- Email: [email protected]
Defining and Developing a Specialty Stroke Transport Team
Defining and Developing a Specialty Stroke Transport Team Elizabeth Ahl, RN, BSN, and Roderick Wold, RN, ND
There are 500 Joint Commission-certified primary stroke centers in the country.1 Of those, seven reside in Colorado and another 18 in the surrounding seven-state region. However, from our research, there has been no identified or established specialty stroke transport team dedicated to the transport of stroke patients from both interfacility and scene transfers. Despite the fact that a very large percentage of patients with the diagnosis of stroke will be transported to those aforementioned centers, there is a distinct lack in equivalent care or standards in stroke transport dictated by Commission on Accreditation of Medical Transport Services (CAMTS) or actively practiced comprehensively by any air medical transport program in the nation. In 2006, we transported 121 stroke patients, in 2007 144, and in 2008 that number rose to 175 patients. Of the patients transported in 2008 with a diagnosis of ischemic cerebrovascular accident (CVA) by our program, 49% received intravenous tissue plasminogen activator (t-PA) before or during transfer. It is estimated that Colorado will treat approximately 7,000 stroke patients/year, with only a 1.1% treatment rate (last reported in 2001).2 According to the May 2005 report from the Colorado Department of Public Health and Environment, Colorado was home to approximately 4.6 million residents in 2004. Further breakdown reveals a population distributed as follows: 12 urban counties, 29 rural counties, and 23 frontier counties (which have fewer than six residents per square mile). Eighty-one percent of Colorado’s 64 counties are classified as rural. Fifty of the 64 counties are designated as health care shortage areas, and, astonishingly, 20 of the 64 do not have a hospital.3 Because of the nature of the distribution of Colorado’s population, many patients in counties with the highest incidence of stroke are also in the areas that are least accessible to a primary stroke center. This makes rapid transport essential to the patient’s opportunity for advanced care and outcome. May-June 2009
We make the assumption that inherent to providing the best chances of survival and rehabilitation is the stroke care delivered peritransport. With the advent of new technologies such as interventional neuroradiology and telemedicine, the time-critical nature of stroke requires a stroke transport team to be well versed not only in the cutting edge of stroke care, but also in the logistics of getting stroke patients to the primary stroke centers that are best equipped and capable of treating them within the described window of time. Over the last few years, the air medical field has started to address stroke care because of the potential to impact the treatment and outcome of stroke patients. Literature review supports the theory that advances in rapid critical care transport have significant promise in changing the landscape of a patient’s life after stroke. Starting in 1998, Silbergleit and Blumstein4 discussed in Academic Emergency Medicine revascularization options and the implications for critical transport. In 1999, Conroy et al5 reported in Stroke that helicopter transfer can offer a potential benefit to patients with acute stroke, and Chalela et al6 reported in Neurology results of a study that looked at the safety of air medical transportation after t-PA administration in acute ischemic stroke. In 2000, Marler et al7 reinforced the potential benefit of air transport in a report in Neurology that demonstrated that early stroke treatment was associated with better outcomes. In 2003, three articles were published in the area of stroke transport, illustrating increased interest and advances in the transport of stroke patients. Silbergleit et al8 reported in Academic Emergency Medicine the analysis of a model that showed that air medical transport of stroke patients for thrombolysis within 6 hours is cost effective. TraumaOne Flight Service in Shands-Jacksonville and Silliman et al9 in Stroke described the use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. They reported that a helicopter-based transport 133
cated stroke transport team could ultimately improve system can link a rural region to a stroke center and promote 10 patient outcome. Those tenets—education, collaboration, access to t-PA. LaMonte et al in Stroke described stroke treatment center experiences and the use of t-PA during and communication—have provided the foundation for our telemedicine consultation in “Telemedicine for Acute Stroke, goal of providing seamless stroke care to the seven-state Triumphs and Pitfalls.” They reported that telemedicine conregion that relies on rapid transport to a primary stroke censultation provided treatment options not previously availter for early intervention. Additionally, reviewing the effect able at remote hospitals and that administration of t-PA was of this specialty team through the creation of an associated feasible and safe. outcome study was a logical and necessary tool in deterIn March 2006, our program introduced a dedicated mining our impact on care, outcome, and morbidity and stroke transport team that advanced air medical transport of mortality of the stroke patient. stroke patients to a new level. Inextricable to the developBuilding Consensus ment of this specialty team is the concurrent review of data collected to establish the true influence of this endeavor. In November 2005, the proposal for a dedicated stroke Data points specific to air medical transport, and also those transport team was given to members of this flight propoints mirrored in information gathered