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The Role of EMS in Emergency Cardiac and Stroke Care PowerPoint Presentation

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Slide 1-

The Role of EMS in Emergency Cardiac & Stroke Care Name, Date County, Agency
Slide 2-

Introduce Washington’s new Emergency Cardiac and Stroke System Review cardiac & stroke protocol guidelines Review cardiac & stroke triage tools Administer stroke F.A.S.T. assessment Apply triage tools Discuss cardiac & stroke quality improvement opportunities Objectives
Slide 3-

Emergency Cardiac & Stroke System Why do we need a system? What are the components? How will it work in Washington?
Slide 4-

Why do we need a system? Systems minimize delays in the chain of survival Deliver the right patient, to the right place, in the right amount of time.
Slide 5-

People aren’t getting proven treatments Only 3% strokes get t-PA Only 35 of 95 hospital administered t-PA Estimated 39% of heart attacks get PCI Only 55% of hospitals give lytics under 30 min OHCA survival rates very low Variation in care and outcomes across the state Population at greatest risk increasing rapidly Time to treatment makes big difference in outcomes Because we can do better Why do we need a system?
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D2N and Mortality McNamara, et al.; American Journal of Cardiology 2007.05.043
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Systems Work! National momentum American Heart Association/American Stroke Association American College of Cardiology Centers for Disease Control - CARES Society for Chest Pain Centers CMS Examples North Carolina RACE Los Angeles Minnesota Cardiac Level 1 Spokane and North Puget Sound Cardiac Level 1 Cascade HeartRescue
Slide 10-

System Components 911 Dispatch Neurology / Cardiology
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Emergency Cardiac & Stroke Technical Advisory Committee made recommendations on: Dispatch guidelines Standardized EMS protocol guidelines Standardized EMS triage tools Voluntary hospital categorization Quality improvement & data collection Public education Washington’s Approach
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SSHB 2396 Passed in 2010
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Slide 14-

Emergency Cardiac Care Prehospital protocol guidelines Triage tool Hospital levels Completely blocked artery
Slide 15-

NOTE: Insert your DOH approved local protocols if different from but consistent with the ACS protocol guidelines that follow this slide. You might also want to insert your CPA-ROSC protocols and any other cardiac protocols you have since the triage and destination procedure includes CPA-ROSC. Prehospital Protocols
Slide 16-

ACS BLS Protocol I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABC’s B) Be prepared to provide CPR/defibrillation
Slide 17-

II. Focused History and Physical Exam A) Assess patient for signs and symptoms of Acute Coronary Syndrome (ACS) Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. Shortness of breath with or without chest discomfort. Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back. ACS BLS Protocol (cont.)
Slide 18-

Other symptoms may include sweating, nausea, vomiting, or dizziness and weakness. Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints. ACS BLS Protocol (cont.)
Slide 19-

B) If possible ACS patient – request ALS response or arrange ALS rendezvous. Optional in areas without ALS or 12-lead capable ILS: Perform 12-lead ECG according to local operating procedures, and alert receiving facility with results; repeat ECG if signs or symptoms change. C) Limit scene time with goal of ≤ 15 minutes ACS BLS Protocol (cont.)
Slide 20-

III. Management A) Administer oxygen per protocol B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) C) Assist patient with own nitro Contraindications: SBP <90 mm Hg. Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) Erectile dysfunction drugs taken within 48 hours. Cautions: Borderline hypotension (SBP 90 to 100 mm Hg) Borderline bradycardia (HR<60/min) Extreme caution in patients who may have RV infarction ACS BLS Protocol (cont.)
Slide 21-

IV. Ongoing Assessment V. Transport Follow State Prehospital Cardiac Triage Destination Procedure Note: If 12 lead ECG and interpretation (by crew or machine) can be obtained in the field—obtain as soon as possible and alert receiving facility with results ACS BLS Protocol (cont.)
Slide 22-

I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABCs B) Be prepared to provide CPR/Defibrillation II. Focused History and Physical Exam Assess patient for signs and symptoms of Acute Coronary Syndrome (same as in BLS) Encourage ILS 12-lead ECG in the field and alert receiving facility with results C) If possible ACS patient – request ALS response 1) Alternative: Arrange ALS rendezvous D) Limit scene time with goal of ≤ 15 minutes ACS ILS Protocol
Slide 23-

