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9 issues stroke systems of care must address to improve outcomes

EMS triage and destination, emergency department, transfer and stroke team protocols are essential to rapid definitive treatment for ischemic stroke


Stroke is one of the high-risk time-sensitive conditions that benefits from a systems of care approach.

Photo/Allied Academies

A system of care is a collection of processes that interact to identify and treat a patient with a specific medical condition. Ideally, a system of care is explicitly designed so that the various processes interact in ways that make it more likely for patients to have better clinical outcomes.

Without an explicit effort by the many different agencies and institutions involved to work together at a systems level, systems of care usually evolve haphazardly over time through a series of policy and procedure decisions. These decisions are commonly made at the individual agency and institution level without consideration of the overall system and its impact on patients.

These non-systemic, but well intentioned, policies and procedures may help the individual organization or improve the performance of a particular process they manage. Unfortunately, these actions may have a net negative impact on the patient. That is because a key principle in systems design is that that the performance of a system is not the sum of the performance of each of its parts – it’s a product of their interactions.

Acute ischemic stroke systems of care

Stroke is one of the high-risk time-sensitive conditions (HIRTSC; pronounced “hurt-see”) that benefits from a systems of care approach. Like other HIRTSC, clinical outcomes for stroke are improved when definitive care is initiated as soon as possible. This is the reasoning behind the phrase “time is brain” when caring for the acute stroke patient. There are two general categories of stroke – ischemic and hemorrhagic. This article will focus on the system of care for acute ischemic strokes (AIS).

Definitive care for AIS is removal of the clot that is blocking flow in the affected arterial vessel(s) in the brain. This is accomplished with either thrombolytic drugs, mechanical thrombectomy or both (if they can be initiated within certain time limits).

Therefore, a stroke system of care should consist of processes that will minimize the acute onset to definitive treatment time interval. Based on the timing and circumstances, the stroke system of care should identify which patients are best suited for thrombolysis versus thrombectomy and direct patients accordingly to the most appropriate hospital.

To accomplish the goals of rapid definitive treatment and long-term favorable outcomes, the stroke system of care should address the following nine issues across the entire community/region, not just for a specific 911 communications center, ambulance service, rescue agency, hospital, rehabilitation center or physician practice:

  1. Public education. The general public will need processes to encourage and help them to quickly and reliably identify stroke symptoms, and convey the urgency in accessing emergency care – preferably via EMS so that field triage and care can direct patients to the most appropriate hospital and manage any complications prior to hospital arrival.
  2. 911 communications. Dispatch should identify potential stroke cases so that appropriate pre-arrival instructions can be conveyed. They can also inform responding EMS units of a possible stroke case so crews have an increased awareness of the possibility in their assessment. Due to the time sensitivity of stroke, EMS unit selection for deployment to the scene decisions should consider the closest available unit, regardless of jurisdictional boundaries. If mobile stroke units are available, the 911 communications center may play a role in dispatching or pre-alerting them based on the dispatch center’s clinical impression.
  3. EMS triage and destination protocols. Non-transport medical first response and ambulance crews will need protocols to guide the triage of likely stroke cases and discern which cases are likely large vessel obstruction cases. Based on parameters for time elapsed since “last known well” and differences in travel time between facilities with and without LVO capabilities, the protocols should inform the selection of a destination hospital. EMS crews should also have protocols for making formal declarations of a stroke alert with early notification of the destination hospital so preparations can be made in advance of patient arrival.
  4. Emergency department protocols. Emergency departments should have protocols in place to quickly screen for stroke cases on walk-in cases and immediately prioritize their care. They should also have processes for how to respond to EMS stroke alerts with preparation for CT scanning and stroke team activation. These protocols may include “direct to CT” policies for patients who meet specified criteria.
  5. Inter-facility transfer protocols. If the initial destination hospital ED does not have mechanical thrombectomy capabilities or if the patient will require more advanced care due to comorbidities or other complicating factors, process will be needed to promptly request and prepare the patient for an emergency inter-facility transfer (a Stat transfer). The ambulance service that provided the scene-to-hospital transport, the ground or air ambulance service that provides the actual interfacility transport and the receiving hospital will all require protocols for these cases.
  6. Stroke team protocols. Processes are needed to quickly notify the stroke team when a stroke alert is declared. Different versions of the protocols may be needed for when the stroke team members are already in the hospitals versus after hours scenarios.
  7. Post-acute care. Processes are needed to ensure a smooth transfer from acute to post-acute care. In cases involving severe disability or complications, this may involve transfer to long term acute care and/or skilled nursing facility care. Even with low severity cases, there should be referral to and completion of a stroke rehabilitation program.
  8. Secondary prevention. Processes are needed to refer stroke patients back to their primary care physicians and any specialists for follow-up to begin processes for secondary prevention and support their compliance.
  9. Systems level QA/QI and research. Throughout this continuum, for an acute ischemic stroke episode of care, there should be processes in place to gather data that is abstracted into registries or similar tools. This data should measure the performance of the various processes outlined and give prompt feedback on a case-by case level to clinicians (and on an aggregate level for organizational and systems level feedback). This abstracted data can then help identify improvement opportunities and research. Participation in formal clinical registries at a state/national level is preferred as the large numbers of cases can support registry-based research. Agencies and institutions that participate in the community/regional system of care for stroke should regularly meet as a group to review systems level performance reports and collaborate in systems-level improvement and research projects.

A community/regional stroke system of care consists of many different organizations, teams and functions within those organizations, hand-offs, communications needs – and opportunities to do each part well and connect it to the next part of the system of care well (or not so well). That’s why the design, operation and improvement of our stroke systems of care needs to address the whole system of care.

Mic Gunderson is the president of the Center for Systems Improvement – a consulting firm specializing in design and value improvement for high-risk time-sensitive care.

His prior positions include national director for clinical systems at the American Heart Association; EMS system director for Kent County EMS in Grand Rapids, Mich.; president at Integral Performance Solutions; national director for quality, education and research with the Rural/Metro Corporation; director of research and education with the Office of the Medical Director in the Pinellas County, Fla., EMS system.

Over the course of his career, he served as a field EMT, paramedic and firefighter, clinical manager and director with military, private and governmental EMS agencies. Mic has authored and edited a wide range of articles and textbooks, and has served on the boards of directors for several national EMS organizations.