# Presentation: 107135

## The North Carolina EMS Stroke Toolkit:Improving Patient Outcomes and EMS Systems

- HDSP State Program Training
- Tuesday Sept 18, 2007

- Ishmael Williams MA
- CDC
- Division for Heart Disease and Stroke Prevention

## North Carolina EMS Stroke Toolkit

- Collaborators and partners:
- Michael Matters, DHDSP – HSRRT
- Margaret O. Casey, NACDD
- Marcus Plescia, NC Chronic Disease Director
- Anita Holmes, NC CVH Program
- Greg Mears, UNC & NC EMS Medical Director
- Cindy Raisor, EMSPIC
- Drexdal Pratt, NCOEMS
- Staff of DHDSP

**Notes:**
Michael Matters – Co-investigator, Health Service Research & Registries Team
Margaret O. Casey – Public Health Consultant, National Association of Chronic Disease Directors
Marcus Plescia, NC Chronic Disease Director, Chief, North Carolina Division of Public Health, Chronic Disease and Injury Section 
Greg Mears, MD Associate Professor Department of Emergency Medicine (UNC-Chapel Hill), North Carolina EMS Medical Director, The EMS Performance Improvement Center
Cindy Raisor Project Director of NC Stroke Toolkit and the staff of the EMS Performance Improvement Coordinator
Drexdal Pratt, Chief North Carolina Office of EMS

## NEMSIS National EMS Information System 

- <date/time>

- NEMSIS National EMS Information System

- Developed by NASEMSO & federal partners:
- Implements a national standard for recording pre-hospital medical emergency care.
- Establishes a central database for national reporting.

- _www.NEMSIS.org_

**Notes:**
Developed by the National Association of State EMS Officers – the organization of State EMS Directors and State EMS Medical Directors along with National Highway Traffic Safety Administration (NHTSA) and Health Resources and Services Administration (HRSA). 

NEMSIS is a national database that implements the NHTSA Uniform Pre-Hospital EMS Dataset, Version 2 – a comprehensive dataset that provides for uniform documentation of EMS service and patient care delivery including Dispatch, Incident Data, Patient Data, Demographics, Medical History, Assessment, Medical Device Data, Treatment/Medications, Procedures, etc.

Includes a core subset of 66 data elements as the minimum number of variables that each state would collect and submit to a national registry for generating reports to better define and describe EMS systems, personnel, and services across the country.

Virtually all states have agreed to participate but implementation has been slow for lack of funding.

## NEMSIS National EMS Information System 

- NEMSIS National EMS Information System

**Notes:**
Evaluate patient outcomes.
Monitor EMS systems performance.
Track standards of care.
Develop EMS training curricula.
Data source for local, state, and national surveillance and research.
Complements hospital registries.
A tool for National and state health planning.

## NEMSIS National EMS Information System 

- NEMSIS National EMS Information System

**Notes:**
Four states (New Hampshire, NC, Minnesota, & Nevada) submitting data to NEMSIS central database. Utah & Nebraska have just started submitting data this month (September 2007).
Idaho: submit late September
New Jersey:  submit November
Tennessee: submit in the fall
North Dakota: asking vendor to submit
Delaware: ready to submit late summer 
Maine: waiting for law to apply

Three states submitting data for review to NEMSIS.
Sixteen states working with Technical Assistance Center to implement NEMSIS.

States Requesting 408 Funding (NHTSA grants to states) for NEMSIS
AL, AR, AS, AZ, CA, CO, CT, FL, HI, ID, IN, KS, LA, ME, MI, MN, MO, MS,
MT, NE, NJ, NM, OH, OK, PA, PR, RI, SD, TN, UT, VT, WA, WI, WY

## Building on NEMSIS with Toolkits

**Notes:**
A toolkit is a web-based program that allows local EMS departments to securely access their data records to generate a series of reports, tables, and graphs that summarizes performance for all stages of EMS response including call screening, dispatch, travel and transport times, diagnosis, and treatment.

