Kern County Stroke Center Policies Implementation Training

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Kern County Stroke Center Policies
Implementation Training

• October 2008
• Policies Effective November 1, 2008
• Time is Brain

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Objectives of the Policy

• Provide rapid evaluation and appropriate
  treatment for all eligible stroke cases in the
  shortest time possible.
• In addition, a stroke center must have a
  component that addresses comprehensive post
  treatment management/rehabilitation, and
  involvement in pre-hospital personnel training.
• The EMS system objective is to transport
  qualifying stroke patients to a designated stroke
  center.

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• Target for Training
• Pre-hospital EMT-1, Paramedic Flight Nurse
  transport personnel
• All base receiving hospital emergency
  department personnel
• Emergency Medical Dispatchers (EMD)
• Purpose
• To implement Kern County Stroke Center Policies
  Countywide

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Presentation Overview

• Policies
• Designated stroke center(s)
• Stroke center activation protocol (CPSS-based)
• Ambulance transport destination policy changes
• Interfacility transfer of stroke cases
• Frequently asked questions and answers
• Further information resources

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Policy Contents

• Effective November 1, 2008 at 0800 hours.
• Contains the following main topics
• Application criteria
• Designation and re-designation process
• Stroke center performance requirements
• Quality improvement
• Stroke center activation protocol
• Pre-hospital transport destination directions
• On Internet at EMS Departments website

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Hospital Standards

• Any paramedic base hospital in Kern is eligible
  to apply to EMS for designation.
• Must be Joint Commission of Accreditation of
  Healthcare (JCAH) certified as a stroke center.
• Must maintain compliance with JCAH stroke center
  requirements and guidelines.
• Must maintain the following
• Core Stroke Team available 24/7
• 2 CT scanners
• Immediate access to neurologist, if needed
• 2 hour time standard for neurosurgeon, if needed

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Hospital Standards

• Extensive stroke center data reporting
  requirements to JCAH
• ALL types of acute stroke are included not just
  cases that are fibrinolysis (tPA) eligible.
• Each stroke center is obligated to accept an
  interfacility transfer from a Kern County
  hospital of any stroke case meeting the stroke
  center activation protocol criteria.

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Hospital Standards

• Re-designation every two years through JCAH
• As of November 1, 2008, there are two EMS
  designated stroke centers in Kern County
• San Joaquin Community Hospital Bakersfield
• Bakersfield Memorial Hospital
• Other hospitals are eligible to become stroke
  center designated in the future.

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SIGNS/SYMPTOMS OF CEREBRAL VASCULAR ACCIDENT

• Examples
• Facial Droop
• One Sided Weakness
• One Sided Paralysis
• Sensory Dysfunction
• Altered Mental Status
• Unconscious

RULE OUT HYPOGLYCEMIA AND NARCOSIS AS APPROPRIATE

• Examples
• Glucose Analysis
• Hypoglycemia Signs or Symptoms
• Opiate Intoxication Signs or Symptoms

ASSESS ONSET OF SIGNS OR SYMPTOMS

• Total Time Since Onset of Signs or Symptoms
• Within 3 Hours
• Over 3 Hours
• Validity of Information?

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• CPSS
• Most common stroke scale in use
• Motor function and speech based
• May not pick up on sensory loss
• Does not replace the need for a full neurological
  exam or further diagnostics if available

ASSESS PATIENT IN ACCORDANCE WITH CINCINNATI
PREHOSPITAL STROKE SCALE (CPSS)

• Drooling from one side of mouth, eye movement
  dysfunction, tongue dysfunction are other
  indicators.

• FACIAL DROOP (Have the Patient Show Teeth
  or Smile)
• - Normal Both Sides of Face Move Equally
• - Abnormal One Side of Face does not Move
  as Well as the Other Side

• Indicative of hemiparesis (one-sided weakness) or
  hemiplegia (one sided paralysis).