by our Joint gram’s administration, including our medical director, proCommission certified primary stroke center, provide the gram director, and chief flight nurse. The education advisor foundation for the examination of this program. and supervisor for the communications center were also The purpose of this article is to describe the developincluded in review of this plan. Unique to this idea was the ment of what we believe to be the first dedicated stroke suggestion that, unlike other “specialty teams,” this deditransport team in the country committed to the transport of cated team would comprise all flight nurses, adding versaboth scene and interfacility stroke patients to a primary tility, and avoiding the time delays often encountered stroke center. Inherent to the development of a dedicated logistically with traditional dedicated teams. Inherent to the stroke transport team is defining the success of this concept was not just standards that support the distinction the approval of the flight program’s The three underpinnings for as such. Although there are programs administration, but also their collecthe creation of a stroke that may transport more stroke or tive passion and commitment to the transport team have revolved neurologic patients, we believe the process. This meeting provided the around education, collaborasum of all parts of this endeavor outframework and springboard for movtion, and communication. weighs any individual aspect of stroke ing forward with a presentation to the care paralleled by other programs. Key hospital administration in December 2005. A crucial audience for this presentation also included to the development of this team is the integration of care on the members from our Joint Commission-certified primary all levels necessary to distinguish ourselves from the rest of stroke center stroke team. the country. Our goal would be to report, in a future article, Before assembling for this meeting, a series of emails our study findings as well as the ongoing progress of this was sent asking each member of the team key questions team. We are aware that assumptions do not always equate regarding individual perspectives on what a dedicated to fact, and we are committed to the ongoing assessment of stroke transport team would encompass, how it could be our influence on stroke care over time. beneficial, and how it should function. In a nutshell, agreeVision ment was sought on the scope of this proposed specialty team. Moreover, a pivotal piece of congregating as a group Our vision for a dedicated stroke transport team was inspired by the spirit of quality improvement and the search and presenting this concept was ascertaining whether the for an outcome study that reflected specific changes in hospital stroke team supported and believed in the concept process and their subsequent impact on patient outcome. of our flight program acting as an extension of them, Specifically, whether by coincidence or as a direct result of “bringing the stroke team to the patient.” Inherently suptransporting more stroke patients, our program was involved porting this concept also translated to their commitment to in several key transports that highlighted areas of needed the flight teams’ initial and ongoing education, collaboratimprovement in communication, consistency in stroke poling on policy/standards consensus, patient follow-up, and icy, and collaboration with the stroke team at our base of the ongoing evaluation of the general process. operations. It became apparent through case review and chart The support of the institution’s CEO paved the way for monitoring that a unique opportunity to provide enhanced presenting the concept to the flight team in the January stroke care was available to us because of our base location at 2006 staff meeting. The implementation of what we believe a comprehensive Joint Commission–certified primary stroke to be the nation’s first defined dedicated stroke transport center, including the innovative practice of interventional team for interfacility and scene transfers to a primary neuroradiologists, the advent of neurotelemedicine, and the stroke center would be a moot concept if it were not commitment of both the flight team and the hospital’s stroke embraced by team members actually transporting those team to raise the standard in stroke care. patients. Team willingness to participate in an ambitious In the global assessment of identified areas of improveundertaking requiring effort above and beyond the status ment, we struck on the three basic tenets of how a dediquo would be the most crucial piece in this mission. 134
Air Medical Journal 28:3
Development As described, the three underpinnings for the creation of a stroke transport team have revolved around education, collaboration, and communication. Each has been central to building a team with substance. Labeling a team as such does not instantly translate to a vision brought to fruition. Although our goal is to provide a service to stroke patients not otherwise offered, we realize reaching that endpoint requires constant scrutiny of what we have defined as necessary requirements to providing this service. That being said, we have focused heavily on these criteria to satisfy what we believe differentiates a “specialty” team from one that is not. Education Critical to being specialized is the level of knowledge that can be brought to the described patient population and, furthermore, translating that knowledge into practice. We approached our goals for education by first assessing our educational needs through a stroke knowledge pretest. This pretest identified several areas of educational focus, which then allowed us to create an initial educational plan that simultaneously defined our ongoing