Stroke Center Designation: Impact on EM

1
Stroke Center DesignationImpact on EM
E. Bradshaw Bunney, MD, FACEP
2
E. Bradshaw Bunney, MD, FACEPAssociate
ProfessorDepartment of Emergency
MedicineUniversity of Illinois at ChicagoOur
Lady of the Resurrection Hospital
E. Bradshaw Bunney, MD, FACEP
3
Global Objectives

• Improve patient outcome for both hemorrhagic and
  ischemic stroke
• EM participation in protocol development
• Hospital financial interest
• Community education

4
Session Objectives

• Stroke management from community to the ED and
  beyond
• The history of Stroke Center designation
• EM role in protocol development and Stroke Center
  designation

5
Clinical History

• A 911 call was taken by the Chicago Fire
  Department dispatch service at 225 pm. The
  caller stated, My husband is having a stroke and
  he can not move the left side of his body. An
  ALS ambulance arrived at 234 pm and found the
  67-year-old patient to be sitting in a chair with
  a BP 140/85, pulse 96, respiratory rate 16 and
  the inability to move his left arm or leg. His
  wife also noticed the left side of his face was
  flat. He was able to speak and denied headache,
  chest pain or shortness of breath.

6
Clinical History

• He had a history of hypertension, was on
  Labetalol and Lasix, with no allergies. The
  paramedics noted the time of onset for the
  symptoms to be 215 pm., which was agreed to by
  both the patient and his wife. The patient was
  placed on a cart, an IV was established, oxygen
  was applied, and glucose was 98. The paramedics
  called into the base station at 248 pm, stating,
  We have a probable stroke, with two out of three
  abnormal on the Cincy scale and arrived in the
  ED at 252 pm.

7
Key Clinical Questions

• Who, What, Why of Stroke Center designation?
• Does my hospital need to become a Stroke Center?
• Does a Stroke Team improve ED care of stoke
  patients?
• Can an ED use thrombolytics if it is not a Stroke
  Center?
• What is EMS role in the process?
• What are the EM controversies in the care of
  stroke patients?

8
Stroke in Perspective An Overview
E. Bradshaw Bunney, MD, FACEP
9
Disability Due to Stroke, 1999
Noninstitutionalized people 18 years
old. Total number of people with
disabilities41,168,000. Numbers may not add up
due to rounding.
Centers for Disease Control (CDC). MMWR.
200150120-125. Available at
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5007a3
.htm. Accessed December 4, 2003.
10
Age-Adjusted Stroke Death Rates by Age and
Gender, 2001
Age-adjusted rate calculated using the year 2000
standard population.
National Center for Health Statistics (NCHS).
Table 37. In Health, United States, 2003.
Available at http//www.cdc.gov/nchs/data/hus/ta
bles/2003/03husupdated.pdf. Accessed January 12,
2004.
11
Age-Adjusted Stroke Death Rates by State, 2001

Arias E, et al. Natl Vital Stat Rep.
2003521-116. Available athttp//www.cdc.gov/nc
hs/fastats/stroke.htm. Accessed December 4, 2003.
12
Age-Adjusted Stroke Death Rates by Race and
Gender, 2001
National Center for Health Statistics (NCHS).
Table 37. In Health, United States, 2003.
Available at http//www.cdc.gov/nchs/data/hus/ta
bles/2003/03husupdated.pdf. Accessed January 12,
2004.
13
Estimated Direct and Indirect Costs of Stroke,
2003
American Heart Association (AHA). Heart Disease
and Stroke Statistics 2003 Update. 2003.
Available at http//www.americanheart.org/downloa
dable/heart/10590179711482003HDSStatsBookREV7-03.p
df. Accessed October 13, 2003.
14
Major Causes of Death in the United States, 2001
COPDchronic obstructive pulmonary disease.
Arias E, et al. Natl Vital Stat Rep.
2003521-116. Available athttp//www.cdc.gov/nc
hs/fastats/stroke.htm. Accessed December 4, 2003.
15
Age-Adjusted Death Rates From Stroke 1950-2001
Age-adjusted rates are calculated using the year
2000 standard population. Data prior to 1970
includes deaths of persons not residents of the
50 states and the District of Columbia.
National Center for Health Statistics (NCHS).
Table 37. In Health, United States, 2003.
Available at http//www.cdc.gov/nchs/data/hus/tab
les/2003/03husupdated.pdf. Accessed January 12,
2004.
16
Different Types of Stroke, 2000
Cerebral Embolus 24
TIA 3
Ischemic Stroke 88
Intracerebral Hemorrhage 9
Cerebral Thrombosis61
HemorrhagicStroke 12
Subarachnoid Hemorrhage 3
TIAtransient ischemic attack.
American Heart Association (AHA). Heart Disease
and Stroke Statistics 2003 Update. 2003.
Available at http//www.americanheart.org/downloa
dable/heart/10590179711482003HDSStatsBookREV7-03.
pdf. Accessed October 13, 2003.
17
HISTORY

