By Heather Stores; Jeff Avinger, CCEMT-P
The statistics are staggering. In the United States alone, stroke occurs every 40 seconds. And every 4 minutes, someone dies from stroke, according to the CDC. As the leading cause of long-term disability, strokes cost Americans an estimated $34 billion each year in associated costs. From education outreach to advanced technologies, the medical profession and associate firms continue to seek innovative ways to improve outcomes.
Many of those ways involve quick response. For years, the slogan, “time is brain,” has stressed the importance of early stroke recognition and care. The easy-to-identify-stroke tool, FAST (face drooping, arm weakness, speech difficulty, time to call 911) helps the general public recognize the signs and call for help. FAST continues to be the first step in the chain of survival, providing better outcomes to those who have suffered a stroke.
The next link in the chain involves EMS teams responding to that 911 call. Historically, EMS field stroke assessments focused on a simple three-part evaluation. The criteria for calling a “stroke alert” was only slightly more advanced than the FAST exam. EMS and hospitals focused on the patient but weren’t working together. That alone often delayed definitive treatment at a hospital with stroke specialists. As medically trained paramedics, the EMS community realized there was room for improvement in this link.
Stroke scales
To improve assessments, paramedics began using advanced field stroke triage scales such as the Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), and Field Assessment Stroke Triage for Emergency Destination (FAST-ED). These stroke scales allowed EMS responders to transport stroke patients directly to appropriate comprehensive stroke centers, where treatment windows can be up to 24 hours from last known well (LKW). Neurologists and hospitals began to see the benefit of using pre-hospital providers to promote better patient outcomes. Because with a stroke, the clock is ticking.
A patient with an ischemic stroke can lose 1.9 million neurons every minute without intervention. The advanced field stroke assessments proved highly valuable in determining the appropriate hospital destinations. Still, more needed to be done in the field to reduce door-to-needle times.
The National Institutes of Health Stroke Scale, or NIHSS, is the gold standard stroke tool that quantifies neurologic impairment, severity and location. NIHSS also strongly correlates to associated outcomes and benefits from reperfusion therapies. For example, a positive score in the limb ataxia assessment can indicate a cerebellar lesion; a positive score in the sensory screening may indicate brainstem involvement. This highly valuable tool was only performed in hospitals and only by specialty trained providers, until now.
Digital resource
Time is brain: Stroke assessment and treatment guidelines
This webinar covers stroke assessment, recognition and timely decision-making as to where to transport a patient for intervention
Leveraging telemedicine to perform NIHSS assessment in the field
Century Ambulance has partnered with medical leaders in comprehensive stroke management to leverage telemedicine technology to connect with the receiving neurologists to perform this NIHSS assessment in the field. The program shaves an average of 7.5 minutes off treatment times through HIPAA-compliant remote videoconferencing. That’s an average savings of 14.25 million neurons per patient.
Telemedicine has become an accepted form of healthcare. Now, this integral tool has reduced the ticks of the clock until treatment by providing early comprehensive stroke assessment and appropriate care. And every clock-tick counts. The American Heart Association says that, in addition to the 1.9 million neurons, patients experiencing a typical large vessel acute ischemic stroke lose 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers each minute. With a trained EMS crew using telemedicine, that critical first phase of treatment – including stroke recognition, neurological assessment and CT imaging – begins almost immediately and is followed by intervention and recovery.
Shifting the NIHSS assessment from a fixed environment to a moving ambulance presented initial challenges. Overcoming those challenges required collaboration. Key stakeholders adopted various training methods, extensive testing and troubleshooting to achieve standardized, reproducible NIHSS assessments with the same quality and accuracy of bedside tests.
Advanced training was provided with the technology via multiple trials, simulations and active training with identified “superusers” at all points of connection. Paramedics also trained directly with neurologists and other specialists for advanced education on NIHSS assessments, alteplase (tPA) infusions, blood products and ventilator management. Training and testing were meticulous prior to going live in the field, and continue through real-time feedback in our search to improve our technology and interventions.
Since August 2018, Century Ambulance has been at forefront of curbing total brain tissue lost during hospital-to-hospital transfers by using telemedicine in critical-care mobile units. The program is appropriately named Telestroke. Because of Telestroke, neurology teams in comprehensive stroke centers can conduct patient neurological assessments with the assistance of the transporting EMS crews while the patient is in route.
The time saved may appear insignificant, but it can improve patient outcomes on a grand scale by saving precious brain tissue and neurological function. In addition to the training mentioned above, the EMS crews directly involved with Telestroke have received years of clinical experience and higher education via critical-care certifications.
Telestroke combines state-of-the-art mobile telemedicine, real-time neurological intensivist assessment, and EMS professionals with advanced training to diagnose and appropriately manage critical stroke patients. This innovative program is a natural for the EMS community. Our passion is saving lives. And Telestroke unifies that passion with advanced training, neurology specialists and adaptation of emerging technology in a new way that not only saves lives but also helps make the lives we save the best they can be.
About the authors
Heather Stores is training manager, and Jeff Avinger is station supervisor, Century Ambulance.
This article, originally published in December 2019, has been updated.