The first, first responder: Reducing door-to-drug times for stroke patients
Richmond Ambulance Authority and Medic EMS share lessons from implementing the Medical Priority Dispatch System to improve stroke alert response
By Chuck Gipson
Thinking outside the box can lead to untapped potential from a previously overlooked resource. All of our agencies have a dispatch center of some sort that gets the right resources to the right place at the right time. Right? That call taker is the first person to make contact with the patient after the 911 system is activated. Many times as EMS providers, we forget the care that gets delivered to that patient before the first response vehicle ever arrives on scene.
Elapsed time is a big factor in the outcomes for stroke patients as a stroke occurs roughly every 40 seconds, 87% of which are thrombolytic in nature.
Richmond Ambulance Authority (RAA) in Richmond, Virginia, is exploring the possibility of using its dispatch resource to reduce the time to care for stroke patients. The current state of alerting the EDs in Richmond is likely familiar – the on-scene provider assesses the patient and alerts the hospital in their medical control radio report. RAA is now engaging their certified stroke-receiving facilities to see if the call takers can initiate stroke alerts after gathering proper information and assessment from the caller over the phone.
MEDIC EMS in Davenport, Iowa, implemented this program in 2014 and has had great success in helping the hospitals reduce the door-to-drug times for stroke patients. RAA is looking to see if implementation of a similar system can lead to decreased stroke alert activation times as well.
Both MEDIC EMS and RAA services use the Medical Priority Dispatch System (MPDS) protocols through the International Academies of Emergency Dispatch (IAED) and have successfully delivered accurate and timely care to callers . MPDS has a protocol to care for a stroke patient that includes a stroke diagnostic tool to accurately assess a patient complaining of stroke-like findings using a FAST type exam including:
- Facial droop
- Arm weakness
- Speech difficulty
- Time to call 911 (last known well time)
The information provided during the call intake process using the stroke diagnostic tool determines if there is no evidence, partial evidence, strong evidence or clear evidence that the patient is experiencing a stroke. Now the dispatch center has the right information they need to assist the responding crews and the hospital to perform at their best for stroke care. The trick is to get all of the players involved to make optimal care decisions using this valuable information.
The availability of such crucial information not only enables care providers to make fast and accurate decisions but, it also ensures continuity in the continuum of care for the stroke patient – each stakeholder will be aware of what interventions have already been provided to the patient. Continuity of care potentially enhances patient outcomes and reduces overall cost of care for the patient.
Bringing prehospital and hospital providers together
The journey to implementation with hospital systems can be a task that proves difficult. Everyone agrees that we all want to perform at our best to take care of all of our patients all of the time – it’s pretty hard to dispute that. But sometimes change or the unknown can be our biggest roadblock. From our implementation process of dispatch activated stroke alert experiences with the MEDIC EMS system, we learned that the key to success lies in relationships.
Key stakeholder engagement is fostered by inviting EMS agencies to attend, or hold a seat on committees, and cultivating relationships that encourage the development of trust in one another and eventually lead to collaborative efforts that should result in better patient care.
Often, the two sides of healthcare are unaware of what they can do for each other. Implementation begins with a champion on both sides of the patient handoff (prehospital and in-hospital care). Getting those champions together to ask the question of “what can we do to help each other” is important to getting the ideas on the table for discussion. Project management ultimately rests with the medical directors of both the EMS agencies and the hospitals, their innovative thinking and support will drive any new process.
Some ideas remain just that; ideas. However, good ideas are coupled with data and research presented to create a process that others can use as a vision of what is possible, especially when other examples of successful models are unavailable.
Early stroke alert activation by a dispatch center can allow a hospital to have more time to mobilize resources for receiving the patient, e.g., having:
- A CT scanner available for quick scanning
- Lab personnel present to receive the blood sample tubes from the field crew
- Pharmacy notification of possible need for thrombolytic being mixed
- Neurologist activation
- Several other small processes that come into play depending on your system
None of those processes seem like they take much time but, collectively, they add up, and brain tissue begins to die in less than 5 minutes without perfusion . Additional time shavers to implement include no more than an ED “pit stop” followed by a direct route to the CT scanner while still on the ambulance cot. It seems that once the patient lands in an ED bed, time easily gets away from everyone and they are much more difficult to move around.