• 1995- NINDS- TPA therapy for ischemic stroke
• 1996- EM controversy over use of TPA in stroke
• 1997- Brain Attack Coalition (BAC) formed
• 2000- Primary Stroke Center criteria published
• ?- Comprehensive Stroke Center criteria published

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Stroke-site.org
19
BAC Members

• NINDS
• American Academy of Neurology
• American College of Emergency Physicians
• American Assn of Neurological Surgeons
• American Stroke Association
• National Stroke Association
• Am Soc of Intervent and Therapy Neuroradiology
• American Society of Neuroradiology
• Congress of Neurological Surgeons
• Stroke Belt Consortium
• Veterans Administration
• National Association of EMS Physicians
• Centers for Disease Control and Prevention
• American Assn of Neuroscience Nurses

20
Brain Attack Coalition

• Stroke scales
• Guidelines
• Pathways
• North Carolina
• Stanford
• Thomas Jefferson
• www.stroke-site.org

21
Strokeassociation.org
22
American Stroke Association

• Acute Stroke Treatment Program
• Operation Stroke
• Get with the Guidelines-Stroke
• Stroke Center Certification
• www.strokeassociation.org

23
Stroke.org
24
National Stroke Association

• Public Health Stoke Summit
• CDC sponsored
• Increase public awareness
• Develop state programs to decrease the incidence
  and death rate
• National Tutorial on Stroke

25
Why Were Stroke Centers Developed?
E. Bradshaw Bunney, MD, FACEP
26
TIME IS BRAIN
E. Bradshaw Bunney, MD, FACEP
27
Time is Brain

• Narrow therapeutic window
• t-PA within three hours of symptom onset
• Rapid identification, transport, diagnosis and
  treatment
• Stroke chain of survival (AHA)

28
Trauma Center Model

• Military experience with rapid evacuation
• 1966 Accidental Death and Disability The
  neglected disease of modern society
• National Academy of Sciences document
• Strong government leadership proposed
• Called for improved training, education, and
  research
• Role of prehospital care emphasized
• Radio communication
• EMS training
• Categorize hospital capabilities 4 categories
• Resulted in the National Highway Safety Act

29
Trauma Center Model

• 1993 report 20 states had trauma systems with
  legal authority
• 5 States had full implementation many states
  failed to enforce limitations on the number of
  centers based on need (due to political obstacles
• Financial Crisis decreased federal support,
  managed care, DRGs, staff retention
• Trauma center implementation has provided an
  infrastructure for the provision of emergency care

30
Who is Designating Stroke Centers?

• American Stroke Association
• Joint Commission

31
ASA GWTG Measures
Focus is quality of care

• Acute Stroke Treatment
• Time of symptom onset
• Time from EMS receiving call to EMS arrival
• Time patient arrived at Emergency Department
  (ED)
• Time of CT/MRI Scan
• Time of thrombolytic therapy

• Ischemic Stroke Prevention
• Smoking Cessation Counseling
• Lipid Lowering Therapy
• Blood Pressure Treatment
• Weight and Exercise Management
• Diabetes Management
• Atrial Fibrillation Management

32
Disease Specific Care Certification
JCAHO

• Premise is that certification process will drive
  quality measures and improve outcomes
• No emergency medicine society has endorsed this
  initiative
• t-PA controversy
• Overcrowding
• Medical legal implications

