King County EMS Stroke Quality Improvement Program
A Report from the King County EMS Medical QI Section March 2012
Prepared by Sofia Husain, Jim Duren, and Norm Nedell
OBJECTIVE
The goal of the King County EMS Stroke QI program is to evaluate and improve upon the care provided to stroke patients in the pre‐hospital setting. We will also work with hospitals to obtain follow‐up information, including final diagnosis, treatment and outcome, on suspected stroke patients. These pre‐
hospital and hospital data will allow us to identify areas for improvement in pre‐hospital care.
PROGRAM PLAN
Over the last few months, KCEMS has been collaborating with a King County hospital to conduct a pilot of our Stroke QI Program. While encouraging, the results of the pilot, which are presented in this report, highlight areas for improvement in patient care. The pilot provides a strong impetus for establishing an ongoing clinical audit of pre‐hospital stroke patients.
Going forward, we will collaborate with additional hospitals in King County and will expand our QI efforts to include all EMS patients who receive a final diagnosis of stroke in the hospitals. We intend on reviewing BLS and ALS Medical Incident Report Forms (MIRFs) and Computer Aided Dispatch (CAD) reports for these patients and we will emphasize complete documentation of patient care when a cerebrovascular accident (CVA) or transient ischemic attack (TIA) is suspected. We will evaluate CAD reports and MIRFs based on the following criteria:
‐ “CVA/Stroke Protocol” alerts are sent in all cases when dispatchers/call receivers suspect a stroke
‐ Complete documentation of vital signs – blood pressure and heart rate – in all cases
‐ Measurement and documentation of glucose levels in all suspected stroke patients
‐ ALS evaluation for all severely hypertensive (sys BP>200/diasBP>110), hypotensive (sysBP<90), or hyperglycemic (>300mg/dL) patients
‐ Documentation of all 4 components of the FAST exam (Face, Arms, Speech, and Time of last seen normal), listed individually, for all suspected stroke patients
‐ Documentation of call to hospital for all suspected CVA/TIA patients, even if transported by private ambulance
‐ A goal of on scene time of < 15 mins
‐ A goal of time from 911 call to hospital arrival of < 30 mins
Focusing on these aspects of patient care will allow the entire KCEMS system to facilitate, when appropriate, rapid hospital initiation of care for stroke patients. Improving the provision of care to stroke patients in the pre‐hospital and hospital setting is an EMS priority.
The collaborating King County hospital reported 68 stroke patients who arrived via EMS from January to June 2011. Of those patients, 57 linked to King County patient records; the remaining were likely transported directly by private ambulance, without initiating a traditional EMS response. We reviewed BLS and ALS MIRFs and CAD reports for all 57 King County EMS patients.
Study population
Demographics of the 57 King County patients
58% female
Median age = 72yrs; 68.5yrs for males; 74yrs for females
70% of incidents occurred at patients’ homes
Summary of BLS and ALS MIRFs (Key points of interest are highlighted in red.)
BLS MIRFs, n = 57 ALS MIRFs, n = 10
Documentation of blood pressure 55 (96%) 9 (90%)
Hypertensive patients (sysBP>200/diasBP>110) 15 (27% of 55) 2 (22% of 9)
o Received ALS evaluation 2 (13% of 15) ‐
Hypotensive (sysBP<90mmHg) 0 0
o Received ALS evaluation ‐ ‐
Documentation of glucometry 41 (72%) 5 (50%)
Hyperglycemic (>300) 2 (5% of 41) 1 (20% of 5)
o Received ALS evaluation 1 (50% of 2) ‐
Documentation of GCS ‐ 9 (90%)
# of intubations ‐ 4 (40%)
# of IV insertions ‐ 6 (60%)
# of patients who received medications ‐ 4 (67% of 6)
# of patients with 12‐lead ‐ 3 (30%)
Documentation of call to hospital 1 (2%) 6 (60%)
Documentation of time to call 0 0
# of cases with Patient Type Code 234 or 238 or cases where Assessment includes CVA/TIA
41 (72% of 57) 7 (70%)
