“Do or do not there is no try” – Yoda

It has been over one month since everyone’s favorite Paterson ER started to pilot a pre-hospital stroke code.  The goal of this process is ambitious:  to get a patient to the point of go\no-go in terms of TPA within 30 minutes of arrival.

The main obstacles to timely decision-making in strokes are as follows:

  • identification
  • CT of head
  • Obtaining a current platelet count and PT\INR
  • Obtaining reading of above CT
  • Completing a thorough evaluation including NIHSS stroke scale

There are of course other elements that need to be completed but these are the most essential. This paramedic initiated process helps greatly with the first three elements and drives many of the remainder.  Anecdotally door to CT times for these patients are less than five minutes. A great improvement compared with prior (19 of these Pre-Hospital Stroke Codes have been called last month including one who received TPA). Since the paramedics have also been obtaining blood specimens (and labeling them) prior to arrival this eliminates the no-win decision between obtaining labs and getting the CT.

As with all new processes there have been hiccups and plenty of legitimate questions\concerns. Below are the most  common ones with responses:

  • I didn’t get to evaluate the patient prior to CT and\or they were unstable and need immediate care.
  • Clinical judgement is essential. If the patient sounds too unstable based on paramedic report (ie TPA appropriateness is not the first priority) it would make sense to divert the patient to a resuscitation area. As for the exam, for most patients it is unlikely to reveal anything that will change the need for emergent CT.
  • It takes the physician and nurse out of their area and away from the other patients.
  • True and true. However, if the patient had gone to the bed first a nurse would still be going over to CT with the patient immediately anyway.  As the initial workup of an acute stroke patient is really a resuscitation the presence of the physician is needed at bedside regardless. However it is reasonable to limit the amount of time in the CT scanner to the time needed to complete the non-contrast study.
  • My patients were getting CTs quickly even without this process. 
  • While we do not record this data specifically (EMS arriving stroke patients) the general consensus is that even straightforward acute stroke patients have a door to CT time of  20 minutes.
  • What about the other radiologic studies that are typically needed\requested in acute stroke patients (CT angio, CT perfusion)?
  • While these tests can be important and need to be urgently obtained they do not assist with the emergent decision of TPA eligibility. Therefore they have not been included in this process until after the go\no-go decision has been made.
  • Pre-Hospital Labs have been hemolyzing.
  • A process is now in place to track these occurrences. Also in case labs cannot be obtain prior to arriving in the CT room there will be a supply of needed equipment in that room. We will also ensure that the other CT areas have access to MEDHOST for ordering.

As always please let me know your thoughts. I should have another update for you on this process in early January!

 David