33
Accreditation vs. Certification
JCAHO

• Accreditation
• Surveys are organization-based, focused on
  quality and safe care processes and functions
• Traditional JCAHO evaluation product
• 50 years establishing expertise in evaluating
  health care organizations
• Certification
• Reviews are service-based, focused on quality,
  safety, and outcomes of improving clinical care
• Voluntarynot an add-on to accreditation

34
Brain Attack Coalition
Recommendations for Developing Primary Stroke
Centers
E. Bradshaw Bunney, MD, FACEP
35
Major Elements
of a Primary Stroke Center

• Patient care areas
• Acute stroke teams
• Written care protocols
• Emergency medical services
• Emergency department
• Stroke unit
• Neurosurgical services

• Support services
• Stroke center director
• Neuroimaging services
• Laboratory services
• Outcome and quality improvement activities
• Continuing medical education

Alberts MJ, et al. JAMA. 20002833102-3109.
36
Anticipated Benefits
of a Primary Stroke Center

• Increased patient-care efficiency
• Fewer peristroke complications
• Increased use of therapies for acute stroke
• Decreased morbidity and mortality
• Improved long-term outcomes
• Decreased costs to the healthcare system
• Improved patient satisfaction

Alberts MJ, et al. JAMA. 20002833102-3109.
37
Acute Stroke Team

• Personnel with expertise in diagnosing and
  treating cerebrovascular disease (may include
  neurologist or neurosurgeon)1
• Minimum team would include a physician and
  another healthcare provider (nurse, physicians
  assistant, nurse practitioner)1
• National Stroke Association (NSA) organizational
  recommendations2
• Stroke center team should include a specialist
  and support in
• Neurology, neurological surgery, neuroradiology,
  as well as emergency medicine and rehabilitation
  medicine
• Stroke center team should include, on an
  as-needed basis, a specialist and support in
• Cardiology, critical care, gastroenterology,
  hematology, infectious disease, internal
  medicine, pathology, primary care, and vascular
  surgery

1. Alberts MJ, et al. JAMA. 20002833102-3109. 2.
Furlan AJ, et al, 1997. Available at
http//199.239.30.192/NR/rdonlyres/exkgdlqimjxtunr
lwtsd7tpge3i23nwqm5r5uxw3cby4zk6fe3t3ubvtek2kpnp5o
cmymjutwyyofb/StrokeCenterRecommendatio.pdf.
38
Acute Stroke Team (contd)

• Someone from the team should be available 24/7
• Need system for quick notification and activation
  of the team
• One member of the team should see patient within
  15 minutes
• Written document should be developed to provide
  information on stroke team guidelines
• Logbook should be established to document call
  and response times, diagnoses, treatments, and
  outcomes

Alberts MJ, et al. JAMA. 20002833102-3109.
39
Written Care Protocols

• Reduce tPArelated complications
• Protocols should include
• Emergency care of ischemic and hemorrhagic
  strokes
• Stabilization of vital functions
• Initial diagnostic tests
• Initial use of medications
• Protocols should be available any place where
  patients with stroke may be evaluated or treated
• Should be reviewed and updated once per year

Alberts MJ, et al. JAMA. 20002833102-3109.
40
Emergency Medical Services

• Assigned a high priority
• EMS should be integrated with the stroke center
• During transportation, EMS and the stroke center
  need to communicate
• Quickly triage patients with a stroke upon
  arrival
• Educational activities should include stroke
  center and EMS staff and occur at least twice a
  year

Alberts MJ, et al. JAMA. 20002833102-3109.
41
Emergency Department

• ED personnel should be trained to diagnose and
  treat all types of acute strokes
• ED staff should access the stroke team
• Communicate with EMS and be prepared for arrival
  of stroke patients
• Written protocols for stroke management and
  triage
• Educational activities should occur at least
  twice a year to reinforce stroke diagnosis and
  treatment

Alberts MJ, et al. JAMA. 20002833102-3109.
42
Additional Hospital Units and Services

• Stroke Unit
• Does not need to be a distinct unit in the
  hospital
• Personnel should have expertise in managing
  cerebrovascular disease
• Additional infrastructure includes continuous
  telemetry, written care protocols, and ability to
  continuously, noninvasively monitor blood
  pressure

