For Activating and Dispatching the Emergency Medical Services (EMS) Response for Stroke Patients, Stroke Systems Should Require Appropriate Processes That Ensure Rapid Access to EMS for Acute Stroke Patients
Stroke systems should address the following 3 issues to help ensure that stroke patients have rapid access to EMS.
Locate Acute Stroke Patients Rapidly by Ensuring That the Public Has Access to Enhanced Landline (E) and Wireless (W) 9-1-1
- Advocate for funding and legislation at the federal, state, and local levels to provide universal availability of W-E911 capabilities.
- Support public policy initiatives and other activities that promote increased quality and appropriate use of 9-1-1 systems.
- Identify political leaders or champions for rural areas in the state and advocate for funding on behalf of 9-1-1 call centers and wireless carriers that serve rural areas.
- Advocate for the adoption of legislation that will require multiline telephone systems (MLTS) to provide 9-1-1 call centers with sufficient information to locate callers.
- Advocate for the Federal Communications Commission (FCC) to disallow or limit waivers of the rules that require wireless carriers to develop and implement the capabilities necessary to provide caller number and location information to emergency medical systems (EMS) communicators. In addition, advocate for the FCC to enforce compliance with the existing federal requirements for voice-over-internet protocol (VoIP) providers and to develop requirements for portable VoIP services.
- Consider collaborating with in-vehicle services, which locate the caller as well as provide an operator intercept for emergency calls.
Identify Acute Stroke Patients Rapidly and Accurately by Ensuring That EMS Communicators Recognize Stroke Signs and Symptoms as Reported by Callers
- Use stroke educational materials and 1 or more stroke experts (physicians, nurses, emergency medical technicians (EMTs), and paramedics) to provide education to EMS communicators about the signs and symptoms of stroke. These educational materials should reflect current published American Stroke Association/American Heart Association (ASA/AHA) recommended guidelines for emergency cardiovascular care.
- Ensure emergency medical services systems (EMSS) emergency medical dispatch (EMD) guide cards and educational resources are stroke-specific. Such guide cards and educational resources are available within the EMSS community.
Dispatch the Highest Level of Care Available to Suspected Stroke Patients in the Shortest Time Possible by Ensuring That EMS Communicators Use Emergency Medical Dispatch Guidelines Reflecting the Current ASA/AHA Guidelines
- Review dispatch guidelines used by all 9-1-1 call centers within the stroke system to ensure that the highest-priority response is given to callers with signs and symptoms of stroke. Revise guidelines that are incompatible with this priority response principle.
- Promote the use of nationally recognized emergency medical dispatch guidelines reflecting current ASA/AHA recommendations for stroke care among the 9-1-1 dispatch agencies within the stroke system of care. Work with the appropriate federal standard-setting organization for emergency medical dispatch (EMD) protocols— National Highway Traffic Safety Administration (NHTSA) and the American Society of Testing and Materials—to ensure that their standards include the appropriate guidelines for identification of and assistance with stroke patients.
- Advocate for funding for local 9-1-1 call centers to receive training and to acquire an EMD caller interrogation tool to help EMS communicators more effectively identify suspected stroke patients in the field.
- Work with the leading commercial providers of EMD protocol interrogation tools to ensure that their products meet ASA/AHA standards and guidelines for identifying and assisting stroke patients.
- Advocate for state legislation that establishes EMD guidelines consistent with federal guidelines as the standard of care.
- Establish targets for reducing the time-to-dispatch interval. These targets could be included as a component of certification and proficiency programs for EMS communicators.
- Advocate for local, state, federal, and third-party payer funding to ensure the availability of advanced life support (ALS) ambulances and paramedics across the stroke system's catchment area.
- Advocate for state and federal rules or standards to require that ALS units be equipped with electrocardiograph (ECG) monitoring devices and other resources necessary to properly care for stroke patients.
- Collaborate with organizations that provide services and assistance to non–English-speaking patients and callers to improve the ability of EMS communicators to communicate effectively with contacts who do not speak English as their primary language.
- Advocate for state and federal policymakers to support EMS personnel in rural areas to ensure the availability and quality of the emergency response system.