The reports include recommendations for specific interventions or changes in procedures consistent with standard best practices. The report tool also helps to identify local solutions that can be shared anonymously to improve EMS service delivery and patient care across state systems. It also supports strategies to improve staffing, training, and reimbursement 

The process is data driven, measurement-based quality control strategy known as Six Sigma. Pioneered first in the manufacturing sector by Motorola, Six Sigma has been tested and adapted over the years to many other areas including healthcare delivery. It promotes incremental quality improvement and variation reduction of processes such as healthcare delivery through processes for defining, measuring, analyzing, improving, and controlling performance. Progress is compared to past performance, to EMS departments in similar counties, and to statewide benchmarks.

## NEMSIS EMS Toolkits 

- NEMSIS EMS Toolkits

- North Carolina EMS toolkits:
- Local EMS System Delivery
- SMARTT
- Trauma
- Cardiac Arrest
- Pediatric Care
- Airway Management
- Acute Coronary Syndrome
- Stroke (CDC – DHDSP Sponsored)

**Notes:**
Local EMS System Delivery Performance – info on EMS resources (ambulances and personnel), call volume, transport volume, patient contact, type of dispatch (enhanced 911, wireless), hospitals & specialty centers served, distance traveled, response times, etc.
SMARTT is a web-based tool for monitoring hospital, EMS system and health center resources such as hospital bed availability, specialty service capability, and disaster resources, clinical services offered, laboratory capabilities, and any inpatient bed capacity.  EMS systems provide information on a weekly basis to identify personnel and vehicle availability as well as resource capabilities which may be needed in the event of a disaster. 
Trauma Care (injury, burns, etc.)
Cardiac Arrest Care (circulatory failure [no left ventricle pumping] often due to electrical problems or ventricular fibrilation (irregular heart rhythm)
Pediatric Care – care for children)
Airway Management (maintaining open pathway between a patient s lungs and the outside world, and that the lungs are safe from aspiration – fluid in lungs)
Stroke Care - Ischemic stroke is caused by blockage in an artery that supplies blood to the brain, resulting in a deficiency in blood flow (ischemia). Hemorrhagic stroke is caused by the bleeding of ruptured blood vessels (hemorrhage) in the brain. 
Acute Coronary Syndrome Care - unstable or intermediate coronary syndrome and / or Acute Myocardial Infarction (basically a heart attack – dead heart muscle tissue following interruption of blood flow)

## North Carolina EMS Stroke Toolkit 

- North Carolina EMS Stroke Toolkit

- One year project with NCOEMS & UNC-Chapel Hill Dept. of Emergency Medicine.
- Develop report tool for emergency care of stroke using NC’s EMS database.
- Utilizes PreMIS (Prehospital Emergency Medical Information System) used by all 100 NC counties.
- Designed by panel of EMS and Stroke care experts.

**Notes:**
One Year Project with North Carolina Office of EMS and UNC-Chapel Hill Dept. of Emergency Medicine.
Develop report tool for EMS performance in pre-hospital emergency stroke care.

Utilizes PreMIS (Prehospital Emergency Medical Information System) used by all 100 NC counties.

Designed by panel of EMS and Stroke care experts included state health officials from NC Dept Public Health, NCOEMS, regional EMS directors and data managers, neurologists, American Heart Association, Tri-State Stroke Network, CDC, state public health officials from SC & KS.

## North Carolina EMS Stroke Toolkit 

- North Carolina EMS Stroke Toolkit

- Objectives:
- Implement emergency pre-hospital stroke care best practices,
- Facilitate incremental improvement of emergency stroke care,
- Support NEMSIS compliant EMS databases,
- Develop stroke care database with potential for collaborative partnership with Coverdell Stroke Register,
- Strategic partnership in a model state for stroke treatment.

**Notes:**
Incremental improvement because that is often the only sustainable way to effect change of engrained procedures, it allows the success of small improvements to spur additional change.
Working in NC but we wanted the tools and lessons learned to be of use nationally.
In NC we have over 40 hospitals utilizing Coverdell and there is a close working relationship between hospital and EMS managers and a mandate. NC State bill 1860 (passes in 2006) authorized Stroke Advisory Council to designate task force under Dr. Marcus Plescia to devise blueprint for improvement statewide stroke systems of care
Expert panel in advisory group includes the same partners that are serving on our Stroke Toolkit panel
Discussions recognized need to link Coverdale Stroke Registry with EMS Database.
The Health Service Research & Registries Team in the Division recognized the benefit to both hospital and EMS interests. EMS gets a patient outcome and hospitals get critical pre-arrival data.

