Primary Stroke Center

Designation

John W. Young, RN
MIEMSS Office of Hospital
Programs
Maryland Institute for Emergency Medical Services Systems
Objectives
 Describe the incidence, fatality rates and costs
associated with stroke nationally and in
Maryland
 Discuss the structure of Maryland EMS and its
relation to Primary Stroke Centers
 Explain challenges encountered implementing
the program
 Examine early performance measurements
Defining the Problem
 Nationally
 700,000 strokes occur annually; 500,000 new and 200,000
recurring.
 160,000 (22.8%) are fatal.
 Stroke is the third leading cause of death behind heart disease
and cancer.
 Average lifetime medical costs per patient range from $90,000
for ischemic stroke to $225,000 for subarachnoid hemorrhage.
Americans will pay about $57.9 billion in 2006 for stroke-related
medical costs and disability.
 Intravenous t-PA treatment rates for ischemic stroke range from
1-6%.
- American Stroke Association
Defining the Problem
 In Maryland
 More Marylanders will die from stroke in a given year than
from chronic respiratory disease, diabetes, accidents/trauma,
influenza and pneumonia combined. In Maryland, stroke is
the third leading cause of death across all races and
genders.
 In 2005, 2,465 people died from a stroke in Maryland.
 14% of Maryland’s stroke patients are less than 65 years old.
 The total cost of hospitalizations in Maryland due to stroke
was almost $163 million in 2005, with the average hospital
stay costing $12,095.
- Maryland State Advisory Council on
Heart Disease and Stroke
AHA/ASA Chain of Survival
 Rapid recognition and reaction to stroke warning signs.
 Rapid Emergency Medical Services (EMS) dispatch.
 Rapid EMS system transport and hospital prenotification.
 Rapid diagnosis and treatment in the hospital.
Maryland Stroke Action Plan
 Overarching system coordination through the Maryland
State Advisory Council on Heart Disease and Stroke.
 Primary prevention through community physicians,
hospitals, local and State agencies and networks, and
national interest groups.
 EMS coordination through MIEMSS.
 Acute stroke treatment through establishing a network of
Primary Stroke Centers (PSCs).
 Sub-acute stroke care and secondary prevention through
dedicated stroke units, staffing and protocols.
 Rehabilitation.
MIEMSS Overview
 Independent state agency
 Directed by Governor’s EMS
Board
 Oversees and coordinates all
aspects of Maryland’s EMS
system
 EMS provider education
 Licensure/regulation
 Protocols
 Communications
 EMS Base Station, Trauma
and Specialty Center
Designation
 Public education
Maryland’s EMS System
 Over 30,000 career
and volunteer
providers
 Common protocols
 An integrated delivery
system committed to
getting acutely ill or
injured patients to the
right care
 Maryland EMS System
3 32 2 159
H A H A

51 23
Baltimore City H 7
A A
H H
H
H
H A
H
H H A
H A H H H A
H H H H
H H
H
H 160 13
116
H

A
A
Areawide Trauma Centers
H Specialty Referral Centers
H Hospitals
Central Alarms
EMSTel Telephone Network
Medical Consultation Centers
EMS Component Elements
 Dispatch
 Identify
stroke complaints
 Dispatch priority

 Response
 Advanced Life Support/Basic Life Support
 Lights and siren?

 Resources and effectiveness require these

decisions to be made at the local level
EMS Component Elements
 Maryland Medical Protocols for
Emergency Medical Services Providers
 Neurological emergencies protocol
 Operational program Quality
Assurance/Quality Improvement
Physical exam
“The CPSS has excellent reproducibility
among prehospital personnel and
physicians. It has good validity in
identifying patients with stroke who are
candidates for thrombolytic therapy,
especially those with anterior circulation
stroke.”

- Ann Emer. Med. 1999; 33: 373-378

 Circulation 2005;112:IV-111-120IV-

Copyright ©2005 American Heart Association

 Circulation 2005;112:IV-111-120IV-

Copyright ©2005 American Heart Association

Fibrinolytic eligibility
EMS Routing
 “If the patient is a candidate for fibrinolytic
therapy AND can be delivered to the hospital
within 2 hours of sign/symptom onset, transport
the patient to the closest Designated Stroke
Center. If there is not one within 30 minutes,
then go to the nearest hospital.”
 Forpediatric patients, consult closest center and
pediatric base station.
 Online consult with the receiving center is
required to allow hospital preparation
Primary Stroke Center (PSC)
Component Elements
 Based upon Brain Attack Coalition
recommendations for PSCs (JAMA 2000:
283: 3102-3109)
 Prerequisites
 Licensed Maryland hospital
 Designated EMS Base Station
 MIEMSS designation
PSC Expected Benefits
 Improved patient care efficacy
 Reduced peristroke complications
 Increased use of acute stroke therapies
 Reduced morbidity and mortality
 Improved long-term outcomes
 Reduced health care costs
 Increased patient satisfaction

- JAMA 2000: 283: 3102-3109

PSC Evidence
 “Hill, et al. reported on building a "brain attack" team to administer
thrombolytic therapy to patients with acute stroke and on their initial
experience with IV-administered thrombolytics. A complex system
of interventions involving all levels of the system involved in acute
stroke care was reorganized. Over the course of the study period
improvements in certain parameters were noted. Overall, symptom
onset to treatment time was significantly decreased from a mean of
167.8 minutes to 147.4 minutes.”
 “Lattimore and colleagues reported on a similar process of
designation and implementation of processes to enhance
thrombolysis. An increase in the proportion of ischemic stroke
treated with tPA from 1.5 percent to 10.5 percent was noted.”