For EMS Responders, EMSS Should Use Protocols, Tools, and Training That Meet Current ASA/AHA Guidelines for Stroke Care
Stroke systems should address the following 2 issues to ensure the effective response of EMS within a stroke system of care.
Identify Acute Stroke Patients Rapidly and Accurately by Ensuring That EMS Responders Use Validated Screening Algorithms Effectively
- Ensure that EMS responders use validated stroke screening tools to aid in the identification of stroke patients.
- Advocate for consistent use of a single stroke screening tool at the community, state, or regional level, as appropriate, to improve the identification of stroke patients by EMS responders.
- Request that the medical directors of EMSS include a stroke screening tool in the protocols for prehospital stroke assessment and provide education on the use of the screening tool for all EMS personnel.
- Include stroke screening tools within the 10 core advanced cardiovascular life support (ACLS) cases when teaching both prehospital and hospital personnel.
- Request that all emergency department (ED) personnel who receive EMS prearrival patient reports obtain copies of the stroke screening tools for all suspected stroke patients.
- Implement continuous quality improvement (CQI) programs and iteratively improve the accuracy of stroke identifications made by prehospital personnel by comparing completed prehospital stroke screening forms with final hospital discharge diagnoses for stroke patients. EMSS need support and participation from hospitals in the quality assessment/quality initiatives process. Hospitals should report pertinent data back to EMSS, including mortality/morbidity and discharge diagnosis.
- Include research on the use of prehospital stroke severity scales or other triage factors as part of prehospital treatment trials that seek to evaluate the direct routing of certain stroke patients by ground or air ambulance to comprehensive stroke centers, or as part of other EMSS activities where the assessment and recognition of the severity of the stroke could be an important component of care.
Establish Goals for the EMSS Response Time for Suspected Stroke Patients
- Measure and report the overall EMSS response time and on-scene time for all stroke patients. Although the EMSS response time is 1 overall measurement parameter, the times for each component of the response time should be captured and reported to provide the EMSS with the data necessary to measure and improve overall response time performance. Often, precious time is lost during delays in the dispatch time and the turnout time.
- Measure and report additional response times for every element of the EMSS whenever possible. These response times include, but are not limited to, 9-1-1 call center processing time, the response times of first responders, basic life support response times, and the time spent to reach the patient.
- Work with the National EMS Information System (NEMSIS) project to recommend that states collect and submit all necessary data elements for stroke for inclusion in the national EMS dataset.
- For data elements absent from the NHTSA's national dataset, work with state EMS offices to ensure that the appropriate stroke elements are nonetheless captured in state datasets.
- Encourage EMSS to collect NHTSA-defined stroke data elements and use these data for continuing quality improvement (CQI) activities.
Prehospital Providers, Emergency Physicians, and Stroke Experts Should Collaborate in the Development of EMS Training, Assessment, Treatment, and Transportation Protocols for Stroke
Frequent and meaningful dialogue should occur among prehospital providers, EMS medical directors, ED medical and nursing directors, stroke center directors, and stroke neurologists about operational and CQI issues. Stroke systems should address the following 4 issues to help ensure that prehospital providers, emergency medicine physicians and nurses, and stroke experts collaborate in the care of stroke patients and the development of EMS training and protocols.
Promote Ongoing Collaboration Among Prehospital and Hospital Providers in the Acute Treatment of Stroke Patients
- Integrate EMS within ED stroke care and ongoing CQI activities for stroke.
- Provide ongoing feedback to EMS providers who care for and transport stroke patients.
- Incorporate into EMSS protocol algorithms and checklists for the prearrival notification of the destination hospital for suspected stroke patients, and include prearrival notification as a component of EMS training and continuing education courses for stroke. In addition, review the use of prearrival notification for suspected stroke patients as a part of CQI activities within stroke systems of care.
- Incorporate mechanisms to garner participants' enthusiasm in collaborative activities (e.g., create newsletters to capitalize on successes or survey participants for ways to improve participation and attendance at collaborative meetings).
- Create a broad-based coalition of healthcare providers, experts, and regulators to develop improved EMSS processes and protocol enhancements.
