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Stroke Collaboration | | Background
Stroke is the third leading cause of death in the United States. For effective treatment the early identification and rapid assessment of the patient with stroke symptoms is critical. This includes the patient and/or family members recognizing the early warning signs; the ambulance EMT/paramedic staff recognizing and responding to the presence of stroke symptoms; and the Emergency Room/hospital staff rapidly assessing and treating the patient with stroke symptoms.
Act 61 of 2009 charged the Vermont Association of Hospitals and Health Systems with convening a workgroup of neurologists, emergency department (ED) physicians and representatives of the American Heart Association to make recommendations to improve acute stroke care. The Stroke Workgroup met for two years and issued a final report in November 2010, “2010 Recommendations of the Stroke Workgroup”.
A number of specific “next steps” were identified in the report. The most significant of these was the incorporation of the workgroup-developed tools and materials into local community ED processes. To accomplish this, the management of the project was turned over to the Vermont Program for Quality in Health Care an organization with quality improvement expertise and resources.
To view the 2009 legislative report, go to:
http://www.leg.state.vt.us/reports/2010ExternalReports/252654.pdf
The specific workgroup recommendations were as follows:
RECOMMENDATIONS FOR EMERGENCY DEPARTMENTS
COORDINATE PRE-HOSPITAL CARE WITH DISTRICT MEDICAL ADVISORS
Local EMS education and deployment of uniform STROKE ALERT TOOL
- Rapid identification of stroke as the cause of a patient’s symptoms
- Stabilization, manage ABC’s
- Cardiac monitoring, intravenous access, oxygen
- Elimination of co-morbid conditions that could mimic stroke e.g., assess for hypogly-cemia
- Alert local medical control and use established local protocol to determine destination hospital capable of treating acute stroke
- Rapid notification and transportation to destination hospital
PROTOCOLIZE EMERGENCY DEPARTMENT MANAGEMENT 1, 2
An organized protocol for the emergency triage, evaluation, and treatment of patients with suspected stroke is recommended. The goal is to complete an evaluation and decide treatment within 60 minutes of the patient’s arrival in the ED.
- The use of a stroke rating scale, a limited number of hematological, coagulation, and biochemical tests, and an EKG are recommended in the initial emergency evaluation.
- At this time, emergency non-contrast-enhanced CT scanning of the brain remains the primary diagnostic brain imaging study for evaluation of patients with suspected stroke. Goals of 20 minutes to CT and 25 minutes to CT reading are consistent with the 60 minute door to decision timeframe.
- Cautious parameters for the management of arterial hypertension in stroke should be implemented.
- Expert neurological consultation should be available if needed for review of management options. Enhanced data sharing via teleradiology or telemedicine should be explored.
- Treatment with tPA should be anticipated and considered in appropriate patients up to 3 hours after time of symptom onset. Treatment with t-PA in the 3-4.5 hour timeframe is not FDA approved but should be considered in selected patients2.
- Transfer to a tertiary care hospital for endovascular intervention (intra-arterial thrombolysis or clot extraction) in selected patients should be considered.
- Treatment with oral aspirin (325 mg) alone within 24 hours of stroke onset is recommended for most patients.
1Adams, PA, et. al. Guidelines for the Early Management of Adults with Ischemic
Stroke: A Guideline from the American Heart Association/ American Stroke
Association StrokeCouncil, Clinical Cardiology Counsel, Cardiovascular
Radiology and Intervention Council, and the Atherosclerotic Peripheral
Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary
Working Groups: The American Academy of Neurology affirms the
value of this guideline as an educational tool for neurologists.
Stroke 2007;38;1655-1711.
2 Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for
treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a
science advisory from the American Heart Association/American Stroke Association.
Stroke. Aug 2009; 40(8):2945-8
Activities
In December 2010 VPQHC staff began to inventory the ED process for assessing stroke symptoms in all hospital emergency rooms in Vermont with the goal of protocolizing the Stroke Workgroup recommendations. By July of 2011, all EDs had adopted the recommendations and were working on standardizing the charting of this process.
Recommendations for the early recognition, assessment and ED stroke alert by the emergency medical system was also included in the recommendations. Currently all districts are involved with training in the use of the stroke assessment tool and are beginning to use the stroke alert process.
In addition to the standardization of assessment and treatment of strokes in the ED, VPQHC identified resources to assist health care professionals and the general public to understand the latest evidence on assessing and treating stroke symptoms. These resources can be found on this website under Professional and Public Resources for stroke information
The next steps will be to audit ED records and to follow up with the regional emergency response system to provide feedback on process improvement.
Links
Stroke Workgroup
Healthcare Professional
Stroke information for the public
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