Alberts MJ, et al. JAMA. 20002833102-3109.
43
Additional Hospital Units and Services

• Neurosurgical Services
• Neurosurgical care should be available within 2
  hours of determination that surgery is necessary
  (patients can be transferred)
• Hospitals providing the neurosurgical care should
  have 24-hourstaffed operating room

Alberts MJ, et al. JAMA. 20002833102-3109.
44
Additional Hospital Units and Services

• Neuroimaging (CT or MRI) Imaging within 25
  minutes
• Image evaluation within 20 minutes
• Standard laboratory tests should be available 24/7

Alberts MJ, et al. JAMA. 20002833102-3109.
45
Outcomes and Quality Improvement

• Database or registry of all stroke patients
• Benchmarks for comparison
• Can be selected from treatment guidelines
• Each year, at least two patient-care issues
• Pre-specified committees meet at least three
  times a year to review and modify practice
  patterns

Alberts MJ, et al. JAMA. 20002833102-3109.
46
Educational Programming

• Stroke center staff should earn at least 8 hours
  of CME credit per year related to cerebrovascular
  disease
• The stroke center should hold at least two
  programs per year to educate the public
• Prevention and recognition of stroke symptoms
• Availability of acute treatments

Alberts MJ, et al. JAMA. 20002833102-3109.
47
Stroke Center Certification
JCAHO

• Certification review will assess
• Compliance with consensus-based national
  standards
• Effective use of primary stroke center
  recommendations and clinical practice guidelines
  to manage and optimize care
• Performance measurement and improvement
  activities
• Certification for a 1-year period
• A 1-year extension is available

Joint Commission Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO). Disease-Specific Care Update JCAHO Web
site. Issue 1, June 2004. Available at
http//www.jcaho.org/dscc/dsc/dscupdate/dsc_updat
e.htm. Accessed September 15, 2004.
48
Does my Hospital Have to Become a Stroke Center?
E. Bradshaw Bunney, MD, FACEP
49
Opportunity Exists
50
Hospitals That are Stroke Centers

• Approximately 5,000 hospitals in the US
• As of Feb. 2005 there are 88 certified Stroke
  Centers
• 50 more in the pipeline
• California, Florida, Ohio and Pennsylvania each
  have 7
• State certification in Massachusetts and New York

51
Do Stroke Teams Improve Outcomes?
E. Bradshaw Bunney, MD, FACEP
52
Stroke Team vs Stroke Center
E. Bradshaw Bunney, MD, FACEP
53
TIME IS BRAIN
E. Bradshaw Bunney, MD, FACEP
54
Importance of Rapid Identification and Triage
of Emergency Stroke Patients

• Intervention in acute ischemic stroke requires
  the rapid and careful
• Assessment
• Selection
• Treatment
• Within 3 hours of symptom onset
• Multiple disciplines and departments
• Pre-hospital responders and in-hospital care
  providers
• Perceptions, attitudes, and behavior of the
  public
• Warning signs of stroke
• Need for rapid and immediate action

55
Factors Potentially Delaying Response Times in
Stroke

• Inadequate public/patient awareness of signs and
  symptoms and need to call EMS early
• Strokes dont cause pain
• The need for time urgency for emergency stroke
  patients by prehospital and healthcare
  professionals
• Modification of existing EMS programs for rapid
  identification, triage, treatment, and transport
  of emergency stroke patients

EMSemergency medical services.
56
Primary Stroke Center Team Improves Time to
Treatment
Variable Before Stroke Center Team 24-Hour Stroke Team Established
Time until notification of stroke team (min) 24 10
Time for stroke team arrival (min) 28 6
Time from triage to CT scan (min) 52 42
Lattimore SU, et al. Stroke. 200334e55-e57.
57
Stroke Teams and Establishment of Acute Stroke
Pathways

• One EDs 2-year experience
• St. Josephs Hospital
• A 467-bed institution located in Phoenix, Arizona
• Includes a neurologic institute and level I
  trauma center
• Before a stroke team was established, stroke
  patients
• Waited an average of 33 minutes for a physician
  examination
• CT scan took an average of 55 minutes to be
  completed
• An additional 10 to 15 minutes passed until the
  CT scan
• was interpreted