- Urge stroke centers and EMS personnel to collaborate in stroke system research projects as appropriate.
Develop and Implement Stroke Education Activities Collaboratively With Prehospital and Hospital Providers, Including Initial as Well as Continuing Education
- Encourage prehospital providers, emergency physicians, and stroke experts to collaborate in evaluating the evidence for quality stroke care, writing stroke guidelines, and developing stroke training materials and programs.
- Encourage stroke system leaders to determine and facilitate the education needed by EMS personnel to provide optimal care for patients with stroke. EMS medical directors should proactively define the frequency of stroke reeducation on the basis of factors such as the prevalence of stroke care within the EMSS so that skill sets are maintained over time.
- Work with agencies that oversee EMS to ensure that the regulations include adequate requirements for evidence-based stroke training.
- Advocate for funding of professional education training for prehospital providers.
- Advocate for a stroke training requirement for the renewal of EMS responders' licensure.
- Collaborate with professional organizations, such as nursing associations, to provide stroke training and educational opportunities at conferences.
- Ensure that stroke experts are available to help teach the 10 core ACLS cases and to promote the use among providers of computer- and video-based self-directed learning and other training resources.
Develop Stroke System Transport Protocols Collaboratively With Prehospital and Hospital Providers, as Well as With Other Stakeholders
- Obtain support for updated stroke transport protocols from key EMSS, medical, and clinical leaders in the community. Leverage resources of stroke system members to update stroke protocols, such as ambulance electronic run sheets, professional education, CQI activities, and public education. Collaborate with state, regional, and community agencies to modify transport policies for stroke treatment and transport.
- Establish a hospital identification system that provides a transparent list of hospitals that meet standard criteria for primary stroke centers within the stroke system of care. Such a list should be readily available to EMS providers and the public.
- Create a broad-based coalition of healthcare providers, experts, and regulators to develop improved EMSS point-of-entry (transport destination) plans.
- Partner with professional organizations to more effectively communicate with prehospital and hospital providers the evidence supporting current treatment recommendations. Form alliances with professional organizations and advocate for the statewide adoption of transport protocols for stroke.
- Ensure that all available EMS transportation resources are considered for suspected stroke patients to minimize transport time to the appropriate hospital.
- Recognize air transport in the collaborative development of stroke transport protocols.
- Develop relationships with critical care transport (CCT) and ALS interfacility transfer resources to provide for the rapid transfer of patients to more appropriate hospitals when indicated.
- Standardize equipment (including hospital and EMS equipment, such as infusion pumps) and/or cross-train transport personnel in CCT and ALS interfacility transfer procedures to increase available resources for the rapid transfer of patients to more appropriate hospitals when indicated.
- Educate providers to treat the transfer of stroke patients for stroke interventions as a true emergency and eliminate the mindset of characterizing CCT and ALS interfacility transfers as non-emergency transports.
- Develop and measure response time parameters for CCT and ALS interfacility transfers in a manner similar to the measurement of traditional emergency response times.
- Use helicopter transport in cases where resource constraints would adversely affect EMS ground availability.
- Work with state EMS medical director associations, the state chapter of the American College of Emergency Physicians, and the ASA to come to a consensus on common stroke training, triage, and transport protocols.
Engage Collaboratively With Prehospital and Hospital Providers in Continuous Quality Improvement Processes for Stroke Care While Complying With Protections for the Privacy of Personal Health Information
- Ensure active participation by prehospital and hospital providers in the development and ongoing implementation of CQI activities. Include stroke experts in reviewing the prehospital care received by every stroke patient as part of CQI activities.
- Provide education about Health Insurance Portability and Accountability Act (HIPAA) to stroke system providers, including EMS providers and hospitals. Encourage meaningful CQI activities while complying in full with federal and state law involving privacy issues.
- Develop model CQI agreements that address HIPAA concerns for EMSS, hospitals, and other providers within stroke systems.
Patients Should Be Transported to the Nearest Stroke Center for Evaluation and Care If a Stroke Center Is Located Within a Reasonable Transport Distance and Transport Time
Stroke systems should address the following 5 issues to help ensure that EMSS transport patients to the nearest stroke center or the closest hospital for evaluation as appropriate.