When setting out on a journey like this, it is imperative to have a goal in mind, such as coming up with a hypothesis on what should happen if this is put into place. For example, when MEDIC implemented this process, the hypothesis was that on average, there would be 15 minutes saved on early notification by the dispatch staff over when they would receive the field radio report. To come up with this we looked retrospectively. Activating the hospital stroke alert process from the point of call intake is helping hospitals meet defined standards of 60 minutes from arrival at the hospital to medication administration .
Quality improvement measures
After implementation, it is paramount to ensure that the program is gathering data for comparison to the previous process to assess if there is an improvement. Quality measures should include checking the accuracy of the information gathered by the call takers and comparing it to the number of times the crew either confirmed or cancelled the stroke alert to find an over- or under-call rate. Compare that to the hospital data to evaluate how many times their alert was confirmed with yours and how many of them received thrombolytic treatment and did their times improve with the process. After the data is collected and shared with all involved, celebrate the success and let them know if you proved your hypothesis or if other small changes need to be made to the new process.
Some of the challenges to accuracy of the dispatch staff activation process are not able to be “seen” through the phone. Such as “does the patient have a facial droop from Bell’s palsy or trigeminal neuralgia? Is the patient slurring their words due to intoxication or hypoglycemia? Is their arm not equal from a previous stroke or a bad rotator cuff?” MEDIC EMS has found an over call rate fairly consistently in the 40% range on average with the most common reason for the crew cancelling the alert that the symptoms present during call taker assessment had resolved, causing a negative stroke assessment by field staff. Continuing to conduct research and sift through findings is extremely important to constantly improve process for best results and outcomes.
Identify a consistent ED contact
Another lesson learned is to ask for a consistent person in the ED when the dispatch staff calls to advise of an early stroke alert activation. MEDIC EMS chose the charge nurse as the reliably consistent emergency department staff member, counting on this healthcare professional to understand the process field staff need to quickly assess the patient and either cancel or confirm the alert. It was also very beneficial to continually meet with the neuro and ED groups at the receiving facilities to ensure the accuracy and helpfulness of the process by constantly changing and improving.
Choose the correct facility
Implementation will depend on your system. RAA has a 13 hospital systems that they are working with to implement this process. The key to early activation through the dispatch center is choosing the correct facility to call based on the question of the destination of choice while assessing the caller. MEDIC EMS had two hospital systems to coordinate with, which made the buy in and implementation coordination a little easier than a larger system. Ideally this should be completed as a system-wide approach rather than individual hospitals or EMS agencies. The easiest way to set up for errors is to build in inconsistencies.
While consistent practice of these processes can make an ambulance agency shine, or impress the joint commission reviewer evaluating a hospital system, the bottom line is this: timely and efficient care that consistently translates into high value, high performance patient care saves brain for every patient, every time.
About the author
Chuck Gipson is Quality/Education Manager, MEDIC EMS, Davenport, Iowa.
1. Priority Dispatch Corp (PDC). (2020). Protocol 28 (Stroke [CVA/Transient Ischemic Attack [TIA])—a tool in the Medical Priority Dispatch System™ (MPDS®) (Version 13.2, Priority Dispatch Corp., Salt Lake City, UT, USA).
2. Gipson, C., Frederiksen, L., Miller-Guss, B., Vermeer, R. (2018). Saving Brain in Stroke Patients. Navigator Conference,. (Poster Presentation).
3. Lee, J., Grabb, M., Zipfel, G., Choi, D. (2000).Brain Tissue Responses to Ischemia Lee, Jin-Moo Lee. Grabb, Margaret. Zipfel, Gregory. Choi, Dennis. J Clin Invest. 106(6):723–731. https://doi.org/10.1172/JCI11003