## http://www.nccep.org/content/ems/standards/protocols.htm

- Stroke EMS Toolkit & North Carolina State Stroke Protocol

**Notes:**
EMS Stroke Toolkit is consistent with protocols from North Carolina College of Emergency Physicians
EMS Protocols, 2005

## North Carolina EMS Stroke Toolkit 

- North Carolina EMS Stroke Toolkit

- Public Education
- Community Awareness
- Community Education
- Stroke Recognition
- Access 911
- E911 Implementation

**Notes:**
Community education evaluates and analyzes the EMS System’s involvement and participation in community education and prevention initiatives related to heart disease. North Carolina is implementing a statewide Stroke Initiative which engages EMS Systems and Hospitals to optimize care for stroke patients focusing on critical time intervals and interventions.  This includes EMS involvement in community public health promotion programs as well as EMS workforce health and safety as it relates to cardiovascular disease and specifically stroke risk.
Level of 911, basic (universal call number), enhanced wireless telephone # & cell tower location provided to dispatcher; in Phase II lat-long will be provided

## North Carolina EMS Stroke Toolkit 

- North Carolina EMS Stroke Toolkit

- EMS Dispatch
- - Emergency Medical Dispatch (EMD) implementation
- Stroke Recognition
- Quality Management
- Call Location
- Dispatch Time Benchmarks (90 Seconds)

**Notes:**
- level of service (basic or advanced life saving), whether dispatchers and EMS personnel (basic, intermediate, and paramedic) are trained in recognition of stroke recognition, existence of stroke plan addressing patient destinations, and benchmarks for dispatch of ambulances to 911 site.

## North Carolina EMS Stroke Toolkit 

- - Stroke Care requires less EMS intervention or care than other acute EMS events
-  Key interventions
- Quick Response
- First Responders
- Appropriate Timely Transport

- North Carolina EMS Stroke Toolkit

**Notes:**
key EMS interventions relate not to advanced treatment but to diagnosis and timely transport.

## North Carolina EMS Stroke Toolkit 

** ****EMS “Chute” Time or “Wheels Rolling” Time**
** ****EMS Response Time**
** ****EMS Total Response Time**
** ****EMS Scene Time**
** ****EMS Transport Time**
** ****Total EMS Patient Contact Time**
** ****EMS Response Delays**
** ****EMS Scene Delays**
** ****EMS Transport Delays**

- North Carolina EMS Stroke Toolkit

**Notes:**
Dispatch Center Time - Unit Notified by Dispatch Time minus 911 Call Time
EMS Chute Time - Unit En Route Time minus Unit Notified by Dispatch Time
EMS Response Time - Unit Arrived on Scene Time minus Unit Notified by Dispatch
EMS Total Response Time - Unit Arrived on Scene Time minus 911 Call Time
EMS Scene Time - Unit Left Scene Time minus Unit Arrived on Scene Time
EMS Transport Time - Patient Arrival at Destination Time minus Unit Left Time.
Total EMS Patient Contact Time - Patient Arrival at Destination Time minus 911 Call Time
Response Delays – weather, traffic, crowd safety, vehicle failure or crash, language barrier, distance, directions, diversion (for other call), hazardous material.

## EMS Skills
- Documentation
Time of Onset
Contact Information
Stroke Scale
Glucose
Vital Signs
Rhythm is capable
Thrombolytic Screen

- - Documentation
- Time of Onset
- Contact Information
- Stroke Scale
- Glucose
- Vital Signs
- Rhythm is capable
- Thrombolytic Screen

- North Carolina EMS Stroke Toolkit

**Notes:**
Procedures and Treatment critical to quality acute stroke care include:
- Documentation of History, Onset of Symptoms, Vital Signs, and Exam
- Documentation of a Stroke Screen
- Glucose Measurement
- Documentation of the Cardiac Rhythm
- Documentation of the Thrombolytic Screen
- Scene Time of less than 10 minutes