educational plan. The following is a description of that plan: National Institute of Health Stroke Scale Certification One area of focus we identified was establishing consistency in the assessment of the stroke patient. We believed the most efficient way to accomplish this would be to use the same tool each time we encountered the stroke patient. Although not sensitive for all types of stroke, it was determined that each member of the team should be certified in the National Institute of Health Stroke Scale (NIHSS) tool. By speaking the same language, so to speak, and consequently assessing the stroke patient with a common tool, we believed we also could most concisely control interrater reliability. Becoming NIHSS certified required an in-depth 3 hour lecture from the stroke nurse practitioner, an online study course, and finally, an online certification, which took approximately 2 to 4 more hours to complete. We set a deadline for completion of this certification by March 1, 2006. All team members, including administration, completed and passed this certification successfully. Additionally, required reading before the March 1 goal date was assigned by the director of the hospital’s stroke program and the stroke nurse practitioner. Establishing Competency Staying competent in completing stroke assessments via the NIHSS certification was one of the challenges identified early in the process. In discussions with the hospital stroke team and our medical director, we chose the goal of completing four NIHSS assessments within the first three months of the inception of the team (and for new orientees) through stroke alerts in the emergency department (ED) and in-flight transfers. In dialogue with the stroke team, it was deemed that this May-June 2009
would set the stage for an acceptable level of “competent.” Throughout this initial competency phase, each assessment was mentored by either an ED physician participating in the stroke alert, the stroke neurologist, or the stroke nurse practitioner, or it was reviewed by appropriate stroke team members if the assessment occurred on a transport. After initial competency, we further defined different levels of competency, as described in the following sections. Continuing Education/Maintaining Competency In staying with the standards set by Joint Commission for all stroke team members of a Joint Commission certified stroke center, a minimum of 8 hours/year of continuing education was established to maintain competency as a dedicated stroke transport team. Our plan includes any combination of opportunities listed below, which includes a required number of NIHSS assessments. Level of competency was stratified, ranging from proficient to mentor level as determined by the hospital Stroke Team, flight program Education Advisor/Administrator, and the hospital’s Education Committee. Each level of competency has been defined and based on how many hours of continuing education each flight crewmember has accrued: competent. 8 hours; proficient, 8–12 hours; mentor, 12 hours or more. Continuing Stroke Education Hour Accrual Combinations: a. Annual required NIHSS certification b. Four Stroke Alerts or NIHSS examinations within first 3 months of orientation, then one Stroke Alert or NIHSS examinations quarterly to maintain competencies for a total of four/year (can include patients being transported who are also Stroke Alerts, as well as participating in assessment with designated Stroke Team member, obtaining NIHSS, and following to CT/IR). c. Time spent participating in Stroke Alert with ED physician, neurologist, stroke NP, or interventional neuroradiologist. d. Minimum of one stroke article beyond deemed required reading for stroke awareness as determined by flight program Medical Director/Education Committee and hospital Stroke Team (1 hour) e. Stroke Case Conference given monthly by Stroke NP (1 hour) f. Stroke Council meeting (1 hour) g. Attendance of designated “Stroke Month” flight program education meeting (ie, neurology lecture from hospital Stroke Team: 1.5 hours) h. Attendance of annual Joint Commission-certified primary stroke center stroke conference (8 hours) i. Participation in neurovascular educational monthly case conferences presented by interventional neuroradiologist (1 hour) j. Other neurovascular/CVA educational opportunities as they arise Annual Stroke Competency Separate from NIHSS Certification, Written in Collaboration with Hospital Stroke Team 135
Collaboration Collaboration has been a fundamental philosophy in the creation of a dedicated stroke transport team and is inextricable from the related precepts of education and communication. Without the alliances of many people and departments, it would be difficult, if not impossible, to provide our vision of enhanced stroke care in the setting of the air medical environment. First, as discussed, partnering with the hospital stroke team in our education has been a key piece of building the foundation for this undertaking. Moreover, their participation in the review, revision, and implementation of stroke policy that reflects the unique practice of a Joint Commission-certified primary stroke center was a standard we endeavored to attain. Since the inception of this team, our stroke policy has been revised twice, as we have progressed and reevaluated our process. This stroke policy has included guidelines regarding the care and management of both the ischemic and hemorrhagic stroke patient. Dovetailed to our stroke policy is a “stroke packet” created to include symptom history, intravenous t-PA inclusion/exclusion criteria, triple computed tomography (CT) screening criteria, blood pressure goals, t-PA precautions, and an NIHSS documentation form that becomes a part of the patient’s medical record. Of