ARM DRIFT (Patient Closes Eyes and Extends
Both Arms Straight Out, with Palms Up, for 10
Seconds) - Normal Both Arms Move the Same
or Do Not Move at All - Abnormal One Arm
does Not Move or One Arm Drifts Down Compared to
the Other

• May also include a stroke patient that is
  unconscious or unresponsive.

ABNORMAL SPEECH (Have the Patient Say You
cant teach an old dog new tricks) -
Normal Patient Uses Correct Words with No
Slurring of Words - Abnormal Patient
Slurs Words, Uses Wrong Words, or is Unable to
Speak
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• If ANY indicator is abnormal and the onset of
  signs or symptoms are within 3 hours, the
  appropriate stroke center is activated by contact
  of the designated stroke center emergency
  department.

IF ONE OR MORE ABNORMAL CPSS ARE
PRESENT AND ONSET OBSERVED WITHIN 3 HOURS BY
VALID HISTORIAN OR QUESTIONABLE ONSET TIME
EXPEDITE CONTACT WITH DESIGNATED STROKE CENTER
BASE HOSPITAL

• If the history of onset timing is not reliable or
  not available, the appropriate stroke center
  should be contacted and activated. The
  appropriate stroke center may also be contacted
  for advice as needed.

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• EOA 4 West, South, Central Bakersfield
• EOA 5 East, North, Central Bakersfield
• EOA 2 Shafter, Buttonwillow
• EOA 9 Taft, Maricopa, McKittrick
• EOA 8 Lamont, Arvin, Frazier Park, Tehachapi

TRANSPORT AS FOLLOWS

• In Exclusive Ambulance Operational Areas (EOA)
  4, 5, 2, 9, or 8 (excluding the Tehachapi area)
  where transport to a Bakersfield area hospital is
  the closest destination, stroke patients that
  meet the Stroke Center Activation Protocol
  indications shall be transported to a stroke
  center. This is applicable to both ALS and BLS
  level ambulance transports.

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• EOA 1 Wasco, Lost Hills
• EOA 3 Delano, McFarland. Woody
• EOA 6 Kern River Valley, Isabella
• EOA 8 Applicable to Tehachapi area and
  surrounding communities in the area.

• In Exclusive Operational Areas (EOA) 1, 3, 6, or
  8 Tehachapi Area
• ALS Ambulance A stroke patient that meets
  Stroke Center Activation Protocol indications
  shall be transported to a stroke center. A
  stroke patient from these areas may be
  transported to the closest hospital emergency
  department if the patient airway cannot be
  managed appropriately or if the patient
  condition is deteriorating rapidly, at paramedic
  discretion.
• BLS Ambulance A stroke patient that meets
  Stroke Center Activation Protocol indications
  shall be transported to the closest hospital
  emergency department.

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• EOA 7 Ridgecrest, Inyokern
• EOA 11 Mojave, California City, Rosamond, Boron
  surrounding communities

• In Exclusive Ambulance Operational Areas (EOA) 7
  or 11
• ALS Ambulance ALS Ambulance A stroke patient
  that meets Stroke Center Activation Protocol
  indications shall be transported to the closest
  hospital emergency department unless air
  transport is indicated in compliance with EMS
  Aircraft Dispatch-Response-Utilization Policies
  and Procedures.
• BLS Ambulance A stroke patient that meets
  Stroke Center Activation Protocol indications
  shall be transported to the closest hospital
  emergency department unless air transport is
  indicated in compliance with EMS Aircraft
  Dispatch-Response-Utilization Policies and
  Procedures.

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• Based upon Hall Critical Care Transport Medevac-1
  from Meadows Field Bakersfield or Mercy Air
  Service from Mojave.

• Air Transport
• Air transport shall be used if an air ambulance
  is available and the overall time savings will be
  10 minutes or more in comparison with ground
  transport in compliance with EMS Aircraft
  Dispatch-Response-Utilization Policies and
  Procedures. Generally, 10 minutes time-savings
  cannot be attained with ground transport times of
  30 minutes or less.

• Generally, if a ground ambulance is within 30
  minutes driving time from the Stroke Center,
  there will be no time savings by using an air
  ambulance.

