Box 18.3 Time interval goals for fibrinolytic therapy
Arrival via EMS at the closest ED capable of delivering fibrinolytic as soon as safely possible
EMS should provide notification while en route to receiving hospital for suspected stroke patients
Rapid assessment by stroke team or emergency physician
Completion of computed tomography (CT) scan within 20 minutes
Administration of fibrinolytic (tPA) within 60 minutes of arrival to ED and within 4.5 hours of symptom onset for eligible patients
Source: Modified from Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018; 49:e46–e99.
All of these treatments for stroke have potentially devastating complications, the most noteworthy being intracranial bleeding. In addition, these interventions have several exclusion criteria that must be considered when selecting patients, but are beyond the scope of this chapter. Nonetheless, it is important that EMS clinicians have at least a general understanding of available stroke treatments, as well as the rationale for accurate and rapid identification of the stroke victim. Box 18.3 describes the current AHA/ASA time‐to‐treatment goals related to IV tPA. Ideally, the time window from ED arrival to drug administration should not exceed 60 minutes [9].
EMS transport
Given the narrow time windows of opportunity associated with the various interventional stroke therapies and the clearly demonstrated benefit of earlier treatment, EMS is a critical link to ensuring that patients arrive at facilities capable of treating strokes in an expedited manner. Numerous studies have shown that stroke patients accessing the EMS system have a significantly greater chance of timely arrival at an emergency department, which in turn, can promote higher thrombolytic treatment rates [29–32]. More specifically, the California Acute Stroke Prototype Registry (CASPR) collected data from several California hospitals to identify factors that resulted in delayed presentation for treatment. This study indicated that if patients experiencing stroke symptoms (that did not occur overnight) had called EMS immediately, the percentage eligible for tPA would have increased from 4.3% to 28.6% [33]. Furthermore, one randomized trial examining the effect of an intervention comprised of a prehospital stroke assessment tool, an ambulance protocol for hospital bypass for potential thrombolysis‐eligible patients, and prehospital notification of the acute stroke team demonstrated a significant increase in thrombolytic administration. In this study, the time from symptom onset to ED arrival decreased from 150 minutes to 90 minutes, and the proportion of patients receiving tPA increased from 4.7% to 21.4% after the intervention, with 43% of patients having minimal to no disability at 3 months [34].
Knowledge of the stroke treatment capabilities among area hospitals is quite important. Health care facilities that are not stroke centers may be able to administer tPA, but often lack the capability to perform more invasive procedures such as intra‐arterial tPA administration or endovascular thrombectomy [24, 35]. These procedures require an interventional neuroradiologist. In addition, dedicated personnel must be available quickly and trained in the evaluation of stroke. The staffing of EDs throughout the country still varies widely, as does the relative stroke experience of practitioners. Designation by The Joint Commission indicates that a hospital has been evaluated and found to be compliant with specific national guidelines [36, 37].
Currently, The Joint Commission certifies hospitals at the following levels: Acute Stroke Ready Hospital, Primary Stroke Center, Thrombectomy‐Capable Stroke Center, and Comprehensive Stroke Center [38, 39]. The process of certifying hospitals as stroke centers depends on whether they meet specific criteria defined by The Joint Commission, which include availability of a stroke team, neurology consultation, and diagnostic and therapeutic capabilities (Table 18.4) [38]. Acute Stroke Ready Hospitals are able to deliver thrombolytics and promptly transfer patients to a higher‐level center. Primary Stroke Centers have committed to the rapid assessment and treatment with IV thrombolytics as well as an ability to admit acute stroke patients. A designation of Thrombectomy‐Capable or Comprehensive Stroke Center indicates those hospitals are uniquely equipped and staffed to treat the more complex stroke cases.
Each EMS agency must evaluate the community it serves, including its available resources, and then work to develop appropriate patient care guidelines for the evaluation and treatment of stroke patients. This should be done in conjunction with the local and regional health care facilities. It should be determined whether the local community hospital is capable of managing acute stroke victims. Hospital transport destinations should be predetermined based on time and distance variables. In addition, air medical transport may be considered, including direct air medical evacuation of stroke patients from the scene. Air medical transport may be an appropriate option if the ground EMS transport time is expected to exceed 1 hour, and the air medical crew could arrive at a stroke center in time to facilitate appropriate evaluation and treatment within the therapeutic window. In making such a decision, it is important to consider all the elements of air medical response that consume time, including lift time, flight time, time for patient evaluation, and time to load and unload. Guidelines that include air medical dispatch based on telecommunicator information may be considered, specifically for rural areas without local health facilities capable of stroke interventions.
Table 18.4 Joint Commission stroke center comparison
| ASRH | PSC | TSC | CSC | |
|---|---|---|---|---|
| Eligibility | Stroke protocols based on evidence‐based standards | Stroke protocols based on evidence‐based standards | Stroke protocols based on evidence‐based standardsPerformed at least 15 mechanical thrombectomy procedures over past 12 months (or over 30 in past 24 months) | Stroke protocols based on evidence‐based standardsPerformed at least 15 mechanical thrombectomy procedures over past 12 months (or over 30 in past 24 months) |
| Program Medical Director | Possesses sufficient knowledge of cerebrovascular disease | Possesses sufficient knowledge of cerebrovascular disease | Possesses background in neurology | Possesses extensive expertise 24/7 |
| Acute Stroke Team | Available 24/7, at bedside within 15 min | Available 24/7, at bedside within 15 min |
Available 24/7, at bedside within 15 min
|