- Sharma M, Clark H, Armour T, et al. Acute Stroke: Evaluation and

Treatment. Summary, Evidence Report/Technology Assessment: Number
127. AHRQ Publication Number 05-E023-1, July 2005. Agency for
Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/epcsums/acstrokesum.htm
Implementation
 Stakeholder dialogue began 2003
 MIEMSS/Maryland Hospital Association
 EMS protocol deployed mid-2003
 Designation regulations issued mid-2005, finalized December 2005
 First call for applications issued January 2006 (27 respondents)
 Applications received September, 2006
 MIEMSS surveys began January, 2007
 Second call for applications issued March, 2007 (7 respondents)
 Statewide bypass implemented September, 2007
 Second round of MIEMSS surveys began November, 2007
 First statewide Stroke QIC convened November, 2007
 Third call for applications planned Spring, 2008 (~4 respondents)
Challenges
 Surveying organization
 Neurology coverage
 Competition
Fifteen (15) and Thirty (30) Minute PSC Drive Stars
March 1, 2008
Maryland Institute for Emergency Medical Services Systems
 Goals for Management of Patients With Suspected Stroke Algorithm

Circulation 2005;112:IV-111-120IV-

Copyright ©2005 American Heart Association

Stroke Quality Management
 PSC integrated with hospital PI Hospital
PI
 Get With the Guidelinessm –
Involvement
Stroke With EMS
 Process measures Stroke
QIC
 Feedback to EMS operational
programs through QM and
education
 State level QIC
 “Trauma model”
 EMAIS/GWTG linkage
 System adjustment and
change
 Statewide PSC Operating Measures

IVrt-PA 2Hour
Eligible Acute Ischemic Stroke Patients who Received IV t-PA in Maryland PSCs
within 180 Minutes of Symptom Onset
100.00%
90.00%
80.00%
80%
70.00% %of Patients
Individual Values

60.00% Average %
69.4%
50.00% UNPL
70% (172/248
40.00% LNPL
30.00%
20.00% 58.1%
(68/117) Patients who arrived within 120 min and
10.00% 60%
53.5% 53.7% received IV t-PA at MD PSCs ≤180 minutes
0.00%
(38/71 (175/32 from onset of stroke symptoms/Pts with a
Apr 2007
Apr 2005

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Jan 2007

48.6%
) (69/14 primary stroke dx of ischemic stroke and a
50% 45.3% known date/time of onset of stroke
(39/86)

Percent of Eligible Patients

symptoms
38.1
40% % 34.8 Pts who received IV t-PA at MD PSCs ≤180
IVrt-PA 3Hour (8/21 % minutes from onset of stroke symptoms/Pts
(8/23 with a primary stroke dx of ischemic stroke
30% and a known date/time of onset of stroke
100.00% symptoms
90.00%
80.00%
20%
70.00% %of Patients
Individual Values

60.00% Average %

50.00% UNPL
40.00% LNPL 10%
30.00%
20.00%
10.00% 0%
0.00%
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Maryland Institute for Emergency Medical Services Systems

 Individual Values Individual Values

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan 2005 Jan 2005
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DVTProphylaxis
Jan 2007 Feb 2007
Dysphagia Screen

Feb 2007 Mar 2007

Mar 2007 Apr 2007
Apr 2007 May 2007
May 2007 Jun 2007
Jun 2007 Jul 2007
Jul 2007 Aug 2007
Aug 2007 Sep 2007
Sep 2007 Oct 2007
Oct 2007 Nov 2007
Nov 2007 Dec 2007
Dec 2007 Jan 2008

LNPL
LNPL

UNPL
UNPL

Average %
Average %

%of Patients
%of Patients

Individual Values

Individual Values

0
1
2
3
4
5
6
7
8
9
60.00%
65.00%
70.00%
75.00%
80.00%
85.00%
90.00%
95.00%
100.00%

Jan 2005
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Nov 2006 Nov 2006
Maryland Institute for Emergency Medical Services Systems
Dec 2006 Dec 2006
Jan 2007 Jan 2007
Feb 2007
Statewide PSC Operating Measures

Feb 2007
Mar 2007 Mar 2007
LOSIschemic Stroke

Apr 2007 Apr 2007

EarlyAntithrombotics

May 2007 May 2007

Jun 2007 Jun 2007
Jul 2007 Jul 2007
Aug 2007 Aug 2007
Sep 2007 Sep 2007
Oct 2007 Oct 2007
Nov 2007 Nov 2007
Dec 2007 Dec 2007
Jan 2008 Jan 2008
LOS
LNPL

LNPL
UNPL

UNPL
Stroke
Ischemic
Average %

Average LOS
%of Patients
Future Directions
 Acute stroke elements
 Comprehensive Stroke Centers (CSCs)
 Treat those with complex stroke types, severe
deficits or multiorgan disease
 Provide high intensity medical or surgical care,

specialized tests or interventional therapies

Future Directions
 Maryland Stroke Action Plan
 Rehabilitation
 Integration
 Outcome analysis

 Regional networks
 Interstate planning
Objectives
Describe the incidence, fatality rates and costs
associated with stroke nationally and in
Maryland
Discuss the structure of Maryland EMS and its
relation to Primary Stroke Centers
Explain challenges encountered implementing
the program
Examine early performance measurements
Closing thoughts…
 Maryland PSC designation regulations
 www.dsd.state.md.us/comar/subtitle_chapters/30_Chapters.htm
 30.08.11, Designated Primary Stroke Center Standards
 MIEMSS contact
Office of Hospital Programs
John Young, RN
(410) 706-3930
Jyoung@miemss.org
www.miemss.org
 Questions?