significance also is a t-PA worksheet created by the pharmacy to enhance the safe and accurate administration of thrombolytics. Along with the decidedly important role of the hospital stroke team has been our partnership with the ED, pharmacy, radiology department, neurosciences department, our communications center, and telemedicine services. Specifically, the ED is pivotal in recognizing the transport team’s request for stroke alert, CT direct admit, and the communication of updated stroke scores to the stroke team. Pharmacy has assisted in the specific tailoring of a tPA policy that allows for rapid acquisition of the drug for patients requiring thrombolytics in rural communities without appropriate access to this treatment (and, as mentioned, a standardized t-PA administration worksheet). Radiology, by previous practice, has continued their coordination with the ED to accommodate for “CT direct,” a request by EMS that allows for the stroke patient to move directly to CT, with the stroke team meeting the patient there. Our communications center has been crucial in many aspects of collaboration and is discussed in further detail later. Telemedicine service is a breakthrough offered to patients in specific areas of remote Colorado who would not otherwise have the benefit of stroke care from a primary stroke center. Coordinating transport with the telemedicine neurologist offers key time savings, which can make the difference in whether a patient falls within the recommended window for thrombolytics or interventional radiology practices.
Communication: Linking Partners in Stroke Care A crucial piece of the organization, facilitation, and streamlining of the transport of the stroke patient is accom136
plished from our communication center. By defining ourselves as a specialty team, we believe it is imperative that we can consistently provide our services for enhanced stroke care, while also navigating multiple calls such as trauma, pediatrics, and other specialty requests. Built in 2002, it is integral to linking the transport team to the sending facility stroke neurologist, interventional neuroradiologist, or receiving primary stroke center facility. Specifically, the dispatcher guides the conference call between sending and receiving physicians, collecting pertinent information at the same time by also participating in the same phone call. In turn, the stroke transport team is suggested based on an algorithm reference stroke book if the team has not already been requested. This reference book details transport times for all programs in the region, comparing total round trip times from respective bases, all with the intention of providing for the stroke patient the fastest available transport. Add to that the ability of dispatch to launch an airborne standby for those patients being transported by helicopter. For example, a facility that suspects but may not be sure of a patient requiring the services of a primary stroke center may choose to initiate the stroke transport team with the option of canceling the call if appropriate. The option of initiating the team based on clinical findings without waiting for diagnostics satisfies closing the distance, simultaneously saving valuable time when traveling to rural settings while providing the patient with a transport team specializing in stroke care. There is no charge to the patient, facility, or EMS agency if we are canceled. If we are used, the time most programs would traditionally be on the ground while all information is gathered, or waiting on tests completed, has been carved out of the equation. Thus, the adage, “when minutes count…time is brain.” This same process can also be initiated by the stroke neurologist, who assesses the patient via telemedicine technology. Through an entity entirely separate from our hospital base, several telemedicine cameras have been set up for the specific purpose of improving stroke care to remote patient settings. Of these locations, approximately half could benefit from an airborne standby while the telemedicine conference call and assessment by the stroke neurologist are being completed. Ultimately, it is the goal to shave off time that is otherwise lost in the logistics of transport by providing a streamlined process that is managed and executed by our communications center. This process continues throughout the transport, with dispatch communicating with the stroke team and providing information such as NIHSS, activation of stroke alert, or request for CT or IR directly, based on the stroke transport teams’ patient assessment. Furthermore, communication can be directed to the stroke neurologist at the flight crew’s discretion if further guidance is sought. Lastly, the loop of communication is completed when follow-up is provided by the hospital stroke team to the flight team, and visa versa, with real-time feedback regarding issues that may arise during the course of a stroke transport. This dialogue provides the foundation for improvement in the process and the setting for evaluation, Air Medical Journal 28:3
which is necessary in scrutinizing the methods and practices of this specialty team. By closing the loop, so to speak, each call allows for the fine tuning of care provided based on the standards of a Joint Commission-certified primary stroke center. It is also worth mentioning that our program covers four bases currently. Because of our wide coverage both logistically and as a dedicated stroke team, it is the rare occasion that simultaneous calls involving a stroke patient and a non-stroke patient creates a situation in which a decision would have to be made on which call to take. That being said, our philosophy is to refer the nonspecialty call to another program in the event that this would occur.
