Background and Clinical Pearls
Early notification to the hospital of suspected stroke patients allows the hospital to prepare several time-sensitive diagnostic and therapeutic interventions. The first is preparing to perform a CT within 10 minutes to rule out a hemorrhagic stroke, which allows the use of clot-busting medications called fibrinolytic/thrombolytics. A CT with contrast can also be used for patients with severe symptoms to identify large vessel occlusions, which will benefit from mechanical thrombectomy. This can be done immediately at equipped hospitals, or the patient will be rapidly transported to a thrombectomy-capable hospital. The interventional radiology lab may need to call in a team, and early notification prevents delays. Stroke treatment is based on time windows since last known normal. As this time extends, the probability of improvement declines while the chance of causing a hemorrhagic stroke increases. Therefore, establishing the last known normal time is critical to the patient getting the treatment they need and doing so safely. Even therapy within the window is not guaranteed a good outcome; every minute that passes, millions of brain cells are dying. Stroke care must proceed smoothly, rapidly, and flawlessly.Performance Improvement and Best Practices
Obtain the patient’s last known “normal.” This may be difficult to obtain, especially if the patient presents with a ‘wake up stroke’ first thing in the morning. If the timeline is unclear, document the last time the patient was known to be at their baseline. Obtain history to include any recent trauma, anticoagulant therapy, and recent surgery.
A prehospital stroke scale, such as BEFAST, should be performed as soon as possible on all suspected strokes. If the scale is positive, transport to the closest stroke center or most appropriate facility without delay. If applicable, call a pre-alert to the receiving facility. Establish two large-bore IVs that are forearm or higher to facilitate the appropriate imaging.
Hypoglycemia and seizures can mimic strokes. Perform a detailed assessment to include a blood glucose level. If unsure, treat it as a stroke. Be aware of the potential for mental status changes that may require suction or airway control. Depending on local protocols, consider anti-hypertensive therapy that does not dramatically decrease the patient’s blood pressure.
The general inclusion time frame for “clot-busting medication” or thrombolytics such as tP-A is 4.5 hours after onset of symptoms or less, depending on surrounding circumstances. If the receiving facility is an IR-capable facility, they may attempt thrombectomy procedures up to 24 hours after onset of symptoms. A stroke scale should still be completed prior to transport if performing an interfacility transfer of a diagnosed stroke patient. This allows the provider to note and report any changes in the patient’s condition or presentation to the receiving facility staff.
Other Relevant Data and Educational Resources
North Dakota has established the BEFAST stroke assessment as the preferred state-wide prehospital stroke assessment. Information on BEFAST and the North Dakota Stroke System of Care can be found at: https://www.health.nd.gov/north-dakota-stroke-system-care-guidelines. EMS program directors have developed internal resources that align with BEFAST and the AHA recommendations for caring for suspected stroke patients. A North Dakota-based EMS system developed this BEFAST assessment tool; similar tools can be used to improve the care of stroke patients. This publicly accessible video provides an EMS-centric approach to completing the BEFAST stroke assessment.
Rural EMS Counts Stroke Measures
Stroke- Blood Glucose Check Performed for Suspected Stroke
Description:
This report evaluates the percentage of adult suspected stroke patients that received a blood glucose evaluation. As a protocol adherence report, the provider gets credit for performing the assessment if a value is recorded or if it is documented that the patient refused the assessment.
NOTE: The Blood Glucose Check must be documented in the Vital Signs section of the ePCR. Specific filters for this report include:
1. Patient Age (in Years) ≥ 18
2. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient Cerebral Ischemic Attack (TIA)
3. Treatments Documented (per Patient) = Stroke Alert
4. Narrative Treatment Protocol = Suspected Stroke
Stroke- Last Known Well or Time of Onset Recorded by EMS for Suspected Stroke
Description:
This report calculates the percentage of records for patients with suspected stroke or TIA who had time of onset or time last known well (LKW) documented in the appropriate discrete data field as part of the stroke assessment.
Specific filters for this report include:
1. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient Cerebral Ischemic Attack (TIA)
2. Treatments Documented (per Patient) = Stroke Alert
3. Narrative Treatment Protocol = Suspected Stroke
Stroke- Stroke Assessment Performed by EMS for ED-Diagnosed Stroke
Description:
This report calculates the percentage of EMS responses originating from a 911 request for patients with an ED ICD10 diagnosis code indicating stroke, who had a stroke assessment performed during the EMS response.
This report is for EMS Agencies that receive information back from the hospital regarding the patient diagnosis and treatment at the hospital. The EMS ePCR is updated to reflect the ED and/or hospital diagnosis. If the hospital diagnosed the patient with a stroke, the report will flag the ePCRs that did not have a stroke assessment performed by EMS.
This is a learning opportunity for EMS. Knowing the hospital diagnosis allows EMS Agencies to review their assessment, training, and protocols and improve patient care.
Stroke- Stroke Assessment Performed by EMS for Suspected Stroke
Description:
This report calculates the percentage of EMS responses originating from a 911 request for patients with suspected stroke who had a stroke assessment performed during the EMS encounter.
Documentation of any part of a stroke screen will count towards “measure criteria met.” Performance improvement teams may wish to dive further into assessment to determine whether or not all elements of the screening instrument were completed.
Specific filters for this report include:
1. Patient Age (in Years) ≥ 18
2. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient, or Cerebral Ischemic Attack (TIA)
3. Treatments Documented (per Patient) = Stroke Alert
4. Narrative Treatment Protocol = Suspected Stroke
Click here to see a deep dive of North Dakota Stroke measures.