Overview: Emergency Department Panel
Emergency Department Management of Stroke
William G. Barsan, M.D. (Session Chair)
University of Michigan Medical Center, Ann Arbor
The need for rapid identification and treatment of many disorders including trauma and myocardial infarction has been well documented, and systems have been developed to enable the timely treatment of these disorders (1,2). A cohesive system for the early diagnosis and management of stroke patients has not existed in the past, leading to a sense of therapeutic nihilism for this disorder (3)..3 As emergency treatments for acute ischemic stroke continue to be developed, it will be necessary for institutions to develop a comprehensive plan for evaluation and management. Early treatment cannot be accomplished until we analyze the events surrounding the presentation of stroke, the means by which patients access the health care system, and the process for evaluation and treatment in the emergency department (ED).
The National Heart Attack Alert Program has analyzed the events that occur after the onset of acute myocardial infarction (AMI) in an effort to develop strategies for decreasing the time to treatment. They identified three distinct phases that must occur after onset of symptoms of AMI before treatment can be initiated (4). Phase I is the recognition of the signs and symptoms of AMI and the necessity for action. Phase II is emergency care that takes place after the decision to seek medical care has occurred but before the patient has arrived at the hospital. Phase III is the appropriate emergency care that should occur after arrival at the hospital or emergency center. The same phases can be used to evaluate the care of stroke patients (5). Phase I and Phase II are addressed in other parts of this presentation. This section will deal with Phase III and will attempt to outline our current status in the ED management of acute stroke.
There are several critical steps in the ED evaluation of any patient. The patient must first enter the triage and registration process on arrival at the ED (6). For ambulatory patients or those brought in by private car, an interview will take place with a triage nurse, and the nature of the patient's complaint will be elicited. Along with the history of the present illness, the triage nurse will typically obtain vital signs, a list of medications, and any known drug allergies. Immediately after nurse triage or concomitant with it, the patient will undergo registration. An official medical record will be generated based upon the patient's demographic and insurance information. In most ambulatory patients, registration will take place prior to the patient being placed in an examination room. In patients arriving by ambulance or helicopter, triage and registration will commonly take place in the examination area. Prehospital care providers will typically transport the patient directly into the ED and the patient will be placed in an examination area. Registration information will be obtained either from the patient's family members, prehospital care providers, or at the patient's bedside.
Following triage and registration, the patient will be placed in an examination room. The rapidity of this placement will depend upon bed availability and the nature of the patient's chief complaint. Most EDs will have triage guidelines that dictate which patients may wait until an available treatment area is open. Depending upon the nature of the patient's complaint and triage guidelines, certain standing orders may be initiated by the triage nurse or primary nurse. These would include such items as obtaining an electrocardiogram, intravenous access, supplemental oxygen, laboratory tests, or certain x-rays. For example, a patient with chest pain will typically have an electrocardiogram obtained as part of the triage standing orders. The rapidity with which the patient is seen by the emergency physician will depend upon the assessment of acuity by the triage nurse and the volume and acuity of other patients present in the ED. Most EDs have preset guidelines that dictate which patients require immediate physician notification versus those who will "wait their turn."
After the initial physician evaluation, a differential diagnosis and evaluative plan are formulated. Treatment may also be initiated at this point if the diagnosis is relatively clear and the need for treatment is imminent. Further diagnostic tests will typically be ordered at this juncture. At this point or after diagnostic results are received, consultation with appropriate physicians may or may not be necessary. Most hospital EDs will have protocols developed with different services which dictate when consultation will take place.
Many EDs have developed specific protocols to "jumpstart" the system for the treatment of certain disorders. In Level I trauma centers, pre-notification by prehospital providers will initiate a programmed response by a multidisciplinary team, including trauma surgeons, emergency physicians, respiratory therapists, radiology services, and the blood bank and laboratories (7,8). The trauma victim is typically "met" by this team on presentation to the ED enabling treatment and evaluation to begin immediately. In patients with chest pain, prehospital care providers will often notify the hospital en route and may transmit a 12-lead electrocardiogram (9). When the patient arrives, a room is ready and the evaluation and treatment process can begin without delay.
Triage and Registration
Triage and registration for the stroke patient will differ depending upon whether the patient arrives by ambulance, helicopter, or private car. There are few data regarding the triage and registration process for ambulatory stroke patients. Special protocols do not exist for the intake of patients with acute stroke, who will typically go through the same process as other ambulatory patients. In one study evaluating stroke patients treated in eight different EDs, the mean time from arrival to triage was 11 minutes including both ambulatory patients and those arriving by ambulance (10). The mean time from arrival to first documentation of vital signs was 7 minutes. The mean time from arrival to lab orders was 48 minutes, suggesting that no standing orders were used for lab ordering by the triage nurse. The American Heart Association has recommended a battery of standard laboratory tests for patients presenting with acute stroke (11). These include a complete blood count, platelet count, prothrombin time, partial thromboplastin time, electrolytes, glucose, and electrocardiogram. Intravenous access, cardiac monitoring, chest radiograph, and supplemental oxygen have also been recommended. There are no data to suggest how many stroke patients arriving at EDs will receive these procedures as part of standing orders.