encountered. These experiences have paved the way to better logistics, improved practice guidelines, and outreach opportunities that we otherwise would not have had. Lastly, because any program is only as good as the education provided, one of the most significant changes can be seen in the total number of hours of stroke education before and after the development of the stroke transport team. In 2005, the total number of hours for stroke education for the team was 65 hours. In 2006, total hours increased to 330, and in 2007, team totals approached 400 hours. The average stroke education hours for each flight nurse have increased by almost five times the amount in 2005. Although it is rewarding to describe specific examples of the benefits from the development of the stroke transport Evaluation team, we know that the idea needs to be measured to define Evaluation of the Stroke Transport Team includes both its effectiveness in different areas. Our program is in the patient care, which is evaluated against the developed process of evaluating the efficacy of the stroke transport standards, and the evaluation of the effectiveness of the team and how it has impacted a wide range of variables such program itself. Evaluation initially is handled through our as transport times, interventions, time to CT on landing, as quality improvement (QI) process. well as 3- and 6-month modified Each transport is reviewed by a flight Rankin scores to look at functional In improving the life of one nurse and then the QI committee outcomes of stroke patients transstroke patient, we hope to chair. Although not all transports are ported by our program. Additionally, transform the lives of many. taken to our hospital base (and priin our most recent CAMTS survey, the mary stroke center), each transport surveyors made the point of acknowlbrought to this facility gets follow-up of interventions and edging their belief that no other program had defined and results from the stroke team nurse practitioner. Cases also developed a dedicated stroke transport team unique to can be reviewed at the monthly flight staff meeting, with stroke care. We believe that this is only the beginning of the our program’s medical director, or specifically with the process and that our commitment to scrutinizing our impact interventional neuroradiologist. Additionally, the flight on all levels is of the highest importance. crew has the option to participate in the monthly hospital Taking It Beyond Stroke Council meeting, which includes case reviews presented by the stroke neurologists. In conclusion, our dedicated stroke transport team’s Evaluating the effectiveness of the program also can be mission is to provide streamlined, seamless care to neuviewed through the lenses of positive patient outcomes and rovascular patients from point of contact to destination obstacles encountered, as well as a comparison of the numthrough collaboration, communication, and education. ber of stroke education hours since the inception of the Our purpose is to practice as an arm of the hospital-based team. First, we know there are specific cases in which the stroke team, extending stroke services to patients, decreasstroke transport team has been effective in the ultimate ing out-of-hospital time, and enhancing a patient’s opporgoal of improving patient care and patient outcomes. One tunity for timely intervention. The benefits to this are example is a patient being transported from a rural commany, not the least of which are improving patient munity on the eastern plains of Colorado. The patient was care/outcome and addressing community need. Utilization a young man in his late 30s who presented with an initial of available resources such as a rapid transport team partNIHSS of 12. The facility contacted the stroke neurologist nered with a comprehensive Joint Commission–certified through a “ONEcall” line, which is managed by our comprimary stroke