Jahnke HK, et al. J Emerg Nurs. 200329133-139.
58
Improved Approach to Assessment
of Stroke Patient

• St. Josephs Hospital developed a stroke team and
  a written acute stroke pathway
• The acute stroke pathway included a standardized
  set of orders and instructions for the management
  of acute ischemic stroke
• Acute stroke pathway goals to improve the quality
  of patient care
• Decreased length of stay
• Increased use of select medications and treatment
• Improved patient assessment
• Reduced unnecessary testing

Jahnke HK, et al. J Emerg Nurs. 200329133-139.
59
Acute Stroke Pathway
A Two-Armed Approach

• Triage nurses assign stroke patients to Stroke
  Team One or Stroke Team Two
• Stroke Team One?patients lt6 hours since onset of
  symptoms
• Stroke Team Two?patients gt6 hours since onset of
  symptoms OR patients whose symptoms have resolved
  (due to transient ischemic attack)
• ED nurses perform brief neurologic exams every 15
  minutes following patient arrival
• Orientation, motor skills, sensory abilities,
  speech, and vision
• NIHSS score determined by stroke neurologist,
  neurology resident, or stroke research nurse

Jahnke HK, et al. J Emerg Nurs. 200329133-139.
60
Improvement in Patient Care
Since Implementation of Stroke Team and Acute
Stroke Pathway
Adapted from Jahnke HK, et al. J Emerg Nurs.
200329133-139.
61
Stroke Units Improve Outcomes

• Study included 802 patients admitted with a
  stroke diagnosis to a hospital in Norway
• Study patients arrived within 24 hours of stroke
  onset and were at least 60 years old
• Patients were treated in the stroke unit or in
  the general medical ward
• Stroke outcomes were assessed

Ronning OM, et al. Stroke. 19982958-62.
62
Stroke Units Improve Outcomes in Ischemic Stroke
P0.112
P0.144
P0.140
P0.043
P0.017
P0.077
Ronning OM, et al. Stroke. 19982958-62.
63
Stroke Units Improve Outcomes in Hemorrhagic
Stroke
Ronning OM, et al. Stroke. 19982958-62.
64
Drip and Ship?
Is There a Role for
E. Bradshaw Bunney, MD, FACEP
65
Strict Protocol is the KEY
E. Bradshaw Bunney, MD, FACEP
66
Rural Nevada

• One designated stroke center
• 8 rural EDs
• One protocol agreed to by all hospitals
• Managed through the central stroke team
• Site visits to confirm protocol adherence and
  promote team approach

67
Role of Community Education
E. Bradshaw Bunney, MD, FACEP
68
Can Community-Based Education Improve Knowledge?

• Objective
• Assess if the knowledge deficits regarding stroke
  signs, symptoms, and risk factors could be
  improved
• Methods
• Telephone interviews used to assess effect
• Several media resources used
• May to September 1998

Becker KJ, et al. Cerebrovasc Dis. 20011134-43.
69
Community-Based Education Improves Knowledge
Results

• What organ is injured during a stroke?
• Prior to the campaign, 45.2 of respondents knew
  that the brain was injured, after the campaign,
  49.5
• Cant easily teach old dogs new tricks
• Sustained media education
• Begin education earlier in life
• Effect of education campaign
• Respondents were 52 more likely to know a risk
  factor of stroke (P0.005)
• Respondents were 35 more likely to know a
  symptom of stroke (P0.032)

Becker KJ, et al. Cerebrovasc Dis. 20011134-43.
70
Community-Based Education Improves Knowledge
Conclusion

• There is a severe knowledge deficit about stroke
  that is greater in those at a high risk for
  stroke, including
• Elderly
• Less educated
• Persons with low income
• Men
• Asian Americans
• Knowledge deficit can be improved through
  community-based education, particularly through
  public service announcements on television

Becker KJ, et al. Cerebrovasc Dis. 20011134-43.
71
EMSFront and Center
E. Bradshaw Bunney, MD, FACEP
72
Paramedic Quick Screen