• A receiving or base hospital emergency department
  may request interfacility transfer of any stroke
  case meeting Stroke Center Activation Protocol
  criteria to a designated stroke center.
• The designated stroke center cannot refuse to
  accept an interfacility transfer of a stroke case
  that meets Stroke Center Activation Protocol
  criteria.
• Ground or air transport are at the discretion of
  the transferring physician.

• Interfacility Transfer
• A patient that meets Stroke Center Activation
  Protocol indications at a hospital that is not a
  designated stroke center should be transferred to
  a designated stroke center by the receiving
  hospital. If indicated, the receiving hospital
  shall notify the stroke center emergency
  department to activate response.

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• Ambulance Transport Destination Decision/Hospital
  ED Status Policies Procedures
• Stroke Case Specific Added
• San Joaquin Community Hospital listed
• Bakersfield Memorial Hospital listed
• Others will be added as EMS designated
• Stroke Only Status Added
• Can be authorized by EMS Department staff as
  indicated
• Can be deactivated by EMS Department staff or
  the designated stroke center.

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Frequently Asked Questions

• Q If I believe a patient has had an acute
  stroke, but the CPSS is normal, what should I do?
• A Contact a designated stroke center, convey a
  patient information report, request advice
  regarding stroke center activation.
• Q If I have a patient with an onset of abnormal
  CPSS findings that were over 3 hours ago, but the
  history is suspect. What should I do?
• A Contact a designated stroke center, convey a
  patient information report, request advice
  regarding stroke center activation.

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Frequently Asked Questions
Q I have a critical stroke patient with severe
airway problems in the Tehachapi area that cannot
be managed. Should I transport to a designated
stroke center anyway? A No. Transport to the
closest hospital emergency department in this
case to secure the airway, then possibly
interfacility transfer the patient to the
designated stroke center. Q I have a patient
with a past medical history of stroke 3 years ago
reported by an extended care facility. The
patients current complaint is headache for 2
hours with no other acute signs or symptoms.
Should I activate and transport to a designated
stroke center? A Not necessarily. This patient
does not meet the Stroke Center Activation
Protocol criteria for abnormal CTSS time of
onset. This patient can be transported to any
appropriate hospital emergency department,
including a designated stroke center, according
to standard procedures.
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Frequently Asked Questions
Q I have a patient with an abnormal CPSS onset
within 1 hour in the Kern Valley area. Kern
Valley Hospital is 15 minutes away in transport
time. An air ambulance has a 5 minute ETA to my
current location. What should I do? A Have the
patient transported by air ambulance. Q I have
a patient with an abnormal CPSS onset within 2
hours in the California City area. AVHMC is 30
minutes away in ground transport time. A
designated stroke center is 60 minutes away in
ground transport time. An air ambulance has a 30
minute ETA to my current location but has not
lifted off yet. I am ready to start transport.
What should I do? A Begin ground transport
toward AVHMC. It is important to make forward
progress with the transport process. Waiting at
an LZ for more than just a few minutes is
generally excessive. Remember, time is brain.
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Frequently Asked Questions
Q I am a physician at a receiving hospital
emergency department and have an acute stroke
patient that meets Stroke Center Activation
Protocol indications. Do I have to transfer the
patient to a designated stroke center? A It is
recommended to transfer the patient immediately.
However, if the responsible physician believes
the patient can be managed adequately, that
physician can certainly elect to not transfer the
patient to a designated stroke center.
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Additional Resources
Kern County EMS Website http//www.co.kern.ca.u
s/ems Joint Commission of Healthcare
(JCAH) http//www.jointcommission.org/Certificati
onPrograms/PrimaryStrokeCenters/ American Stroke
Association http//www.strokeassociation.org Th
e Brain Attack Coalition http//www.stroke-site.o
rg/index.html Please contact the Kern County EMS
Department at 661-868-5201 or send an email to
blindr_at_co.kern.ca.us with any questions regarding
the Stroke Center Policies.