Georgia Standardizes Ambulance Care for Acute Stroke Patients

Overview

Chad Black, Habersham County EMS, and Chris Threlkeld, Region 10 EMS Director, attend the Georgia Stroke Conference in 2019.

A stroke, sometimes called a brain attack, occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts. A medicine called alteplase can dissolve the clot, but only if given in the first few hours after the stroke.

Since 2001, CDC’s Paul Coverdell National Acute Stroke Program (Coverdell Program) has supported state-based stroke registries across the country. The program works to ensure that all Americans receive the highest-quality care for stroke and to reduce deaths and disabilities from stroke.

The Georgia Coverdell Acute Stroke Registry (GCASR) recognized and prioritized the key role of emergency medical services (EMS) personnel in stroke care. In 2013, GCASR convened a group of health care professionals working in rural and urban areas to develop stroke care guidelines for EMS providers.

The 2013 guidelines outlined the care that EMS should provide while transferring stroke patients from small facilities to larger hospitals that are better equipped to treat stroke patients. In 2015, the hospitals in GCASR developed a protocol to guide the care that EMS personnel provide as they transfer stroke patients who have received intravenous alteplase to a higher-level stroke center.

Challenge and Approach

The goal of updating the transport protocol was to enhance and standardize the quality of care when transferring patients from a smaller hospital to a larger and better-equipped hospital. Changes in a stroke patient’s condition during the transfer require EMS personnel to make critical treatment decisions.

Each Georgia EMS agency had its own medication formularies, a list of preferred drugs to treat certain health conditions. Some formularies did not include preferred medications that needed to be available on the ambulance. EMS agencies needed to revise their formularies to include all recommended medications.

In order to establish consistent care during transfer of stroke patients, a subgroup of the GCASR steering committee, including stroke coordinators and a neurologist, drafted a one-page protocol—the EMS Interfacility Transfer Protocol for Patients During and After Intravenous Alteplase Administration for Acute Ischemic Stroke.

“This protocol provides much-needed guidance for the paramedic when transporting acute stroke patients who receive alteplase. Having this protocol to follow helps both the provider and patient and ensures the correct treatment path is followed during the interfacility transport.”

Accomplishments

As a result of the updated transfer protocol, participating EMS agencies’ formularies now include all the medications recommended for the care of acute stroke patients during the transfer.

The Georgia Office of EMS and Trauma posted the new protocol on its website to alert EMS agencies throughout the state about the protocol and encouraged them to adopt it. GCASR discussed the new protocol at the first GCASR annual educational stroke conference and asked EMS agencies to add the protocol to their training.

The protocol is now included in the orientation for newly recruited GCASR hospitals and EMS agencies. Most EMS agencies, even those that are not participating in GCASR, are using the protocol.

In 2019, the protocol was updated to add checks for vital signs such as blood pressure and pulse and for neurological functioning such as consciousness and motor function.

Lessons Learned

The success of this lifesaving initiative can be credited to several factors, including the following:

• Having the hospital stroke coordinators propose the new protocol ensured buy-in from the participating hospitals.
• Having the support of the state Office of EMS and Trauma, which also identified EMS agencies that would disseminate the protocol, helped ensure EMS participation.
• Having the hospital stroke coordinators use the state-endorsed protocol as part of the national accreditation review process helped ensure the protocol was widely used.

“By putting some guardrails and direction in place, the Interfacility Transfer Protocol created a safer transfer. Hospitals know how to better prepare the patients for transfer, and EMS agencies are more aware of how to respond and who to call if a complication occurs on the way to the hospital. The main result is that the patients are transported safely.”

Next Steps

Rachel Lewallen, Stroke Abstractor at Habersham Medical Center; Beth Hester, ED Manager at Habersham Medical Center; and Teri Newsome, QI Coordinator at GCASR, attend a Stroke Boot Camp meeting in 2018.

The transport agreement between EMS agencies and hospitals will be updated to reduce the time between the arrival of a patient at the emergency department and when the emergency department staff assumes responsibility for the patient.

There will also be an effort to improve communication between EMS agencies and hospitals regarding estimated time of arrival.

“GCASR strives for quality improvement and encourages collaborative efforts across the continuum of care for stroke patients,” said Carol Fleming, RN, clinical and outreach director of the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital. “The interfacility transfer protocol provides the prehospital provider with evidence-based guidance on the treatment of the patient receiving alteplase. This best-in-practice tool streamlines the handoff from the sending facility to the receiving and meets the standards of accreditation requirements.”

Additional Information

• CDC: Paul Coverdell National Acute Stroke Program
• Georgia Department of Public Health: Georgia Coverdell Acute Stroke Registry