Thrombolytic screen - Follow the appropriate protocol for patient’s complaint to assess need for thrombolytics (e.g., Los Angles Pre-hospital stroke screen or other instrument for suspected stroke, 12-lead EKG for suspected myocardial infarction, etc.). If the screen is positive, proceed to step B below.
By history from the patient and/or family members, obtain and document the following information:
1. Onset of signs & symptoms?
2. History of active internal bleeding?
3. History of CNS neoplasm, arterio-venous (AV) malformation, or CNS aneurysm?
4. History of CNS surgery in past 2 months?
5. History of severe, uncontrolled hypertension (>200/130)?
6. History of bleeding disorders?
7. History of aortic dissection?
8. History of allergy to tPA?

## Patient Care
Scene Time limited to 10 minutes
Low probability of Airway compromise
IV if > 15 minutes transport time
Stroke Screen
Oxygen if <97%
Assessment
Neurologic Exam
Mental Status Exam
NPO

- Scene Time limited to 10 minutes
- Low probability of Airway compromise
- IV if > 15 minutes transport time
- Stroke Screen
- Oxygen if <97%
- Assessment
- Neurologic Exam
- Mental Status Exam
- NPO

- North Carolina EMS Stroke Toolkit

**Notes:**
NPO - abbreviation for nothing by mouth (from the Latin Nil peros) , stroke patients can have difficulty swallowing so no meds or water. Let ER make determination.

## Transport and Destination
- Stroke Plan/ Policy
Thrombolytic drugs if 2 hours or less
Invasive intervention in 6 hours or less
Scene Times less than 10 minutes
If Transport Times greater than 15 minutes consider
Specialty Center
Specialty Care Transport Services

- - Stroke Plan/ Policy
- Thrombolytic drugs if 2 hours or less
- Invasive intervention in 6 hours or less
- Scene Times less than 10 minutes
- If Transport Times greater than 15 minutes consider
- Specialty Center
- Specialty Care Transport Services

- North Carolina EMS Stroke Toolkit

**Notes:**
In NC Stroke Plans are built regionally by stroke treatment centers, other hospitals, and EMS so that decisions have been made before hand so that EMS doesn’t have to authorize diversions unilaterally.

Thrombolytic clot dissolving drugs include TPA (Tissue Plasminogen Activator),  r-tPA, streptokinase, urokinase and prourokinase.

Eligibility for IV treatment with rt-PA
Age 18 or older.
Clinical diagnosis of ischemic stroke causing a measurable neurological deficit.
Time of symptom onset well established to be less than 180 minutes before treatment would begin.

Invasive Intervention – arterial intervention like angioplasty (inserting a balloon and installing a stent to widen the artery with filter to catch clots), also carotid endarterectomy - cutting opening the carotid artery and scraping away the plaque.

## Concluding remarks 

- Concluding remarks

- NEMSIS establishes a common EMS data standard and national database.
- Toolkits track EMS performance, monitor patient outcomes, and facilitate improvement in both.
- Linkage of EMS and hospital registries will become an important next stage of development in tracking CVD from EMS to hospital release.
- Interlinked datasets like these will provide a vehicle for assessment of local health service delivery and identification of disparities in emergency health care.
- These tools will help EMS stakeholders recognize interventions that work and focus improvement efforts where most needed .

**Notes:**
Embraced by all states and endorsed by all federal agencies and other stakeholders. The movement is towards regular reporting of EMS using this database at the local, state, and national level. Public Health is a logical end user of such EMS reporting.
NC is building toolkits and the Technical Assistance Center (Utah) is designing various state and national report templates.
Newly developed toolkits are bringing real value to the extensive data being collected. They are being tested and refined for eventual sharing with other NEMSIS users as states implement NEMSIS.
Database linkages are already being discussed and planned in NC of their EMS database with the Stroke Coverdell Registry and will likely follow in other toolkits. This will enable much more complete assessments of patient outcomes and health service delivery especially for regional systems of care.
These data and tools will give us hard data on medical services and patient outcomes and help us focus interventions including public health outreach where it is most needed.

## Questions?