Timely Access to Emergency & Acute Stroke Care
Acute care for stroke is all about timing. The longer blood flow to the brain is interrupted, the greater the chance of permanent brain damage. Brain tissue can only be saved with timely access to the right location, trained and organized clinicians and appropriate therapies.
The recommended goals for initial treatment time in Canada (included in B.C.’s Next STEP Guidelines) are as follows for patients who present with a time since stroke symptom onset of 4.5 hours or less:
- Patients who arrive at the hospital should be seen by an ER physician within 10 minutes.
- A physician with stroke expertise should be available to see the patient within 15 minutes of arrival at hospital.
- Stroke patients should have a CT scan within 25 minutes of arrival at the hospital.
- CT scans for these patients should be interpreted within 45 minutes.
- Patients receiving rt-PA should have it administered within 1 hour of hospital arrival.
- For patients presenting to a telestroke site, the time between ER arrival and the time when a call is placed to the physician referral centre should be less than 30 minutes, and the call-back time should be less than 10 minutes.
This timely access to care is only possible with organized protocols and guidelines spanning ambulance transport to radiology to neurology/internal medicine. The current system in B.C. stands in the way of achieving these goal times, especially for those patients that are inappropriately transported to a hospital that does not have a CT scanner, due to the ensuing delays for consultation and transportation to a more appropriate site.
Protocols for treatment of stroke in the field and the conveyance of patients to the closest medical facility have been developed by the Heart and Stroke Foundation of Ontario. These protocols classify patients according to their condition and eligibility for rt-PA. They also outline recommended levels of care based on the type of hospital resources that need to be provided. The levels of care designation are also intended to facilitate speedy pre-hospital transfer of potential stroke patients to the right hospital at the right time.
Recommendations to improve timely access to care:
- As indicated in the Stroke Awareness and Public Education recommendations, a multimedia campaign to heighten awareness about the signs and symptoms of stroke is required. Patients would arrive at hospitals and be treated more quickly in communities with heightened stroke awareness.
- Establish and implement protocols for EMS response to stroke as an emergency. This includes education and training for EMS personnel for early detection (use of field assessment tools), treatment and transportation of stroke in the field, required knowledge of the level of stroke care provided at B.C. hospitals in their region (and appropriate bypass protocols), and improving the interface between hospitals. When EMS personnel are able assess ‘hot stroke’ accurately in the field, and call ahead to the hospital, this facilitates the achievement of recommended goal times for CT scanning (item 4, below).
- At all BC hospitals, implement and monitor recommended goals for initial treatment time for patients who present with a time since stroke symptom onset of 3 hours or less in agreement with B.C.’s NEXT STEP Guidelines.
- At hospitals with CT scanners, ensure that a CT technician and radiologist are on call 24 hours a day, 7 days a week, and that they can reach the hospital within an acceptable timeframe to provide a stroke patient with a scan.
- Increase advertising for, and use of, the BC Nurse Line to help residents understand when and where to seek emergency medical help for stroke.
The following prototype projects are planned or underway in B.C. as part of the BC Stroke Strategy: