Sophisticated Prehospital Stroke Systems of Care

1. Kerry Ahrens, MD MS

2. Kerry Ahrens MD, MS
Emergency Physician BayCare Clinic
Medical Director Oshkosh Fire Dept
Medflight Physician
Co-Chair Wisconsin Stroke Coalition
Associate Professor EM UW School of Medicine

3. MJ, 53 yo M
08:08
53 yo M pmh of obesity, mild aortic stenosis here as a
interfacility transfer from County X Hospital with acute
onset of L-sided weakness L facial droop. OSH did found
large vessel occlusion L-MCA. Patient presumed to be
out of tPA window at the time & tPA not given. Sent here
for intervention. Neg ROS. He did have some right-sided
neck pain earlier this week was unclear if it was related
to today's events. His wife reports that he woke up 0500
was able to put his glasses on, stood, walked a few steps
then collapsed. Wife called 911.

4. Why Build a Stroke System of Care?
• Leading cause of serious long-term disability
• $34 billion/yr
• 5th leading cause of death
• Over the past 15 yrs adults age 18-54 have had
increased stroke hospitalizations
• Estimated that 80% of strokes are preventable
• We are not doing well at reversing this trend…

6. Why Build a Stroke System of Care?
• Current standard of care:
• tPA within 4.5 hours of LKWT
• Embolectomy for large vessel occlusions (MCA,
Carotid, Basilar) within 6 hours
• Data consistent points to the quicker tPA &
embolectomy are performed, the better the
patient outcome*
• Is an multinational problem, and we are still
working towards a solution.
* Khatri et al 2009, Khatri et al 2014

7. Why Build a Stroke System of Care?
•Faster times yield improved outcomes
(based on Modified Rankin Score)*
• NNT for tPA
• 4 tx within 90 min
• 5 tx done 90-180 min
• 7.5 tx done 180-270 min
*Lansberg 2009

8. • Practical to implement & supported by existing clinical data
• Goal: optimize patient care & improve patient outcomes
• 14,000 stroke-related hospitalizations in Wisconsin*
• 2,952 deaths d/t stroke in WI (2016) 5.19% of WI population
dhs.wisconsin.gov/heart-disease/facts.htm
Stroke continues to be a devastating disease resulting in
life-changing disability. Survivors can require long-term
rehabilitation as they integrate back into their community
*Wisconsin Hospital Inpatient Discharge Data base, 2013, Wisconsin Hospital
Association
Why Build a Stroke System of Care in
Wisconsin?

9. Why(bother to)Build a
Stroke System of Care?
• There is a great deal of ED resistance to using
current standard of care (tPA) in treating strokes,
so why build a system?
• ED RN: “And they’ll go back in there and double-
check that patient 7 times in order to say, oh,
they’re improving, you know, as one of the relative
contraindications….Their stroke score was 14 and
now it’s 12 so they’re improving - we don’t have to
give it. You know. Whew! That kind of a thing.”

10. Why(bother to)Build a
Stroke System of Care?
“A lot of it has to do with how much influence
certain big-shots in emergency medicine
have. There are some - one in particular who
practices at Hospital X, just 10 miles down
the road, he’s been very outspoken against
the use of tPA. And if you ever go the the
national [emergency medicine] meetings and
listen to these…docs speak, they can be very
convincing. And I think that has had some
influence on some people.”

11. 1984
1st tPA
use for
STEMI
1995
NINDS
Trial
tPA
for CVA
tPA
considered
level 1A
for CVA Tx
by:
The Great tPA Debate Timeline
2008
European
Stroke
Assoc
1996
FDA
Approval
CVA
2002
AAEM
data
insufficient
to warrant
tPA for CVA
as standard
of care
Canadian Stroke
Network,
Australian Nat’l
Stroke
Foundation
2010
2012
Japanese
Stroke Soc,
ACCP
Amer Acad
Neuro
2002
ACEP
“insufficient
evidence to
endorse
tPA”
2013
ACEP
2017
?

12. Emergency Medicine Physician
Monthly 3/2014 on-line Poll

13. The Data is out there: tPA & Embolectomy are
effective treatments for a disease that had no
previous treatment

14. Our Mission
Improve EMS
ability to
detect
patients with
LVO in the
field 1
Understand
Endovascular
Therapies will
improve with
more data &
more
experience1
Despite a tPA
times,
improvement in
field to puncture
times have not
improved in 10
years2
1. Stroke. 2016; DOI: 10.1161/STROKEAHA.115.011149.
2. Journal Of NeuroInterventional Surgery. 2016. http://dx.doe.org/10.1136/neurintsurg-2014-011626

15. Rise UpRise Up!
• Many Healthcare Facilities have
risen to this challenge
‣ Acute Stroke Ready Hospital
‣ Primary Stroke Center
‣ Comprehensive Stroke Center
Accreditation granted through TJC, DNV-
GL, or HFAP

16. In WI, we have already begun developing
stroke systems of care within our local
hospitals:
• Acute Stroke Ready Hospital (ASRH)
➡ Drip & Ship Capability
• Primary Stroke Center (PSC)
➡ Drip & Ship for advanced tx
➡ Drip & keep
➡ May receive drip/ship from ASRH
• Comprehensive Stroke Center (CSC)
➡ Receive drip/ship for adv Tx
➡ Act as referral center for ASRH,PSC
➡ Accepts Pts w LVO for adv Tx
1 ASRH In
Wisconsin
40 PSC’s In
Wisconsin
4 CSC’s In
Wisconsin

17. What exactly is a ‘Stroke
System of Care’?
1. Community Awareness of CVA
2. Dispatch & EMS
3. Acute Stroke Care @ Hospitals
4. Post Stroke Care - primary care, rehab facilities

18. Stroke System Target Goals
• 3 Critical ‘Large Picture’ Functions
1. Effective interaction & collaboration among
Agencies = Services = Personnel in all aspects of identification
& tx of stroke patients in their region
2. Promote use of organized, standardized approach
3. ID performance measures - process & outcomes with a
mechanism to evaluate efficiency.
• Acute Stroke Treatment Main Goals (EMS, ED)
• IV tPA w/in 30 min
• Picture (CT) to puncture for LVO <90 min

19. Step 1: Know the players
•What are your regional EMS systems
capabilities?
• Basic, Intermediate, Paramedic, Crit Care
•What are your regional hospital
capabilities
• not interested in stroke vs ASRH/PSC/CSC
•Where are these facilities in relation to
your population?

20. Wisconsin Stroke Designated Hospitals

21. Does Focus & Building an EMS Component of
a Stroke System Make a Difference?
• In WI 40% of stroke patients arrive via EMS1
➡Increases the odds that patient will present
w/in 3 hr time window2
➡significant ↓ time from sx onset to CT
evaluation3.
➡For Large Vessel CVA, likelihood of a good
outcome decreases by 10% for every 30 min
delay in recanalization4 - planning LVO
destination
1.WARDS data, 2.Kothari 1999, 3.Vagal 2014,
4.Schroeder 2000.

22. The Importance of EMS in Stroke
Treatment
• Often are first to provide medical care for
stroke patients when 911 called
• Can provide public education outreach
• Can provide early on triage and decipher
true stroke vs mimic

23. Impact of EMS on Stroke Center
Certification in California
• A study on effect of EMS stroke routing
protocols effect on incentivizing hospitals to
become PSC accredited
• Yearly rate of hospital conversion to PSC
designation↑from 3.8% before EMS enacted
stroke protocols to 16.2% during.
Schuberg. Stroke 2013

24. Step 2: How to Build it
• Training
• EMS Dispatchers & Personnel
• Clinical Decision Support Tool
• Relationships within Regional Stroke
Systems
• Destination protocols
• Data to drive performance & care
delivery

25. Sample Stroke Protocol:
•EMS Arrival </= 10 min
➡ Stroke Scale
➡ Blood glucose
➡ Blood Pressure
➡ Last Known Well Time
(LKWT)

26. Training Goals: Metrics
• Dispatch time < 1min
• Turnout time < 1 min
• EMS response time < 8 min
• time elapsed from receipt of the call by the
dispatch to arrival
• On scene time < 15 minutes
Travel time is equivalent to trauma or
acute MI calls.

27. Clinical Decision Support Tools
*van Gaal et al. 2017, **Brandler et al 2014
• Purpose:
• Improves EMS ID stroke to 90%+
• Assist with EMS ability to identify stroke
patients who should be diverted to a stroke
center with 24-7 embolectomy capabilities.
• Avoid the unnecessary transfer of
ineligible/futile patients into the embolectomy-
ready centers*
• Has been implemented in 1-3 hours of paramedic
training**

28. Northeast Wisconsin Embolectomy-Ready
Centers
Neenah
Green Bay

29. Which Stroke Scale Should EMS Use?

30. • 3 main exam components
• Face, Arm, Speech, Score 1-3
• It’s simple - often seen as greatest attribute
Cincinnati Stroke Scale, 1997
• Validated in the Field: Sn
89%, Sp 73%
• Probability of acute CVA
• 1 of 3 = 72%
• 2 of 3 = 85%
• > 2 predicts severe CVA

31. LA Motor Score (LAMS), 2000
van Gaal et al 2017
• 3 exam components
• face, arm grip
• Score 0-5
• > 4 = LVO
• Easy to train all levels ~1-3hrs
• Validated in field, multiple live
sites tested, internationally
accepted
• feasibility confirmed through
multiple large-sale
implementations w/in
regionalized systems for
thrombolysis

32. LAMS Kidwell et al 2000
• Prospective study
• LAFD, 60 min training
session
• 206 pts in field
• 31 ID as CVA
• 167 as not CVA
• Sp 97%, Sn 91%
• NPV 98%

33. RACE, 2007
Rapid Arterial oCclusion Evaluation
5 items, total of 10 points:
• face, arm, leg, gaze-eye deviation, aphasia-
agnosia

34. RACE, 2007
Rapid Arterial oCclusion Evaluation
• Correlates best w NIHSS
• EMS education 1hr +4 hour ‘refresher’
• >5 LVO likely, go to CSC
• 85% Sn, 68% Sp, NPV 94%*
• disadvantages:
• more complex to learn
• variable results<4 can still be a LVO but
intervention is less likely
*Ossa 2014

35. Last Words on Stroke Scale
• Choose only 1 for your service
• Studies find that choice of stroke scale is
not as important… So just choose 1.
• Limitation of all scales: no ability to
clinically distinguish ICH vs severe ischemic
stroke.

36. Final Step: Find out who your local stroke centers
are & build a relationship with them…
Destination Protocols

37. Stroke EMS Destination Protocols
• Based on improving functional outcomes, act to avoid
tPA/recanalization delays*
• likelihood good functional outcome ↓
• by 3-4% for every 15min delay tPA
• by 12% for every 30min delay in endovascular tx
• Interventional Management of Stroke (IMS) III trial:
mRankin Scale <2 at 90 days*
• AHA recommends EMS bypass ASRH/PSC for a CSC IF
additive transport time < 20 min⍴
*Khatri 2014, ⍴Higashida 2013

38. Wisconsin Stroke Designated Hospitals
Washington Island?
Boulder Jcn?

39. The PSC Bypass Debate for LVO
Pro-Bypass
• IV tPA not that
effective on LVO,
delay tPA negated
• faster reperfusion =
better outcome
• endovascular tx is
safe & effective
NNT 2.5-7
Nay-Bypass
• PSC selective bypass =
multiple endovascular
ineligible patients triaged
to facilities where no
additional therapy is
offered
• results in unnecessary
delay for IV tPA

40. ?Flight Activation?
“EMS systems should consider developing a
policy of transporting acute stroke patients by
air if the closest facility capable of treating acute
stroke is >1hr away.
(Yes, please)
NAEMSP
Position Statement
Crocco 2007

41. What Rhode Island did
•95 agencies, majority fire based (55%)
•Est RI Stroke Task Force 2009
•Legislation mandated EMS rapidly transport
patients to PSC or bypass if CSC within 30 min
•Used LAMS >4 cutoff
Developed a stroke
diversion protocol
through a
collaborative
approach

42. What Rhode Island did
• Empowered EMS to screen rather than
transport blindly
• Allowed paramedics to transport patients with
tPA running for interfacility transports when
warranted
Legislation…f
or EMS stroke
protocols

43. Other States Following Suit:
• Wyoming: requires EMS to issue a “Notification Stroke Alert” to
receiving stroke center ASAP with +FAST
• Washington D.C:est prehospital care stroke protocols for stroke triage
assessment, tx & pt transport to the closest, most appropriate facility
(ASRH, PSC or CSC)
• Missouri: “transporting suspected stroke patients by severity & time
onset to the stroke center where resources exist to provide
appropriate care”
• Louisiana: EMS required to recognize 4 levels of stroke facilities
• Nebraska: DHHS must adopt and distribute to EMS nationally
recognized, standardized stroke triage assessment tool
• Illinois: disseminate an ‘evidence-based statewide stroke assessment
tool to clinically evaluate potential stroke patients’
CDC Policy Statement 2017

45. Mobile Stroke Units:
Is the juice worth the squeeze?
Alternative: Nursing home ~ $278/day, $101,470/yr
(+4%/yr inflation) ~10 years = $1 million
+ $500,000/yr operating costs
VS

46. MJ Case Conclusion
Arrival @ CSC 3hr8min
Large M1 Occlusion
CT Perfusion 08:30
Groin Puncture 09:09
Arrival NIH: 20
Post-Procedure NIH: 8
D/C NIH: 0