In patients arriving by ambulance, notification of the ED prior to arrival is recommended (12). In patients with myocardial infarction, prehospital electrocardiogram transmission and pre-notification to the hospital have been shown to decrease the time to treatment with thrombolytic agents from 130 to 81 minutes (13). Data suggest that stroke patients arriving by ambulance will also receive more rapid evaluation by a physician than those arriving by car (10,14). The mode of transport of the patient (advanced life support versus basic life support) will also make a difference in the time of a physician evaluation. Kothari et al demonstrated that patients transported by advanced life-support units were seen by a physician within 10 minutes of arrival at the ED versus 20 minutes if transported by basic life-support units (14). Bratina et al showed that patients arriving by ambulance were examined by the emergency physician within 20 minutes as opposed to 48 minutes for those arriving by car (10). A caveat for pre-notification in stroke patients is the recognition of stroke by the prehospital care providers. In a tiered response system, the diagnosis of stroke by the EMT or paramedic was accurate in 72% of patients (14). However, only 52% of patients with a stroke were recognized by the dispatchers when the call was received.
When the patient is examined by the physician, the diagnosis of stroke appears to be reliable in most cases (15). Kothari et al reviewed 351 patients with a discharge diagnosis of stroke and found that 346 were correctly identified by the emergency physician. Of importance, all patients with intracerebral or subarachnoid hemorrhage were correctly identified by the emergency physicians. The physicians were all in a teaching hospital that had participated in acute stroke studies and may not be representative of all emergency physicians.
In their guidelines for management of patients with acute stroke, the American Heart Association "strongly recommends that emergent CT be the initial brain imaging study" (11). Noncontrast CT is necessary to differentiate ischemic from hemorrhagic stroke and should be done on a priority basis. The time to obtain a CT and interpretation can vary widely. In some cases, CT may not even be performed during the patient's ED stay (10). In one study of five different hospitals, the time from hospital arrival to CT ranged from 50 to 151 minutes with an overall mean of 100 minutes. The time from arrival to CT has also been shown to significantly affect the time to deliver thrombolytic treatment (16). Similar to AMI, pre-notification and arrival by ambulance can lower the time to obtain CT in the ED. Kothari et al (14) demonstrated that patients arriving by advanced life-support units underwent CT within 47 minutes versus 69 minutes for those arriving by basic life-support units.
Once the patient has been evaluated and diagnosed, a neurological consult is often made. The time from patient arrival to consultation with a neurologist has been found to be variable (10,17,18). Bratina et al showed a mean delay of 123 minutes until neurology evaluation (10). Gomez et al documented an average delay of 76 minutes (18). There are data to suggest that outcome is improved when patients are seen early by a neurologist. Davalos et al (17) showed that the relative risk of poor outcome in patients seen by a neurologist later than 6 hours from symptom onset was 5.6. Prompt neurological evaluation correlated with shorter patient stays as well.
In the care of trauma patients the team approach has been shown to be effective in lowering the time to definitive treatment and decreasing morbidity and mortality. The team approach has also been advocated for care of the stroke patient (12,19). A coordinated approach to the stroke patient has led to decreased time to treatment (16). A stroke team led to decreased time from arrival to triage and arrival to CT, and a higher percentage of patients admitted to an ICU (10). In another study, the stroke team led to earlier arrival of neurological consultation and earlier time to treatment (18). In the absence of a stroke team, treatment for the stroke patient may not be optimal. Blood pressure was often inappropriately treated and excessively lowered and hypotonic glucose-containing fluids were administered frequently (10).
It has been suggested that the team should consist of a neurologist or neurosurgeon with stroke interest and expertise as a team leader (19). In hospitals or areas without readily available neurological expertise, emergency physicians may form the core of the stroke team. Other members of the team should include a nurse or physician extender with neurological expertise, neuroradiology, phlebotomy, and respiratory therapy. The access to the team should be consistent and simple, such as the use of a single paging number which can be accessed similarly to a "Code Blue" or "Trauma Alert" in many hospitals.
The team should develop prehospital protocols for early identification and notification of the receiving hospital. Pre-notification should initiate a response in the ED designed to rapidly evaluate and treat the stroke patient. This would include stroke team activation, early notification of CT prior to patient arrival, standing orders for blood work to be initiated on patient arrival, and evaluation for acute stroke treatment.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last updated May 17, 2011