The Minnesota Emergency Medical Services Stroke Treatment Survey 2006 provided valuable information about current opinions on stroke, transport and treatment practices, and training format preferences for Minnesota ambulance service personnel. For example, few services reported using a helicopter to transport stroke patients. Although helicopter transport may not be practical within the Twin Cities metro area because distance and traffic congestion are not significant barriers, services in rural areas should consider using air transport to reach a hospital within the window for using thrombolytic therapy.
A minority of EMS have a written policy for where to transport patients with acute stroke. Although most hospitals in Minnesota claim to be prepared to either treat or transfer stroke patients, the current practice of transporting to the nearest hospital highlights the need to increase the capacity of hospitals statewide to treat patients with acute stroke according to current clinical practice guidelines.
Respondents reported CD-ROM- or Internet-based training curricula and conferences or seminars as the most effective vehicles for training ambulance personnel. However, no further details were obtained about how effectiveness was assessed.
The Minnesota Acute Stroke Treatment System Survey 2006 identified many areas of strength in stroke care. These include around-the-clock laboratory services and CT scan services, plans for transferring stroke patients in hospitals without coordinated post-ED care, and ability to administer intravenous tPA for treatment of acute stroke. However, much work remains to build an effective and efficient system of care for stroke patients in Minnesota hospitals.
At the time of the survey, only six hospitals had been certified as Primary Stroke Centers; since then, three additional hospitals have been certified. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. The Joint Commission Primary Stroke Center certification program is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
Limitations of both surveys should be considered in interpreting results. First, accuracy of responses was limited to respondents' knowledge about stroke practices and capacity. The extent to which respondents queried more informed colleagues to answer questions for which they were unsure is unknown. In addition, self-reported information has the potential for bias toward positive answers when the opposite may be true. Moreover, none of the responses were confirmed by external review or formal inquiry. Despite their limitations, these data are valuable for planning changes and developing a coordinated system of stroke care in Minnesota.
The MSP Steering Committee developed the following recommendations for consideration by ambulance services, hospitals, state agencies, and collaborating partner organizations in making systems-level improvements in stroke care. These suggestions and strategies were based on the results of these surveys and on discussion in quarterly meetings during 2006 after the surveys.
Prehospital EMS personnel should continue to treat stroke as an emergent event.
Because a large proportion of respondents reported that first responders typically provide only vital sign information to ambulance staff about a patient with a suspected stroke, without indicating they suspect a stroke, MSP and its partners should consider teaching first responders to recognize the signs of stroke and to communicate such information to ambulance personnel.
MSP and its partners should encourage all ambulance service organizations to use the Cincinnati Stroke Scale as the standard for assessing patients suspected of having stroke. By having all ambulance organizations voluntarily adopt the Cincinnati Stroke Scale, a common standard can be established for training and educating ambulance personnel.
MSP and its partners should inform hospital ED staff that this stroke scale standard is being encouraged, and prehospital providers should include instructions in their standard operating procedures to always verbally provide stroke scale information to hospital ED staff. This communication will potentially aid the efficiency of care provided in the destination hospital.
MSP and its partners should inform prehospital EMS providers about the locations of primary stroke centers and educate them about recent recommendations for stroke systems of care.
MSP and its partners should provide training for prehospital EMS providers on stroke issues annually or semiannually. This training should be offered, but not mandated, for ambulance personnel.
MSP and its partners should provide classroom education or regional conferences and seminars — probably the most effective methods for education and training. Internet-based training also should be provided as an option for continuing education.
Hospitals that do not currently have standing orders for treating acute stroke in the ED should develop and share protocols. The state agency (MDH), in collaboration with partners, may be in the position to provide technical assistance to ED staff in all hospitals — but especially small and rural hospitals — to aid implementation of protocols and standing orders.
ED protocols in rural hospitals should consider including telemedicine. Relationships should be fostered between appropriate facilities (e.g., hospitals within the same health systems) to help development of telemedicine to improve acute stroke care.
MSP and its partners should develop care protocols and pathways for inpatient care of stroke patients and share these tools among hospitals, particularly rural hospitals.
Staff at hospitals that do not have a stroke code for inpatient stroke events should be trained on developing and implementing protocols.
Quality improvement and education
MSP and its partners should provide technical assistance and lessons learned to all hospitals that plan to become certified as Primary Stroke Centers by the Joint Commission.
MSP and its partners should provide ongoing stroke training and continuing education opportunities for hospital staff on the following topics:
- Protocol development and implementation
- Evidence-based use of tPA
- Early and rapid assessment of stroke (National Institutes of Health Stroke Scale training)
- Updates and current practices for stroke care
Partner organizations may collaborate with hospital education and outreach departments to develop community-based stroke education efforts, particularly during May (Stroke Awareness Month).
Partners should collaborate on increasing the number of hospital EDs that administer intravenous tPA in appropriate and eligible stroke patients.
MSP and its partners should develop a voluntary hospital network, where purpose, infrastructure, and initiatives are defined and implemented by multiple partners, including the state quality improvement organization, state hospital association, state office of rural health, and the statewide coalition or task force for stroke.
The results of these surveys will guide MDH and MSP in planning for systems-level intervention and programs to improve acute stroke care in Minnesota. In addition, ambulance services and hospitals can use these results to change their health systems to improve the quality of care for their stroke patients. Finally, these surveys highlight the need to develop a statewide or regional system for transportation and treatment of stroke patients to better facilitate coordination between EMS and hospital care. This system may involve development of formal or informal agreements to divert patients to appropriate facilities, establishment of a structure for providing continuing education to health care providers, and opportunities for health care organizations to improve their overall stroke care capacities.