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Stopping Stroke Down Under

In southeastern Australia a team of healthcare providers has launched a new initiative to improve care for patients with stroke by synchronizing all aspects of communication and treatment beginning the moment the patient is first seen by emergency personnel. Initial results have shown significant reductions in treatment times, potentially leading to improved outcomes for stroke victims.

Stroke is a leading cause of death and disability worldwide, with 15 million individuals experiencing one each year. Every nine minutes a person in Australia suffers from a new or recurrent stroke. The growing burden of stroke care around the globe highlights the need for advances in treatment, particularly rapid identification of symptoms and quick delivery of definitive care. 

Time is a key factor in the treatment of acute ischemic stroke, as a few minutes gained or lost can make the difference between return to a normal life, permanent disability, or death. Treatments such as tissue plasminogen activator (tPA) and endovascular therapy can reperfuse vital brain tissue and minimize permanent disability if administered quickly enough. 

Systems across the globe constantly evaluate and adjust their stroke care models in efforts to decrease the time a stroke patient waits for definitive care. This interval, often referred to as “door-to-needle time,” is a critical factor in the long-term outcome for a patient experiencing an acute ischemic stroke. 

The Limitations of Linear Care

Currently most ischemic stroke patients in Australia are treated in a similar fashion, with communication and treatment both following a linear pattern. In the field the initial treating paramedics assess the patient and identify potential stroke symptoms. They then notify the receiving facility’s emergency department, usually via radio, that they are bringing in a patient who meets stroke team activation criteria.

When the ambulance arrives the receiving hospital physician assesses the patient, and initial imaging is performed to rule out intracranial hemorrhage. When it is confirmed that the patient meets criteria for treatment, the rest of the hospital team, including the neurointerventional radiologist and anesthesiologist, is alerted and begins preparing to treat the patient. 

This model creates a period of time—after the patient is identified as meeting treatment criteria but before treatment is initiated—when the patient waits in the emergency department, the reperfusion clock ticking away. Although implementation of systemwide guidelines for stroke care has dramatically reduced this time in some systems, room for improvement remains. Mobile care coordination technology offers a promising solution to the delays caused by a linear model of care. By permitting members of the patient care team to communicate simultaneously, mobile care coordination technology allows for multiple team members to begin their preparation and assessment at the same time, creating a parallel-process model. 

In Victoria, the Australian state that includes Melbourne, Bendigo Health Care Group, Ballarat Health Services, and Ambulance Victoria, led by the Florey Institute of Neuroscience and Mental Health, have partnered to use mobile care coordination technology to improve treatment for patients experiencing acute ischemic stroke. Their mobile technology platform, designed by Pulsara, is configured to allow rapid, simultaneous, and accurate transmission of critical information to all members of the care team. 

Florey professor Chris Bladin, PhD, a neurologist and director of stroke services at Ambulance Victoria, recognized an opportunity to use mobile technology to improve door-to-needle times for stroke patients. This opportunity is particularly relevant in the area’s smaller regional hospitals, where a rotating junior medical staff, limited specialists, and a lack of sophisticated infrastructure contribute to delays in patient care. 

“Some delays in care were inherently built into the system,” Bladin says. “The Pulsara platform is a useful tool to get communication to the entire team directly from the emergency department. There is no longer a need for multiple phone calls between staff, which allows us to keep a close eye on time metrics.” 

How It Works

For example, upon identifying symptoms of acute ischemic stroke, the treating paramedic uses the application on a smartphone to input patient information and activate a universal clock that times the delivery of care. The paramedic enters their scene arrival and departure times and selects the destination hospital. Crucial data such as the last-known-well time, blood glucose level, anticoagulant use, stroke scale findings, and known medications are also entered. The technology calculates an approximate arrival time using GPS and alerts the receiving hospital emergency department that a patient with suspected stroke is inbound. The receiving clinician can review the information and activate the stroke team. 

When this happens, members instantly receive an alert on their mobile devices. The data entered by the paramedic and the patient’s anticipated arrival time are available for their review. Each member of the team can see when others acknowledge the activation. As individual elements of stroke treatment are prepped and available, the entire team is notified, so each provider knows the status of the patient at all times. Individual team members can be called or messaged directly via the platform, streamlining communication and delivery of care.

Another benefit is the ability to deliver complex patient information via secure, encrypted text. This allows receiving physicians to begin their assessment before the patient passes through the hospital doors, saving critical time. 

Kathleen Bagot, PhD, a researcher with the Florey Institute, is closely monitoring the implementation of the system in Victoria. “We have received very positive feedback about the notion of streamlining communication,” Bagot says. “For the EMS personnel there are minimal fields to complete initially, with the ability to add more [information] later without any delay. Paramedics can get the initial alert out and get things in action quickly.” 

After transferring patients to the hospital team, EMS personnel can continue to monitor their progress through the platform. Field personnel “really value the case summary coming back to them after the case is concluded,” Bagot says. It allows paramedics to continually evaluate the care they delivered and their overall role in patient outcomes. 

If a patient is delivered to a regional hospital initially and then transferred to a higher-level facility with specialized stroke care, their information can be shared with experts at the final destination hospital. This allows the patient to be transferred directly into the neurology or interventional radiology department.

Time Savings

In an initial six-month pilot program at Bendigo Health, a hospital about 100 miles northwest of Melbourne, results were promising. In preliminary data presented at the Paramedics Australasia conference, the median time from a patient’s arrival at the hospital until their initial CT scan was cut in half, from 46 to 23 minutes. Median door-to-needle time decreased from 111 minutes to 78, a 30% reduction.1 

The EMS system also discovered benefits after implementing the streamlined communications for stroke and STEMI patients: When ambulances arrived at the hospital, patients were triaged earlier, transfer of care happened faster, and ambulances that had transported a suspected stroke case left the hospital to return to service in significantly less time than before.

Healthcare providers in Victoria hope their continuing trial in two regional hospitals served by 25 ambulance branches will gather important additional data about the use of mobile care coordination in the treatment of acute ischemic stroke and allow them to continue to deliver the highest-quality care to the patients they serve.  

Reference

1. Bagot KL, Cadilhac DA, Bernard S, et al. Improving acute cardiac and stroke treatment times by streamlining multi-disciplinary communication: Preliminary results for the Pulsara App Pilot. Poster presentation at Paramedics Australasia International Conference, 2017.

Shawna Renga, AS, NREMT-P, is a writer and paramedic in California, where she also serves as an instructor at the United States Coast Guard Medical Support Services School.

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