center, and collaboration with telemedicine munications center. During this conference call, the stroke services at a patient’s bedside, impart the highest level of neurologist recognized the potential benefit of thrombolytcontinuity of care. The development and success of this ics. On his request, which was relayed through dispatch, specialty focus revolves around a lasting coordination with the JCAHO-certified primary stroke team, defining, revisthe stroke transport team brought t-PA to the patient, ing, and improving criteria supporting requirements for a because this particular hospital did not keep any in stock. “dedicated stroke transport team”; ongoing development The transport team was able to initiate the t-PA bolus and of an aggressive flight team education plan beyond merely infusion with 1 minute to spare in the 3-hour window of being NIHSS certified; a current community outreach administration of thrombolytics. The patient’s symptoms plan; and a refined logistical plan for the transport of improved dramatically, and he was ultimately discharged local, rural, and out-of-state patients. from the hospital without any neurologic deficits. Scrutinizing our collected data for the most objective As with any process or significant endeavor, some of the evaluation of our impact on stroke care peritransport is most fruitful experiences in retrospective evaluation are crucial. We will aspire to review and publish our results at those in which obstacles and/or challenges have been May-June 2009
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7. Marler J, Tilley B, Lu M, Brott T, Lyden P, Grotta J. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 2000;55: 1649-55. 8. Silbergleit R, Scott P, Lowell M, Silbergleit R. Cost-effectiveness of helicopter transport of stroke patients for thrombolysis. Acad Emerg Med 2003;10:966-72. 9. Silliman S, Quinn B, Huggett V, Merino J. Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34:729-33. 10. LaMonte M, Bahouth M, Hu P, Pathan M, Yarbrough K, Gunawardane R. Telemedicine for acute stroke, triumphs and pitfalls. Stroke 2003;34:725-8. Epub 2003 January 30.
5 years. If we can show a positive impact, we would venture to propose that having a dedicated stroke transport team would be a worthy criterion for those primary stroke centers applying for comprehensive JCAHO-certified stroke center designation. It is our vision to offer our program’s experience to other transport teams across the country in an effort to reach beyond past and present limitations unique to the stroke patient based on access to timely care and intervention. In improving the life of one stroke patient, we hope to transform the lives of many.
Elizabeth Ahl, RN, BSN, and Roderick Wold, RN, ND, are flight nurses with Airlife Denver at the Swedish Medical Center in Englewood, CO.
References
1067-991X/$36.00 Copyright 2009 by Air Medical Journal Associates doi:10.1067/j.amj.200x.xx.xxx
1. The Joint Commission. Certification master mailing list, revised 070108. Available at http://www.qualitycheck.org/Consumer/SearchQCR.aspx. Accessed July 17, 2008. 2. Smith D, Nettro P. A report to the Colorado Legislature from the Colorado Stroke Advisory Board. Colorado Department of Public Health and Environment. 2003 November. 3. Colorado Department of Public Health and Environment. 2004 Colorado Population Data and Statistics. 2005 May. Available @ http://www.cdphe.state.co.us/hs/vs/2004/ 2004population.html. Accessed April 26, 2008. 4. Silbergleit R, Blumstein H. Revascularization options: Implications for critical transport. Acad Emerg Med 1995;2:568-9. 5. Conroy M, Rodriquez S, Kimmel S, Kasner S. Helicopter transfer offers a potential benefit to patients with acute stroke. Stroke 1999;30:2580-4. 6. Chalela J, Kasner S, Jauch E, Pancioli A. Safety of air medical transportation after tissue plasminogen activator administration in acute ischemic stroke. Stroke 1999;30:2366-8.