Assess Stroke Patient Eligibility for Acute Stroke Therapies Using a Stroke History Checklist or Algorithm Designed for Prehospital Personnel
- Develop and ensure the use of stroke triage and transport protocols that reflect current recommendations for assessing stroke patients for eligibility for acute stroke therapies, including thrombolytic therapy.
- Ensure that EMS responders have adequate education and training to screen patients accurately for acute therapies.
Establish EMSS Transport Destination Protocols That Reflect Optimal Patient Care With Transport to Stroke Centers as Appropriate
- Amend EMS transport destination protocols to place a greater priority on transporting patients to recognized stroke centers.
- Transport suspected stroke patients to the nearest stroke center that provides definitive treatment if such a hospital is within a reasonable transport time, taking into account regional issues such as availability of stroke centers and geography and whether transportation to a stroke center is possible within the appropriate time for acute therapeutic interventions. Alternatively, patients should be transported to the hospital considered to be best prepared to treat stroke patients on an emergency basis.
- Advocate for a statewide plan for EMS protocols to ensure stroke patients receive high-priority care at recognized stroke centers. Advocate for the development of a public statewide hospital identification system identifying hospitals that meet the criteria for primary or comprehensive stroke centers.
- Involve all affected hospital systems and EMS providers in the development of prehospital transport and triage protocols.
- Include stroke survivors and family members of stroke survivors on committees that develop stroke transport protocols to help mitigate the likelihood that patient destination may be manipulated for economic reasons.
- Advocate for local, state, and federal legislation to facilitate and reimburse for the care and transportation of stroke patients to stroke centers.
- Promote Joint Commission on Accreditation of Healthcare Organizations certification as well as other recognition programs that use similar quality-based outcome measurements.
- Encourage rural hospitals to enter into collaborative relationships with stroke centers to access expertise needed to initiate acute therapy before transporting patients to a stroke center.
- Advocate for funding for telestroke technologies and telestroke consultation services.
- Extend mutual aid agreements with neighboring EMSS agencies for trauma patients to include stroke patients, or establish mutual aid agreements for stroke patients to obtain assistance from neighboring EMSS where transport out of the area to a stroke center would leave portions of the community without adequate EMS coverage.
Establish Protocols for the Transfer of Stroke Patients From Nonstroke Center Hospitals to Stroke Centers as Appropriate
- Adopt goals for stroke patient arrival detailing initial evaluation and subsequent transfer with treatment at rural nonstroke center hospitals.
- Create community-wide guidelines for the interfacility transfer of stroke patients who are candidates for short-term therapies or who have conditions requiring more complex care.
- Provide stroke-specific education to assist providers in using system-wide interfacility transport protocols and in making medical decisions about when the benefits of transporting patients outweigh the risks in the context of stroke care and compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.
- Use the trauma system as a model for stroke system development of transport and interfacility transfers.
- Develop model preestablished referral processes and interfacility transport agreements that reflect EMTALA requirements and any other state or local requirements. Create easy-to-complete forms that address such requirements that physicians can complete before patient transport.
- Advocate for the development of an interfacility transport component of EMS agencies.
- Advocate for the creation of model legislation to remove unnecessary legal and regulatory barriers to interfacility transfers.
- Develop for interfacility transfers a reverse transfer agreement, which returns the stroke patient after the receipt of acute care to the community hospital for subacute care and rehabilitation as appropriate.
Transport Stroke Patients to Stroke-Ready Hospitals Regardless of the Patients' Geopolitical Locations
- Educate state EMS office personnel and regional and local EMS officials regarding EMSS efforts and goals for the development of stroke systems of care.
- Identify key stakeholders involved in the development of state and regional trauma systems and discuss their experiences and "lessons learned" that are applicable to the development of stroke systems of care.
- Form a coalition to address the development of polices and regulations that are specific to patient destination with regard to the stroke patient. This coalition should include representatives of key stakeholder organizations, such as state EMS offices, regional and local EMS offices, the state legislature, the state chapter of the American College of Emergency Physicians, the state chapter of the Emergency Nurses Association, hospitals, and hospital associations.