• Paramedic Quick Screen
• Focal neurological symptoms including
• Unilateral weakness
• Numbness
• Blindness
• Loss of speech
• Loss of balance
• Well-established time of onset less than 3 hours
• Age gt18 years
• Notify Base Station to activate Code Stroke on
  potential patients during transport

1. Lyden PD, et al. J Stroke Cerebrovasc Dis.
19944106-113. 2. Rapp K, et al. J Neurosci
Nurs. 199729361-366.
73
University of CincinnatiPrehospital Stroke Scale

• Facial Droop (Patient shows teeth or smiles)
• Normal (Both sides of face moves equally well)
• Abnormal (One side of face doesnt move as well
  as other side)
• Arm drift
• Normal (Both arms move the same OR both arms
  dont move at all)
• Abnormal (One arm either doesnt move OR one arm
  drifts down compared to the other)
• Speech (The patient says The Cubs arent going
  to the playoffs)
• Normal (Patient says correct words with no
  slurring of words)
• Abnormal (Patient slurs words, says the wrong
  words, or is unable to speak)
• Source Adapted from Kothari R, et al. Acad Emerg
  Med. 19974986-990

74
AHA-Recommended Assessment of a Person With
Suspected Stroke by EMS Personnel

• Assure adequate airway
• Monitor vital signs
• Conduct general medical assessment
• Evidence of trauma to head or neck
• Cardiovascular abnormalities
• Ocular signs
• Conduct neurological examination
• Prehospital assessment (eg, Cincinnati
  Prehospital Stroke Scale)
• Level of consciousness (Glasgow Coma Scale)
• Pupils size, equality, reactivity
• Presence of seizure activity
• Prearrival notification estimated time of onset,
  Glascow Coma Scale score

AHA. BLS for Healthcare Providers. 200136-47. 
75
Assessing the Role of Paramedic Diagnosis and ED
Efficiency

• Houston study
• Performance data from paramedics and 6 hospital
  EDs
• Data collected from 446 patients with suspected
  acute stroke
• Data were used to assess the effect of
• Establishing emergency stroke centers
• Paramedic education program
• Target treatment times were based on ASA
  standards
• Unenhanced CT scan of the brain within 30 minutes
• Maximum of 60 minutes for initiation of tPA

ASAAmerican Stroke Association.
Wojner AW, et al. Am J Crit Care. 200312411-417.
76
Effectiveness of Paramedic Diagnosis and ED
Treatment Patterns

• Stroke diagnosis 321/446 (72) cases
• Onset of signs/symptoms 359/446 (80.5) patients
• Of these 359 patients, 210 (58.5) arrived at the
  ED within 120 minutes of onset
• There were 319 case report forms submitted with
  thrombolysis data 195 of these cases had acute
  ischemic stroke diagnosed hospitals 3 and 6 did
  not administer thrombolytics

Wojner AW, et al. Am J Crit Care. 200312411-417.
77
EMS and ED Stroke Care Are Improved With Education

• Houston paramedics are able to diagnose stroke
• Aggressive stroke education initiative during the
  NINDS study
• Close interaction between paramedics and hospital
• Community awareness of signs/symptoms
• Allowed gt65 of patients with confirmed stroke to
  arrive in the emergency department within 3 hours
• ASA standards can promote uniform stroke
  assessment and treatment processes

Wojner AW, et al. Am J Crit Care. 200312411-417.
78
ED Stroke Protocol

• All very similar
• Specific to nuances within the specific hospital
• Must be strictly followed
• Must be implemented in ALL appropriate patients

79
Treatment of Stroke Patients Following Admission
to the Hospital
E. Bradshaw Bunney, MD, FACEP
80
Admission to the Hospital and Complications

• Approximately 25 of patients can worsen during
  first 24 to 48 hours after stroke
• DVT/PE
• Pneumonia/aspiration
• Neurological complications
• Most to a monitored setting
• OT/PT are essential

Adams HP, et al, a scientific statement from the
Stroke Council of the American Stroke
Association, approved by the American Heart
Association Science Advisory and Coordinating
Committee. Stroke. 2003341056-1083.
81
Recommendations for Stroke Care Following
Admission to Hospital