47. In Conclusion:
• Collaborate with local hospitals & EMS to
determine capabilities, set up protocols
• Know where your PSCs, CSCs are & their
capabilities
• Use a single, given stroke scale & stick with it
• Should we wait for government to push us
towards any medical behavior?
• Become WI Coverdell EMS Partner

48. Become a Coverdell Stroke EMS
Partner
•WI 1 of 9 states with CDC Coverdell Stroke Grant
https://www.dhs.wisconsin.gov/coverdell/ems.htm
•Access to many resources
•best practices
•building a more technical plan
•community outreach material
•Peer-Peer contact/mentoring
•Recognition of your service on state stroke program website
•Must agree to do 1 of 6 actions associated with stroke best practice
behaviors
•Questions: contact David Fladten
•dfladten@metastar.com
•1-800-362-2320 ext 8215

49. Thank You!

50. References
• American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association
Printing. p. 137. ISBN 978-1-61669-010-6.
• Khatri et al. Good clinical outcomes after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009: (73)
1066-1072.
• Khatri et al. Time to Angiographic Reperfusion & Clinical Outcome after Acute Ischemic Stroke in the Interventional Management of
Stroke Phase III (IMS III) Trial: A Validation Study. Lancet Neurol. 2014: 13(6). 567-574.
• Lansberg et al. Treatment time-specific number needed to treat estimates for tissue plasminogen activator therapy in acute stroke
based on shifts over the entire range of the modified Rankin Scale. Stroke. 2009: 40. 2079-84
• Vagal et al. Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke. 2014: (45). 3625-30.
• van Gaal et al. Approaches to the filed recognition of potential thrombectomy candidates. International Journal of Stroke. 2017:
0(0). 1-10.
• Brandler et al. Prehospital stroke scales in urban environments: a systematic review. Neurology. 2014; 82: 2241-2249.
• Crocco et al. EMS Management of Acute Stroke-Prehospital Triage (Resource Document to NAEMSP Position Statement).
Prehospital Emergency Care. 2007. 11(3): 313-317.
• Kothari et al. Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med. 1999. 33(1): 3-8
• Schroeder et al. Determinants of use of emergency medical services in a population with stroke symptoms: the second delay in
accessing stroke healthcare study. Stroke. 2000(31): 2591-96
• Kidwell et al. Identifying Stroke in the Field: Prospective Validation of Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000
(31): 71-76.
• Schuberg et al. Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California.
Stroke. 2014 (44). 3584-3586.
• Higashida et al. American Heart Association Advocacy Coordinating Committee. Interactions within stroke systems of care: a policy
statement from the American Heart Association. 2013 (44): 2961-2984
• Ossa et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion
evaluation scale. Stroke. 2014(45)1: 87-91

51. Acute Stroke Ready Hospital
(ASRH)
51
• Requirements vary according to region
• Ability to triage, treat, and transfer acute
stroke patients
• Written stroke protocols
• ED Management for acute Stroke
• Transfer agreement with PSC or CSC for
acute Ischemic & Hemorrhagic
• Cerebral and cerebral vascular imaging
• Administrative and org support
• Outcomes and quality improvement
• Belong to stroke registry
• Educational programs
1 ASRH In
Wisconsin

52. • experts recommended improving stroke
systems of care to increase timely and
equitable access to this therapy

53. Coverdell helps bridge the gap between EMS and Healthcare Facilities

55. Arkansas Stroke Systems of Care

56. In Illinois - hospitals can now
apply for the new designations;
your respective Regional Stroke
Advisory Subcommittee, should
be meeting to update protocols
in recognition of three tiers of
stroke care and to reflect the
capabilities and best interests of
your specific EMS Region.
Regions differ drastically around
the state, it is imperative that
any triage and transport
protocols are established locally.
State of Illinois

57. • Southerland, A.M., Johnston, K.C., Molina, C.A., Selim, M.H., Kamal, N. Goyal, M.(2016). Suspected
Large Vessel Occlusion: Controversies in Stroke
• Gupta, R., Xiang, B., Ge, S., Sun, C.H., Yoo, A.J., & Mehta, B. (2014) Stagnation of Treatment Times over
a decade: Results of a poold analysis from the MERCI registry, MERCI, TREVO, and TREVO 2 trials.
• Wisconsin Coverdell Stroke Program : Facts and Figures
http//dhs.wisconsin.gov/coverdell/data.htm3e3182a6d2b2
• Higashida, R., Alberts, M.J., Alexander, D.N., et.al. (2013) Stroke. https://doi.org/10.1161/STR.0b01
• Higashida, R. Alberts, M.J., Alexander, D.N., et. Al Interactions Within Stroke Systems of Care: A policy
statement from the AHA/ASA. Stroke. 2013; 44:2961-2984