III. Management A) Administer oxygen per protocol B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) C) Administer nitro Contraindications: SBP <90 mm Hg. Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) Erectile dysfunction drugs taken within 48 hours. Cautions: Borderline hypotension (SBP 90 to 100 mm Hg) Borderline bradycardia (HR<60/min) Extreme caution in patients who may have RV infarction D) IV access (do not delay transport to gain IV access) ACS ILS Protocol (cont.)
Slide 24-

IV. Ongoing Assessment V. Transport A) Follow State Prehospital Cardiac Triage Destination Procedure B) IV, NTG ACS ILS Protocol (cont.)
Slide 25-

I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABCs B) Be prepared to provide CPR/Defibrillation II. Focused History and Physical Exam Assess patient for signs and symptoms of Acute Coronary Syndrome (same as BLS and ILS) 12-lead ECG (repeat ECG if signs or symptoms change) Limit scene time with goal of ≤ 15 minutes ACS ALS Protocol
Slide 26-

III. Management A) Notify receiving hospital with transmission and/or interpretation of ECG B) Administer oxygen C) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) D) Administer nitro Contraindications: SBP <90 mm Hg. Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) Erectile dysfunction drugs taken within 48 hours. Cautions: Borderline hypotension (SBP 90 to 100 mm Hg) Borderline bradycardia (HR<60/min) Extreme caution in patients who may have RV infarction E) IV access F) Administer opiates as needed for pain control G) Complete fibrinolytic checklist (recommended) H) Consider field fibrinolysis if transport time ≥ 60 minutes and acute symptom onset < 3 hours ACS ALS Protocol (cont.)
Slide 27-

IV. Ongoing Assessment A) Cardiac Bio Markers (optional) B) Repeat ECG every 15 minutes V. Transport A) Follow State Prehospital Cardiac Triage Destination Procedure B) IV, NTG ACS ALS Protocol (cont.)
Slide 28-

Triaging to “the right place” Level One Level Two Perform PCI 24/7 within 90 minutes Interventional cardiologists and cath lab team available within 30 minutes 24/7 Cardiac surgery onsite or transfer agreements Administer fibrinolytics 24/7 within 30 minutes ACLS trained providers
Slide 29-

Cardiac Triage Tool Assess Applicability for Triage Post cardiac arrest with ROSC -OR- ≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease: Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. Pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back. Shortness of breath with or without chest discomfort. Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. Other symptoms may include sweating, nausea/vomiting, lightheadedness. NOTE: Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints. Transport per regional patient care procedures YES If ALS has not been dispatched, upgrade if available. NO Assess Immediate Criteria Post cardiac arrest with return of spontaneous circulation Hypotension or pulmonary edema EKG positive for STEMI (if available) YES
Slide 30-

Cardiac Triage Tool (cont.) If EMS personnel still suspect ACS, contact medical control for destination. If not, transport per regional patient care procedures. Assess High Risk Criteria In addition to symptoms in Box 1, pt has 4 or more of the following: Age ≥ 55 3 or more CAD risk factors:  family hx  BP  cholesterol  Diabetes  current smoker Aspirin use in last 7 days ≥2 anginal events in last 24 hours, including current episode Known coronary disease ST deviation ≥ 0.5 (if available) Elevated cardiac markers (if available) NO Assess Immediate Criteria Post cardiac arrest with return of spontaneous circulation Hypotension or pulmonary edema EKG positive for STEMI (if available) YES If ALS has not been dispatched, upgrade if available. NO YES YES
Slide 31-

Assess High Risk Criteria (4 or more) 3 or more CAD (coronary artery disease) risk factors: Age ≥ 55 (epidemiological data in WA State show that incidence of heart attack increases at this age) Family history: father or brother with heart disease before 55, or mother or sister before 65 High blood pressure: ≥140/90, or patient/family report, or on blood pressure medication High cholesterol: patient/family report or on cholesterol medication Diabetes: patient family report Current smoker: patient family report Aspirin use in last 7 days: any aspirin use in last 7 days ≥2 anginal events in last 24 hours: 2 episodes of symptoms described in first box of the triage tool, including the current event Known coronary disease: history of angina, heart attack, cardiac arrest, congestive heart failure, balloon angioplasty, stent, or bypass surgery ST deviation ≥ 0.5 mm (if available): ST depression ≥ 0.5 mm is significant; transient ST elevation ≥ 0.5 mm for < 20 minutes is treated as ST-segment depression and is high risk; ST elevation >1 mm for more than 20 minutes places these patients in the STEMI treatment category Elevated cardiac markers (if available) CK-MB or Troponin I in the "high probability" range of the device used. Only definitely positive results should be used in triage decisions.
Slide 32-

