Pre-Hospital. 8 Minutes stops the clock but doesn t burst the clot. Gerry Egan

Transcription

1 Pre-Hospital 8 Minutes stops the clock but doesn t burst the clot Gerry Egan

2 First contact ACC Medical Priority Dispatch System MPDS sets the questions SAS set the Call acuity SAS set the Response Cat A, B, C, calls CAT A Challenge

3 8 Minutes Stroke calls Cat A response Nearest response goes Car/Bike single Paramedic Conveying response (ambulance) stood down Long on scene times

4 09-10 Number of Incidents 5,307 % Given % Blood Glucose Measured % Given Glucose 0.21 % Given Glucagen 0.28 % BP Recorded % Given Crystalloid 1.26 % Alive at Hospital % Conscious at Hospital Number HAS 4,153 Number CTF <= 60 Mins 2,832 % Call to Facility within 60 Mins 68.19

5 Time on scene Scotland

6 We needed a + change Amber call = Cat B F.A.S.T in control Ambulance double crew resource Paramedic or Technician crew Education NO STAND DOWN 12 months to make the change

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9 Time on scene Scotland %

10 12-13 Number of Incidents 6,400 % Given % Blood Glucose Measured % Given Glucose 0.19 % Given Glucagen 0.19 % BP Recorded % Given Crystalloid 0.84 % Alive at Hospital % Conscious at Hospital Number HAS 2,277 Number CTF <= 60 Mins 1,712 % Call to Facility within 60 Mins 75.19

11 Time on scene Scotland %

12 Comparison 6-10 mins less on scene >26 mins Mins On scene On scene 32% 29% 31% 28% scene>26 mins 30% 29% 28% 27% On scene Mins scene 27% 26% 25% 24% On scene 26% 23% 25% Year 22% Year

13 The Complete Timeline of Emergency Medical Response After Acute Stroke: Are Delays Changing? Authors: Hart SR 1, Tough D 2, Lee R 3, Doubal F 3, Mathews T 3, Gray A 3, Fernandes P 3. 1 Division of Clinical Neuroscience, University Of Edinburgh EH4 2XU. 2 Scottish Ambulance Service. 3 Royal Infirmary Of Edinburgh, EH16 4SA Abstract Early assessment, diagnosis and treatment of acute stroke reduces morbidity and mortality 1. Patients who present with an acute stroke need immediate clinical assessment and treatment 1,2. Our Complete Stroke Timeline Audit demonstrates that, despite interim local programs to raise staff awareness, time to CT brain request increased and time in all other medical responses to acute stroke showed a trend towards increased delays. Introduction and Aims Early investigation and intervention is essential for effective stroke treatment. This study defines the complete Timeline of Interventions, from stroke onset to ambulance and emergency department responses. The audit was repeated before and after introduction of local programs aimed to improve delays in the emergency response to Acute Stroke. Method s The following times were audited in a large teaching hospital (n=200): acute stroke onset, emergency services contact, ambulance arrival and departure, non-medical triage, A&E medical assessment, blood tests, CT brain requested and CT performed. There were two audit cycles one year apart: 01/11/ /05/2010 and 01/11/ /05/2011. Between cycles, local stroke staff lectures were commenced, 24 hour specialist telemedicine was launched and the FAST campaign was re-launched locally. Results Figure 1. Timeline: Stroke Onset to A+E Arrival (Minutes) Timeline: Median Emergency Response Times From A+E Arrival (Minutes) * Median Stroke Onset to A&E Arrival Time = 129 minutes * * * * * * 1 st cycle 2009/10 Arrival at A&E Median Stroke Onset to A&E Arrival Time = 81 minutes Non Medical Transferred from A&E to medical assessmen Blood Brain CT Brain CT another clinical area triage t started tests requeste performed completed requeste d d * * * * * * nd cycle 2010/11 KEY POINTS OF RESULTS In the year between the 2 cycles, median time to request a brain CT significantly increased from 61 to 94 minutes (p<0.05) After arrival at A&E, overall, Medical Assessment began after median 31 mins (14-51). When a Stroke Specialist was contacted, this happened after a mean 66 (+/-35) mins. Overall, following A&E arrival, CT was requested after median 1 hour 12 mins and performed after 2 hours 25 mins. A&E attendance lasted a median 3 hrs 40 mins ( mins) Comparing 2009/10 to 2010/11, patients arrived sooner at A&E, but in 2010/11 median initiation time of all emergency response interventions showed a trend towards Conclusions increased delays Acute stroke patients often did not receive early clinical assessment or investigation. The trend was towards increased delays despite interim measures to educate A&E This study is important because it shows that time to CT Request increased. There is a trend towards increased delays in all other medical responses. This is despite staff to act fast educational measures that were implemented between the audit cycles. Reasons for these increased delays may include diminution in awareness or urgency after the the initial launch and publicity of a Hyper-acute Stroke Service and competing demands on A+E staff. Further initiatives are required to improve or just maintain the timing of the emergency response to Acute Stroke. References: 1. Management of Patients with Stroke or TIA: Assessment, Investigation, Immediate Management and Secondary Prevention. SIGN Guideline Stroke. National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack. NICE 2008.

14 Cardiology experience Transmit data Clinical decision support Pre alert Direct to care Bypass protocols MCN s FEED-BACK to crews

15 MEDICAL DIVISION Scottish Ambulance Service NHS Lothian University Hospitals Division A&E and Stroke Medicine Royal Infirmary of Edinburgh 51 Little France Crescent, Edinburgh EH16 4SA Date: Enquiries: Stroke team Telephone: Dear Colleagues With reference to the case below and as agreed with the SE Division Head of A&E Services we have detailed clinical feedback on your management of this patient who suffered an acute stroke and our service was pre-alerted to their arrival. We trust that this feedback and shared experience will be helpful to you and your colleagues. Case data Name: Address: Date of incident: * 999 call received (time): * Incident no. * Call sign: [* SAS to complete before sending to attending crew] Clinical feedback Time of SAS call to hotline / A&E: Time of arrival in A&E: hospital site: Diagnosis of stroke confirmed? [Yes/No] Thrombolysed? [Yes/No] If not thrombolysed, why not? Patient progress: Any comments for SAS crew: Yours sincerely Consultant name Stroke Medicine, NHS Lothian

16 Thank you Questions and Discussion