Minnesota Acute Stroke System Council

1. Minnesota Acute Stroke System Council February 22, 2012

2. Agenda • Destination Protocol Update • Stroke Units • Other updates

3. Destination Protocol • Old Draft (December): problems with incorporating time-to-destination decision points, distinguishing hospital type destinations • Steering Committee discussion (2/6/2012): • Simplify! • Develop a ‘statewide’ protocol • Local EMS should submit a ‘local’ protocol consistent with statewide protocol • Develop state map of designated hospitals • Basically: Within six hours: patients should be transported to nearest designated hospital • Model: New York State BLS protocol (see next slide)

4. Draft destination protocol (1) • Perform initial assessment. • Assure that the patient’s airway is open and that breathing and circulation areadequate. • Administer high concentration oxygen, suction as necessary, and be prepared to assist ventilations. • Position patient with head and chest elevated or position of comfort, unless doing so compromises the airway. • Perform Cincinnati Pre-Hospital Stroke Scale: • Assess for facial droop: have the patient show teeth or smile, • Assess for arm drift: have the patient close eyes and hold both arms straight out for 10 seconds, • Assess for abnormal speech: have the patient say, “you can’t teach an old dog new tricks”.

5. Draft destination protocol (2) • If the findings of the Cincinnati pre-hospital stroke scale are positive, establish onset of signs and symptoms by asking the following: • To patient – “When was the last time you remember before you became weak, paralyzed, or unable to speak clearly?” • To family or bystander – “When was the last time you remember before the patient became weak, paralyzed, or unable to speak clearly?” • Transport of patient’s with signs and symptoms of stroke to the appropriate hospital: • Transport the patient to the closest Minnesota Department of Health designated Stroke Center if the total pre-hospital time (time from when the patient’s symptoms and/or signs first began to when the patient is expected to arrive at the Stroke Center) is less than six (6) hours. • Transport the patient to the closest appropriate hospital emergency department (ED) if: • The patient is in cardiac arrest, or • The patient has an unmanageable airway, or • The patient has (an) other medical condition(s) that warrant(s) transport to the closest appropriate hospital emergency department (ED) as per protocol, or • The total pre-hospital time (time from when the patient’s symptoms and/or signs first began to when the patient is expected to arrive at the Stroke Center) is greater than six (6) hours, or • An on-line medical control physician so directs.

6. Draft Destination protocol (3) • Maintain normal body temperature; do not overly warm the patient. • Protect any paralyzed or partially paralyzed extremities. • Ongoing assessment. Obtain and record the patient’s initial vital signs, repeat en route as often as the situation indicates. • Notify the receiving hospital as soon as possible of your impending arrival with an acute stroke patient, Cincinnati Stroke Scale findings, and time signs and symptoms began. • Record all patient care information, including the patient’s medical history and all treatment provided, on a Pre-hospital Care Report (PCR).

7. Stroke units: criteria (draft) • Defined group of beds/staff/protocols • Does not need to be distinct ward or unit • Staffed with personnel trained in stroke • Continuous multichannel telemetry • Written care protocols • Documentation on staffing and operations

8. Stroke Units: issues • Stroke unit is mainly about structure, organization, and nursing expertise • Current definition only addresses acute medical management • Needs to also address: • Ability to provide patient education • Ability to prevent complications • Ability to prevent extension of stroke • Early rehabilitation • Acute stroke-ready hospitals should be able to meet all criteria for admitted patients • ASR hospitals can meet criteria by having formal consult relationship with external experts/specialists

9. Stroke units: discussion • Acute stroke ready hospitals: challenges in meeting criteria? • Other issues? • Consensus • Create a new/final checklist (criteria)

10. Next Steps, Reminders • Next teleconference: March 21, 2012 (noon on third Wednesdays) • Upcoming conferences, meetings, and presentations • Minnesota Hospital Association Rural Hospital Committee, Plymouth: 3/7 • MN ACEP, Location TBD: 3/19 • Minnesota Stroke Conference, St. Paul: 6/4 • Minnesota Rural Health Conference, Duluth: 6/26 • MN EMS Medical Directors Conference, Alexandria: 9/7-9 • Submit concerns and questions: • Email (health.stroke@state.mn.us) • Online: http://www.health.state.mn.us/divs/hpcd/chp/cvh/strokesystemcomment.cfm