• Admission to a stroke unit with comprehensive
  rehabilitation for patients
• Frequent neurological status checks and vital
  signs during the first 24 hours
• Early mobilization and measures to prevent stroke
  complications
• Aspiration, malnutrition, pneumonia, deep vein
  thrombosis (DVT), pulmonary embolism, pressure
  sores, orthopedic complications, and contractures
• Prophylactic treatment to prevent DVT
• Treatment of infectious complications with
  antibiotics
• Treatment of concurrent medical conditions

82
EM Controversies
in Stroke Management
E. Bradshaw Bunney, MD, FACEP
83
ACEP.org
84
SAEM.org
85
AAEM.org
86
EM Concerns

• Internal and external validity of the NINDS trial
• Single trial (two parts)
• Treated group not as sick as the placebo group
• Hemorrhage rate
• Neuroradiology interpretation
• Infrastructure needed to provide timely care
• EMS not prepared for their role
• Hospitals not prepared for their role
• Medical legal concerns in the emergency medicine
  and neurology communities
• Reimbursement issues

87
EM Role in the Process and Center

• A hospital can not embark on becoming a stroke
  center without EM participation
• Models exist where EM has taken the lead role in
  developing the stroke team
• Conversely, models exist where EM has blocked the
  initiative

88
ACEP and Stroke Centers

• October 2003 ACEP Council and Board of Directors
  unanimously adopted a resolution to monitor the
  progress of any federal stroke legislation and
  dedicate resources to make members of Congress
  aware that
• Standards of care in stroke treatment remain
  controversial
• The designation of stroke centers based on their
  ability / willingness to adhere to such standards
  of care may have many unintended negative
  consequences

89
SAEM MAY 18, 2004

• Background
• Policy statements Andy Jagoda
• American Stroke Ellen Magnis
• Panel Presentations
• American Stroke Mark Alberts
• ACEP Brian Hancock
• SAEM Jim Adams
• NAEMSP Robert OConnors
• JACHO Maureen Connors Potter
• Panel Discussion

90
Where do We go From Here?

• Work with the Brain Attack Coalition
• Educational programs
• Medical students
• Residents
• Implementation packets for stroke center
  certification
• Pathways, protocols, tools
• Focus on future therapies and having systems in
  place to facilitate utilization

91
Clinical Course

• The patient was met by a nurse, a doctor and
  an EM tech and taken to the resuscitation room.
  They confirmed the onset time of 215pm. Vital
  signs were BP 142/88, P 98, R 16, T 99.2 F.
  HEENT eyes were deviated to the right but came
  back to midline with command, PERRL, Ears clear,
  neck supple. Heart, lungs and abdomen were
  normal. Neurological exam CN mild left facial
  droop, strength 5/5 R arm and leg, 1/5 L arm and
  leg, no light touch or pin prick sensation in the
  L arm and leg. NIHSS17-18.

92
Clinical Course

• The stroke team was called at 305pm
• Labs were drawn and sent.
• The patient went to CT at 320 pm and returned at
  3 41pm.
• The stroke team assessed the patient on return
  from CT and agreed with the diagnosis of CVA and
  NIHSS18.
•  Head CT reading was negative for bleed, normal
  brain at 403pm.

93
Clinical Course

• The patient was felt to be a good candidate for
  thrombolytics. The patient was advised of the
  risks and benefits.
• The patient, along with his wife refused
  thrombolytic therapy, stating I want nature to
  take its course.
• The patient was given 325 mg. of aspirin and
  admitted to the hospital.
• His 24 hour NIHSS14.
• On discharge, 5 days later, NIHSS10.

94
Key Learning Points

• JACHO Stroke Center certification requires
  multi-disciplinary cooperation with one central
  champion
• Strict adherence to stroke protocols improves
  outcomes in these patients
• EMS plays a KEY role in maximizing the management
  of stroke patients
• The EM community has numerous concerns about the
  Stroke Center designation concept

95
Questions?? www.ferne.orgferne_at_ferne.org E.
Bradshaw Bunney, MD, FACEPbbunney_at_uic.edu312
413 7484
formatted_bunney_strokecenter_aaem_2005.ppt
2/11/2005 732 PM
E. Bradshaw Bunney, MD, FACEP