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Do You Have that in Writing?

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Review of:Albright KC, Schott TC, Boland DF: "Acute stroke care in a neurologically underserved state: Lessons learned from the Iowa stroke survey." Journal of Stroke and Cerebrovascular Diseases. 18(3):203-207. 2009.

The Science

This is a survey-based study of all hospitals in Iowa that attempted to determine their capability to treat patients with stroke. The authors' first attempts to collect this information via a mail survey were met with a 56% success rate. But the four-page questionnaire illustrates the typical results obtained with cumbersome, multi-page surveys. In this second attempt, which was obtained via telephone, the researchers honed the lengthy survey into the basic, most important information they desired. The survey included the following questions.
  1. Do you have EMS in your town/city?
  2. If a patient arrives with the signs and symptoms of stroke, do you immediately transfer them to another facility?
  3. Is your emergency department (ED) staffed by a physician 24 hours a day, seven days a week?
  4. Do you ever have to call in a physician from home to evaluate a stroke patient?
  5. Do you have t-PA (aka: Alteplase or Activase) available for stroke 24 hours a day, seven days a week?
  6. Can you obtain a noncontrast CT of the head on site?
  7. Do you ever have to call in a lab tech from home in order to get labs?
  8. Can you obtain an immediate neurology consult, either in person or by phone?
  9. Who decides whether t-PA is given: physician, PA/NP or other?
  10. Does your ER have standing orders or a stroke protocol for treating stroke patients?

Of the 118 hospitals with EDs, 109 (92.4%) had CT available. However, only 15.1% had in-house radiology technicians to run the CT 24 hours a day, seven days a week. Of the 118 hospitals, only 42.2% had in-house physicians and 38.8% had in-house laboratory technicians 24 hours a day, seven days a week. Within the subset having CT capabilities, 89.9% (98/109) had IV tissue plasminogen activator (IV t-PA) available.

Of those 89 facilities with CT and IV t-PA, 45 (46%) had around-the-clock in-house physician coverage. Of those 45 sites with CT, t-PA, and an in-house physician, 14 (31%) had an on-site radiology technician. Only 14 of the total 118 hospitals (12%) could offer all essential components. In all, 88% of Iowa hospitals didn't provide all of these components. Regardless, just 31% reported protocols for stabilization and immediate transfer of acute stroke patients while 42% had prehospital stroke protocols in place.

Despite these in-house deficiencies 95.6% had neurologist consult (via phone or other means), and 91.9% had radiologist consultation available 24 hours a day, seven days a week.

They found a correlation between the smaller hospitals and the lack of resources, which is no surprise. But they were surprised at the lack of written protocols for the rapid transfer of stroke patients to definitive care.

The Street

Although this paper may be an incrimination of the lack of preparedness of some rural hospitals to deal with stroke patients, 98% of the hospitals in the study stated they had EMS serving their community. Of this, 85% were certified at the ALS level. So what does this mean to you?

For years we've learned the importance of delivering trauma patients to definitive care within the "Golden Hour." Almost every state has some form of trauma system, and EMS has triage and transportation guidelines designed to rapidly move the multiple trauma victim to the highest level of care. The data is clear that trauma patients do better when delivered rapidly to trauma centers, but there is little evidence that their outcomes are as time sensitive as the care we render to patients having a stroke.

For stroke, the window for definitive care is three hours in the vast majority of cases. The process of transporting the stroke victim to a hospital that may or may not have an in-house physician to evaluate whether the patient is a candidate for reperfusion, then call in a CT tech to perform the scan, then wait for a radiologist's interpretation and possibly a neurology consultation wastes valuable time. This is very much like the early days of heart attack care. In the past, EMS took the reins. Perhaps we must do so again.

The results of this study should lead every EMS agency to ask the following critical questions:
  • "Does my hospital have a commitment to stroke care?"
  • "Is that commitment demonstrated in policies that allow EMS to activate a 'Stroke Code?"
  • "Am I taking my patient to themost appropriate facilityfor the care of a suspected stroke?" and, most importantly,
  • "Am I providing the stroke patient the same level of urgency and priority of care as I do for trauma?"

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