Even if patient does not meet High Risk Criteria (i.e. only 3 boxes positive), EMS crew may still have high index of suspicion that patient is a high risk ACS patient (i.e. patient has had 4 stents and states “this feels just like last heart attack”) Contact medical control and consult with physician or RN for appropriate patient destination. No High Risk Criteria—but EMS still suspects ACS Patient
Slide 33-

Cardiac Triage Tool (cont.) Go to Level I Cardiac Hospital and alert destination hospital en route ASAP Assess Transport Time and Determine Destination by Level of Prehospital Care* Level I Cardiac Hospital w/in 30 minutes Level I Cardiac Hospital w/in 60 minutes Level II Cardiac Hospital 60 minutes closer than Level I? Level II Cardiac Hospital 30 minutes closer than Level I? Go to Level I Cardiac Hospital and alert destination hospital en route ASAP Go to closest Level II Cardiac Hospital and alert destination hospital en route ASAP YES Unstable patients with life-threatening arrhythmias, severe respiratory distress, or shock unresponsive to EMS treatment should be taken to the closest hospital. YES YES NO NO YES NO BLS/ILS ALS YES
Slide 34-

Asses Transport Time & Determine Destination by Level of Prehospital Care Slight modifications to the transport times may be made in county operating procedures. Consider ALS and air transport for all transports greater than 30 minutes. If there are two or more Level I facilities to choose from within the transport timeframe, patient preference, insurance coverage, physician practice patterns, and local rotation agreements may be considered in determining destination. This also applies if there are two or more Level II facilities to choose from.
Slide 35-

Determine Destination The general guideline is to take a patient meeting the triage criteria directly to a Level I cardiac (24/7 Cardiac Cath Lab) hospital within reasonable transport times. For BLS, this is generally within 30 minutes transport time, and for ALS, generally 60 minutes transport time (see next section for further guidance). Inform the hospital en route so staff can activate the cath lab and call in staff if necessary.
Slide 36-

Cardiac Destination Examples Insert examples from your area BLS examples: A) minutes to Level 1 – minutes to Level 2 = 29: go to Level 1 B) Minutes to Level 1 – minutes to Level 2 = 35: go to Level 2 ALS examples: A) minutes to Level 1 – minutes to Level 2 = 45: go to Level 1 B) Minutes to Level 1 – minutes to Level 2 = 68: go to Level 2 If ineligible for fibrinolytics, transport to closest Level 1 hospital even if greater than 60 minutes or rendezvous with air transport. EMS must inform the hospital en route so staff can initiate cardiac protocols and call in staff if necessary.
Slide 37-

Cardiac team activation policy and criteria based on EMS pre-arrival notification Cardiac protocols include use of induced hypothermia for post-cardiac arrest patients. Participate in regional QI program that includes EMS Provide training for EMS if requested, particularly in reading ECG for STEMI No divert policy for emergency cardiac cases Emergency Cardiac Hospitals
Slide 38-

Hospital Levels-Emergency Cardiac Level One Level Two Perform PCI 24/7 within 90 minutes Interventional cardiologists and cath lab team available within 30 minutes 24/7 Cardiac surgery onsite or transfer agreements Administer fibrinolytics 24/7 within 30 minutes ACLS trained providers
Slide 39-

Our Local Cardiac Hospitals Level Ones Level Twos
Slide 40-

Insert Local Destination Examples
Slide 41-

Acute Stroke Prehospital protocol guidelines Triage tool Hospital levels
Slide 42-

Signs of a Stroke
Slide 43-

I. Scene Size-Up/Initial Patient Assessment A) Support ABCs B) Check glucose, temperature, SpO2 (if possible) C) Treat hypoglycemia (if possible) D) NPO II. Secondary Survey A) Perform FAST Assessment (Face/Arms/Speech/Time last normal). If one component is abnormal, high probability of stroke. Refer to stroke destination triage tool. Time from last normal will determine destination. B) Limit scene time with goal of ≤ 15 minutes. Stroke Protocol
Slide 44-

III. Transport A) Early hospital notification - specify FAST findings (issue stroke alert & share abnormal physical findings and time last normal). B) Transport according to Washington State Stroke Triage Tool and regional patient care procedures. C) If closest appropriate facility is greater than 30 minutes, consider air transport when appropriate. Stroke Protocol (cont.)
Slide 45-