# of cases with any documentation of “FAST” or any component of the FAST exam
39 (95% of 41) 7 (100% of 7)
# of cases with documentation of Face 27 (66% of 41) 1 (14% of 7)
# of cases with documentation of Arms 32 (78% of 41) 4 (57% of 7)
# of cases with documentation of Speech 33 (80% of 41) 5 (71% of 7)
# of cases with documentation of Time of last normal/onset
38 (93% of 41) 7 (100% of 7)
# of cases with complete documentation of ALL 23 (59% of 41) 1 (14% of 7)
BLS Patient Type Codes (pre‐hospital diagnosis by BLS)
Frequency Percent
115 Trauma‐Head‐Closed internal injury 1 1.8
221 Shortness of breath 1 1.8
231 Seizure 1 1.8
232 Syncope 2 3.5
233 Headache 1 1.8
234 Suspected CVA 34 59.6
236 Decreased LOC 4 7.0
238 Suspected TIA 4 7.0
239 Other neurologic 1 1.8
256 Dialysis problem 1 1.8
269 Other alcohol/drug 1 1.8
284 Fever / infection 2 3.5
299 Other illness 4 7.0
Total 57 100.0
Summary of CAD reports
Initial Dispatch Codes
Response Level Frequency Percent
BLS Red IDCs 43 75
ALS IDCs 11 19
Upgrades 3 5
Medical Condition Frequency Percent
Head/Neck 1 1.8
OD/Poisoning 1 1.8
Sick (unknown)/Other 4 7.0
Stroke 37 64.9
Unconscious/Syncope 3 5.3
Falls/Accident/Pain 2 3.5
Breathing difficulty 2 3.5
Cardiac arrest 1 1.8
Chest pain 2 3.5
Diabetic 4 7.0
“Stroke/CVA Protocol” Alert Sent by Dispatch
Number of incidents where Dispatch sent this alert to EMS prior to their arrival on scene = 17
Patient Transport
Unit Frequency Percent
ALS 6 10.5
BLS 13 22.8
Ambulance 37 64.9
Unknown (not
documented on MIRF) 1 1.8
Summary of hospital data
Final discharge diagnosis
Ischemic stroke = 50 (88%)
Intracranial Hemorrhage (ICH) = 6 (11%) Subarachnoid Hemorrhage (SAH) = 1 (2%)
Description of the 50 ischemic stroke patients
Number of patients who received IV and/or IA tPA = 10 (20% of 50 ischemic stroke patients) o Number of tPA patients evaluated by ALS = 0
o Transport:
# of tPA patients transported by EMTs = 2 (20%)
# of tPA patients transported by ambulance = 8 o FAST results for these tPA patients:
Abnormal Face = 4
Abnormal Arms = 4 (+ 2 that talked about one‐sided weakness/weak grips)
Abnormal Speech = 7
Documentation of time of last normal/onset = 9
Documentation of all components of FAST = 6
Time of last normal/onset based on pre‐hospital records:
o <1 hr prior to 911 call = 21 (42%) o 1‐3.5 hrs prior to 911 call = 5 (10%)
Response and Treatment Times (for all 57 patients, including 2 outliers with long hospital times)
Time from 911
Call to First Unit on Scene (min)
Time from First Unit On Scene to Transport Start Time
(min) Goal: 15 mins
Time from 911 Call to Hospital Arrival (min)
Goal: 30 mins
Time from Hospital Arrival to
CT (min)
Number of cases 55* 17° 56† 57
Median 5.6 18.3 39.7 42.0
Minimum 2.4 10.2 27.4 15.0
Maximum 14.4 43.2 64.1 435.0
* excludes 2 cases with an unknown on scene time
° excludes cases with unknown on scene times and those cases transported by ambulances
† excludes 1 case with an unknown hospital arrival time
Response and Treatment Times (for 10 patients who received tPA)
° excludes cases transported by ambulances
Final Discharge Disposition (of all 57 patients)
Frequency Percent
Home 21 36.8
Hospice – Home 7 12.3
Hospice – Health care facility 1 1.8
Acute care facility 4 7.0
Expired 7 12.3
Left against medical advice 1 1.8
Skilled nursing facility 14 24.6
In‐patient rehab 2 3.5
Time from 911
Call to First Unit on Scene
(mins)
Time from First Unit On Scene to
Transport Start Time (mins) Goal: 15 mins
Time from 911 Call to Hospital Arrival (mins)
Goal: 30 mins
Time from Hospital Arrival
to CT (mins)
Time from Hospital Arrival to IV tPA (mins)
Goal: 60 mins
Time from First Unit On Scene to IV tPA (mins)
Time from 911 Call to IV tPA
(mins) Goal: 90 mins
Number of cases 10 2° 10 10 10 10 10
Median 5.6 11.4 32.7 24.5 62.5 97.1 102.4
Minimum 4.2 10.2 28.0 15.0 48.0 74.6 79.2
Maximum 7.8 12.6 48.6 41.0 110.0 134.3 139.2
