Utilizing Dispatchers Against Stroke

If time is essential for helping the stroke patient, then it only makes sense to enlist the earliest link in the 9-1-1 chain in the cause.

A program in San Antonio uses dispatchers to help launch a rapid response across multiple fronts when a call for a suspected stroke comes in. It was described at the Gathering of Eagles by David Miramontes, MD, FACEP, NREMT, medical director for the San Antonio Fire Department and an assistant clinical professor of medicine at the UT Health Science Center San Antonio.

“What we’re trying to do,” says Miramontes, “is decrease the time from call to arrival at the emergency department, so we can then expedite the hospital response and get more people eligible to actually get tPA.”

It’s a straightforward process: When a suspected stroke is called in to 9-1-1, the dispatcher does a simple screening exam using MPDS card #28. They’ll ask why the caller thinks it’s a stroke and inquire about the FAST elements.

Answers are scored to determine the likelihood of stroke. If the total score exceeds 2, they notify the responding crew of a positive stroke score and instruct them to initiate rapid assessment, stroke center notification and speedy transit if alert criteria are met.

At the scene the first-arriving fire crew dives right in: They’ll assess the ABCDs and get vitals, then do a FAST assessment and obtain a blood sugar. Patients only get oxygen with a pulse oximetry below 94%, and nothing is given orally. Then, if the time last known well is less than six hours past, the crew starts readying for a rapid extrication, doing things like moving the patient toward the door, securing pets and relaying any additional info to incoming paramedics.

The medic unit has its own choreography: On arrival crew members will bring the stretcher to the patient as their first action, then take a report from the fire crew and do their own FAST exam. If signs are positive, they’ll initiate the stroke alert and radio the receiving facility. The goal is 10 minutes to load and go, and IVs, EKGs and other treatments wait till en route. Communication with the hospital is maintained throughout.

The hospital (there are nine primary and two comprehensive stroke centers in the San Antonio area) has its own responsibilities. The CT staff is notified of the stroke patient coming, and the ED nursing staff readies to work through an established checklist. When the patient arrives they’re taken straight to CT on the EMS stretcher, stopping only for a brief registration and safety check.

A nurse then takes what’s called an EMS time out report. A locally developed mechanism for standardizing patient handoffs, the report is based on the MIST acronym:

• Mechanism or medical complaint, including age/sex;
• Injuries/inspection;
• Vital signs, including glucose and any changes; and
• Treatment.

When the nurse calls “EMS time out,” all activities stop so full attention is on the report. It takes just 30 seconds, and the overall door-to-treatment goal is 60 minutes or less.

Collectively these measures, implemented at the end of 2015, are helping shave down response intervals. Median on-scene times went from 16.3 minutes last December to 13.1 in February/March (a decrease of 20%), and median dispatch-to-hospital-door times from 33.3 minutes to 30.5 (a decrease of 8.4%). Functionally they’re sharpening the system’s approach and priming everyone on the continuum to raise their game.

Says Miramontes: “If you’re dispatched to a fire alarm at a school, you have a certain response package and posture: ‘Oh, we’re going to that school again, some kid pulled an alarm,’ right? On the other hand, if you get dispatched to a school with reported smoke showing, that’s a different level of alarm response, and you’re going to do things differently in regard to what resources you send, your preplanning and what you do on scene upon arrival. We are doing the same thing for this type of EMS response: We are alerting responding crews that this patient may have different assessment and treatment needs that have to be met in a more urgent manner.”

David Miramontes spoke about this program at the Gathering of Eagles in February. Visit gatheringofeagles.us for information on the 2017 conference.