A Rapid Ambulance Protocol for Acute Stroke

Prof Gary Ford

Freeman Hospital Stroke Service

Newcastle Upon Tyne

Assessment of Suspected Acute Stroke by Stroke Teams

• Accurate early diagnosis and initiation treatment non-stroke present in 20% suspected acute stroke

- Subdural haematoma, epilepsy, cerebral tumour• Initiation early rehabilitation• Early interventions – thrombolysis, aspirin• Improved early management

stroke - carotid dissection, cerebral venous thrombosis, ic haemorrhage,

diagnosis TIA complications – dysphagia, DVT, fluids, BP

Advances in Stroke Care

• Intravenous thrombolysis with alteplase in selected patients with acute ischaemic stroke within first 3 hours

• Aspirin in patients with cerebral infarction within first 48 hours

• Benefits of organised Acute Stroke Unit care • Increasing evidence of the benefits of interventions to

correct disturbed physiology (hypoxia, dehydration, fever, hyperglycaemia) early stages of stroke

• Possible extension thrombolysis time window and use neuroprotective agents within 5 hours

NINDS rt-PA STROKE TRIAL:RESULTS - PART 23-Month Outcome on Four Stroke Scales

NIHSSrt-PAPlacebo

Barthel Indexrt-PAPlacebo

Modified Rankinrt-PAPlacebo

Glasgow Outcomert-PAPlacebo

31 30 22 17

20 32 27 21

50 16 17 17

38 23 19 21

39 21 23 17

26 25 27 21

44 17 22 17

32 22 26 21

% of patients

% of patients

% of patients

% of patients

Minimal/No Disability Moderate Disability Severe Disability Death

Aspirin in Acute Ischaemic Stroke

IST / CASTLancet 1997

Requirements for Early Assessment of Stroke Patients

• Awareness of signs/symptoms of stroke in community

• Rapid Admission to Hospital

• Rapid Assessment at Hospital

• Imaging when required

• Skills to administer interventions

STROKE SYMPTOMS

999 Primary Care Physician

Paramedic AmbulanceAssessment Transport

A&E

Medical/Neurology Stroke UnitWards

Reynolds et al, 1999

Delays in Presentation

• Stroke admissions in Oxford 6 month period• Prospective data collection 183 patients• Uncertain onset time 55% (waking 28%)• 55% arrived within 3 hr, 76% within 6 hr• 24/86 GP cases initially managed at home• Symptom recognition to admission within 3 hr

GP 31% Ambulance 90%• Admission to assessment - 69 min

Wester et al,1999

Delays in Admission

• 15 Swedish Hospitals• 329 patients stroke/TIA• Hospital admission 4.8/4.0 hr• Factors associated with delayed admission

infarct, gradual onset, mild symptoms, not using ambulance, visiting GP

• Factors associated with delayed CT/Stroke unit admissionlarge catchment area, mild/moderate deficitwaiting for ER physician

Acute Stroke

General Practitioner 999

Accident &Emergency Dept

Acute Stroke Unit General Medical WardsFreeman Hospital RVI

Freeman Hospital Stroke Service

• Established Apr 1993• First comprehensive stroke service UK• Accepts all suspected acute stroke patients• 10 acute stroke beds within General Medical Ward• 10-14 Stroke rehabilitation beds non-acute hospital• Multi disciplinary team both units• Initially only GP referrals

Freeman Hospital Stroke Service• 1993 Stroke Discharge Team• 1994 Commenced hyper-acute assessment

stroke trials• 1994 Multidisciplinary stroke review clinics• 1997 Establishment cross city stroke rehabilitation

ward (20 beds)• 1997 Rapid Ambulance Protocol• 1998 IV thrombolysis protocol

Second stroke consultant• 1999 14 bed Acute Stroke Unit• 2000 City wide triage of stroke to unit

30 bed Acute Stroke UnitThird Stroke consultant appointed

Acute Stroke

999 General Practitioner

Rapid Ambulance A & E DeptProtocol

Acute Stroke Unit General Medical WardsFreeman Hospital RVI

Rapid Ambulance ProtocolAcute Stroke Symptoms

Ambulance Control

Paramedical team

Paramedical Assessment

Suspected Stroke Non-stroke

Stroke Unit A & E Dept

radio control

notify unit

Rapid Ambulance Protocol

• All 999 patient with suspected stroke not in coma GCS >6 to be taken to FRH Emergency Admission Suite

• EAS to be informed of pre-arrival information

• FAST assessment to be used to identify and assess suspected stroke cases

Rapid Ambulance Protocol

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Directive City wide Letter to Letter to Training East End Crews Protocol Crews Crews Programme

MonthlyAmbulanceStroke UnitAdmissions

Rapid Ambulance ProtocolMay 97 -Jul 98

123 Patients

102 Confirmed acute stroke/TIA

21 Non-stroke5 acute confusional state5 collapse secondary to vascular instability3 fall/old CVA3 cerebral neoplasm3 collapse secondary to other cause1 seizure1 normal pressure hydrocephalus

Rapid Ambulance Protocol Symptom onset to admission

Median (range)

GP referrals (n=108) 6.0 (0.5-23.5) hrRapid Ambulance Protocol 1.2 (0.5-18.7) hr

Symptom onset to contact emergency service 33 minContact to arrival paramedical team 8 min Arrival at home to arrival stroke unit 22 min