IV. Management/Ongoing Assessment en route A) Lay patient flat unless signs of airway compromise, in which case elevate no higher than 20 degrees. B) IV access (as able) Ideally, 16 or 18 ga IV in unaffected arm (affected arm is acceptable) Normal saline (avoid glucose-containing and hypotonic solutions) 3) Optional: Blood draw with IV start C) 2nd exam/neuro reassessment D) Optional: initiate tPA checklist Stroke Protocol (cont.)
Slide 46-

Stroke Triage Tool Yes?
Slide 47-

Stroke Triage Tool
Slide 48-

FAST Assessment
Slide 49-

FAST Assessment (cont.)
Slide 50-

FAST Assessment (cont.)
Slide 51-

Destination if YES on F, A, or S “Possible stroke w/ x symptoms”
Slide 52-

Important Considerations Report possible tPA contraindications to ED: Symptom onset more than 180 minutes Head trauma or seizure at onset Recent surgery, hemorrhage, or AMI Any history of intracranial hemorrhage Minor or resolving stroke Sustained BP> 185/110 (do not treat!)
Slide 53-

Level 1-Comprehensive Stroke Center Certified Primary Stroke Center that also has: Neurologist w/in 20 minutes 24/7 Neurosurgeon w/in 30 minutes 24/7 Vascular neurologist and vascular surgeon Other highly specialized stroke care capabilities Level 2- Primary Stroke Center Has the necessary staffing, infrastructure, and programs to stabilize and treat most acute stroke patients. Some may also have capability to do more advance intra-arterial therapies Level 3-Acute Stroke Center Have the infrastructure and capability to care for acute stroke, including administration of IV t-PA Most stroke patients would be transferred to a Level 1 or 2 post-treatment Hospital Levels-Stroke
Slide 54-

Our Local Stroke Hospitals
Slide 55-

Insert Local Destination Examples
Slide 56-

Working Systems Data collection Quality improvement Resources & tools
Slide 57-

ECS TAC Report: Develop a comprehensive data system to demonstrate the effectiveness of the ECS system and improve performance. Include dispatch, EMS and hospitals, and use existing data systems (WEMSIS!) to avoid duplicate data entry and analysis. EMS/T Strategic Plan: Goal 19, Objective 5: Local Quality Improvement By June 2012 regional cardiac and stroke systems evaluate system performance through a quality improvement process. Data and Quality Improvement
Slide 58-

Time from onset to 911 call Time from first medical contact (EMS or first ED) to treatment (e.g., balloon or t-PA) On-scene time Time from onset to treatment (e.g., balloon or t-PA) Key System Measures
Slide 59-

% of cardiac/stroke patients that arrive by EMS % of patients EMS notified hospital pre-arrival Cardiac arrest measures (future) Key System Measures
Slide 60-

Time of symptom onset PSAP call receipt Time of dispatch Time of EMS arrival at patient’s side Time left scene Time arrived at hospital FAST, ECG or other clinical findings (Resuscitation efforts and outcomes) Medications administered Some of the Data Elements
Slide 61-

Patient reports on paper (e.g., run sheets) to the receiving hospital are critical for system evaluation and QI. Data elements to be determined, consistent with NEMSIS. Essential from EMS for QI
Slide 62-

Dispatch, pre-hospital and hospital partners should work together to set goals and ensure they are being met Quality Improvement Washington’s law allows cardiac and stroke cases to be discussed in the regional EMS/Trauma QI forums
Slide 63-

Emergency Cardiac and Stroke System http://www.doh.wa.gov/hsqa/hdsp/default.htm Development of Systems of Care for STEMI Patients: The EMS and ED Perspective; http://circ.ahajournals.org/cgi/reprint/116/2/e43 Implementation Strategies for EMS Within Stroke Systems of Care http://stroke.ahajournals.org/cgi/reprint/38/11/3097?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Implementation+strategies&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT&eaf AHA E-learning: Learn Rapid STEMI ID, Prehospital Stroke http://www.onlineaha.org/index.cfm?fuseaction=main.courseCatalog Stroke Rapid Response™ Prehospital Education Training http://www.stroke.org/site/PageServer?pagename=SRR_testimonials Washington Stroke Forum http://strokeforum.doh.wa.gov/ Resources & Tools