke center and received all stroke patients from EMS.

The session concluded with a presentation from David Persse, MD, medical director for city of Houston, about the implementation and impact of a mobile stroke care unit to speed ED to needle times by taking ED-level services to the stroke patient. Houston is in the midst of a prospective randomized clinical trial investigating a mobile stroke unit response to neurological emergencies.

Memorable quotes on stroke assessment and care

"Transport is the most important thing (for a stroke patient). Diesel is the only drug the patient needs. The goal is to call (the hospital) and load the patient with a platinum on-scene time of 10 minutes."
 David Miramontes, MD

"In the chain of survival can we move 'Data' collection before 'Delivery'?"
 W. Scott Gilmore, MD

"Triage is the professional specialty of paramedics to get patients to the right place in the right time."
- Jason McMullan, MD

"EMS provides high quality stroke care and EMS can go home today and make change."
 Peter Antevy, MD

"We take people directly from the ambulance to a CT scanner on the ambulance stretcher which decreased door to scan time significantly."
 Christopher Hunter, MD

"A stroke is like a gunshot wound to the brain, except that treatment can reverse a stroke."
 David Persse, MD

Key takeaways on stroke assessment and care
Here are key takeaways for medical directors and field providers from the six presentations.

  • Stroke patient assessment can begin during dispatch and before EMS even begins driving to the patient. Dispatch assessment of stroke triggers a paradigm shift in first response, medic unit arrival, hospital notification and transport destination.
  • A simple intervention, like a business card with stroke center contact information, can begin a process of a neurologists gathering patient data before the patient is delivered to the hospital.
  • Over- or under-triage of stroke patients has significant impacts on patient outcomes, but EMS currently lacks the assessment tools to definitively decide which destination is best for a stroke patient. EMS needs more data, including the hospital treatment time intervals, to make better decisions.
  • Door to cath lab improvements are significant when EMS sends a stroke alert and the cath lab is activated for ELVO before CT scanning.
  • Patients at a comprehensive stroke center had CT scans faster and received tPA sooner after the center transitioned from a primary stroke center to a comprehensive stroke center.
  • To improve stroke care requires a passionate leader to guide a collaborative community effort which includes all the hospitals and the EMS system.

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