Purpose Paramedic Stroke Instrument

• Identification stroke - direct to Stroke Unit

- rapid transfer- obtain relevant information

at scene - administer neuroprotective therapies

• Identification non-stroke

• Increase profile stroke

Kothari et al, 1997

Cincinnatti Instrument

• 74 patients treated in thrombolysis trial and 225 non-stroke patients evaluated in ER

• NIHSS all patients• Facial palsy, motor arm and dysarthria

identified 100% stroke patients (specificity 92%)

• Out-of Hospital scale facial palsy, arm weakness, language disturbance

Kothari et al, 1995

Cinicinnati EMS experience

• 4413 evaluations• Paramedic diagnosis Stroke/TIA 96 2%• Confirmed in 62/86 72%

22 paramedic interventions• Mean time to scene 3 min after 911 call• Earlier arrival with basic units compared to

paramedics (40 vs 45 min)• Physician assessment (10 vs 20 min) and

CT (47 vs 69 min) earlier with paramedics

Kidwell et al, 1998

Los Angeles Instrument

• Exclude age<45 yrs, seizure, symptoms >24 hr, patient wheelchair bound or bedridden

• Arm strength, facial smile, grip• Evaluated in patients entered 6 hr intervention

trials• 41 ischaemic stroke by ambulance• 93% ‘would’ have been identified

San Francisco Instrument

• 4 items

• Language - 3 step command, name objects, speech fluency

• Motor - Smile, pronator drift, lift each leg

• Visual fields - confrontation testing

• Gait

Smith et al, 1998

San Francisco experience

• Retrospective review stroke admissions and paramedic evaluations

• Paramedics identified 49/81patients

• 15 patients identified by paramedics non-stroke

• Patients/families waited 2.5hr before calling 911

FAST assessment

Face Arm Speech Test

Facial Palsy

affected side

Arm Weakness

affected side

Speech Impairment

FAST Assessment

Paramedic Training Package

• Lecture notes

• Handout

• Overheads / slides

• Video

• MCQ test

Paramedic knowledge

• MCQ assessment before/following training package 57 ambulance staff

• Score 14.0 before 16.8 following

• Errors GCS scoring affected sideCerebral haemorrhage

commonest cause Headache present >80% patients Depressed conscious level most patients

Identification non-stroke

• Male 75 yrs admitted with suspected stroke via General Practitioner, symptoms dizziness

• Ambulance personnel undertake FAST assessment - negative

• Examine patient - bradycardic

• Complete Heart block - pacemaker insertion

Acute Stroke

999 A&E Dept General PractitionerNGH (Hospital Direct)

Rapid Ambulance Protocol

Acute Stroke Unit Medical WardsFRH - - - - - - - (single Trust) - - - - - - - - RVI

Rapid Ambulance Protocol

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MonthlyAmbulanceStroke UnitAdmissions

Rapid Ambulance Protocol

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Stroke

Non stroke

Diagnostic Accuracy Stroke Referrals1 Feb 00 – 31 May 00

GP A&E Paramedic Total

Stroke/TIA 89 45 95 229

Non-stroke 34 12 24 70 Proportion of referrals 28% 21% 20%

Paramedic Stroke Detection

1 Feb – 31 May 2000

129 stroke patients initial contact 999

97 admitted directly via RAP

75% detection

80% accuracy

Stroke Referrals - subtypes Paramedic GP

(n=84) (n=73)

TACS 37% 10% p<0.001

PACS 37% 34% n.s.

LACS 14% 33% p<0.01

POCS 2% 14% p<0.01

PICH 10% 10% n.s.

4 month period (Feb-May 00)

Hospital Assessment

• Emergency Room staff

• Acute medical team

• On call Acute Stroke Team nurse / stroke doctor

SWAT Team

• Stroke Watch Action Team

• St Luke’s Hospital, Kansas City

• SWAT beeper

• Nurses trained to identify stroke and summon doctor

Links with Accident & Emergency

• A&E doctors used to acting quickly

• Clear protocol - who requests imaging?

• Need for stroke recognition instrument

• Support of stroke team

• Admission to Stroke unit vs A&E

Freeman Stroke Service

• Admission suite staff notify stroke nurse• Collect data from paramedics• Stroke nurse undertakes initial evaluation (SNSS/NIH) takes

bloods, speaks to/contact relatives• Contacts stroke doctor further neurological evaluation • If non-stroke direct further management in discussion with

stroke consultant• Urgent CT requested if required• Thrombolysis/neuroprotectant trials initiated in Admission

unit

Freeman Thrombolysis Experience

• 17 patients treated in 2 years (2% referrals)

• 15 admitted via 999 contact

• Main contraindications, delayed admission and co-morbidities

• Outcomes similar to NINDS trials

• 1 symptomatic intracerebral haemorrhage as complication

Establishing an Ambulance Protocol

• Go the top• Establish agreement colleagues across district• Incorporate stroke instrument in patient report form• Protocol must be unambiguous and simple• Initiate audit and involve ambulance staff• Regular feedback to crews on the ground• Change takes time

Acute Stroke Patient Flow

Suspected Acute Stroke Community education

Emergency Services Primary Care Physician

Paramedic Paramedical assessment Professional Education

Training

Acute Stroke Unit Emergency Room

Organised rehabilitation Health Care Purchasers