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Air Medical Journal 28:3
There are 500 Joint Commission-certified primary stroke centers in the country.1 Of those, seven reside in Colorado and another 18 in the surrounding seven-state region. However, from our research, there has been no identified or established specialty stroke transport team dedicated to the transport of stroke patients from both interfacility and scene transfers. Despite the fact that a very large percentage of patients with the diagnosis of stroke will be transported to those aforementioned centers, there is a distinct lack in equivalent care or standards in stroke transport dictated by Commission on Accreditation of Medical Transport Services (CAMTS) or actively practiced comprehensively by any air medical transport program in the nation. In 2006, we transported 121 stroke patients, in 2007 144, and in 2008 that number rose to 175 patients. Of the patients transported in 2008 with a diagnosis of ischemic cerebrovascular accident (CVA) by our program, 49% received intravenous tissue plasminogen activator (t-PA) before or during transfer. It is estimated that Colorado will treat approximately 7,000 stroke patients/year, with only a 1.1% treatment rate (last reported in 2001).2 According to the May 2005 report from the Colorado Department of Public Health and Environment, Colorado was home to approximately 4.6 million residents in 2004. Further breakdown reveals a population distributed as follows: 12 urban counties, 29 rural counties, and 23 frontier counties (which have fewer than six residents per square mile). Eighty-one percent of Colorado’s 64 counties are classified as rural. Fifty of the 64 counties are designated as health care shortage areas, and, astonishingly, 20 of the 64 do not have a hospital.3 Because of the nature of the distribution of Colorado’s population, many patients in counties with the highest incidence of stroke are also in the areas that are least accessible to a primary stroke center. This makes rapid transport essential to the patient’s opportunity for advanced care and outcome. May-June 2009
We make the assumption that inherent to providing the best chances of survival and rehabilitation is the stroke care delivered peritransport. With the advent of new technologies such as interventional neuroradiology and telemedicine, the time-critical nature of stroke requires a stroke transport team to be well versed not only in the cutting edge of stroke care, but also in the logistics of getting stroke patients to the primary stroke centers that are best equipped and capable of treating them within the described window of time. Over the last few years, the air medical field has started to address stroke care because of the potential to impact the treatment and outcome of stroke patients. Literature review supports the theory that advances in rapid critical care transport have significant promise in changing the landscape of a patient’s life after stroke. Starting in 1998, Silbergleit and Blumstein4 discussed in Academic Emergency Medicine revascularization options and the implications for critical transport. In 1999, Conroy et al5 reported in Stroke that helicopter transfer can offer a potential benefit to patients with acute stroke, and Chalela et al6 reported in Neurology results of a study that looked at the safety of air medical transportation after t-PA administration in acute ischemic stroke. In 2000, Marler et al7 reinforced the potential benefit of air transport in a report in Neurology that demonstrated that early stroke treatment was associated with better outcomes. In 2003, three articles were published in the area of stroke transport, illustrating increased interest and advances in the transport of stroke patients. Silbergleit et al8 reported in Academic Emergency Medicine the analysis of a model that showed that air medical transport of stroke patients for thrombolysis within 6 hours is cost effective. TraumaOne Flight Service in Shands-Jacksonville and Silliman et al9 in Stroke described the use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. They reported that a helicopter-based transport 133
cated stroke transport team could ultimately improve system can link a rural region to a stroke center and promote 10 patient outcome. Those tenets—education, collaboration, access to t-PA. LaMonte et al in Stroke described stroke treatment center experiences and the use of t-PA during and communication—have provided the foundation for our telemedicine consultation in “Telemedicine for Acute Stroke, goal of providing seamless stroke care to the seven-state Triumphs and Pitfalls.” They reported that telemedicine conregion that relies on rapid transport to a primary stroke censultation provided treatment options not previously availter for early intervention. Additionally, reviewing the effect able at remote hospitals and that administration of t-PA was of this specialty team through the creation of an associated feasible and safe. outcome study was a logical and necessary tool in deterIn March 2006, our program introduced a dedicated mining our impact on care, outcome, and morbidity and stroke transport team that advanced air medical transport of mortality of the stroke patient. stroke patients to a new level. Inextricable to the developBuilding Consensus ment of this specialty team is the concurrent review of data collected to establish the true influence of this endeavor. In November 2005, the proposal for a dedicated stroke Data points specific to air medical transport, and also those transport team was given to members of this flight propoints mirrored in information gathered by our Joint gram’s administration, including our medical director, proCommission certified primary stroke center, provide the gram director, and chief flight nurse. The education advisor foundation for the examination of this program. and supervisor for the communications center were also The purpose of this article is to describe the developincluded in review of this plan. Unique to this idea was the ment of what we believe to be the first dedicated stroke suggestion that, unlike other “specialty teams,” this deditransport team in the country committed to the transport of cated team would comprise all flight nurses, adding versaboth scene and interfacility stroke patients to a primary tility, and avoiding the time delays often encountered stroke center. Inherent to the development of a dedicated logistically with traditional dedicated teams. Inherent to the stroke transport team is defining the success of this concept was not just standards that support the distinction the approval of the flight program’s The three underpinnings for as such. Although there are programs administration, but also their collecthe creation of a stroke that may transport more stroke or tive passion and commitment to the transport team have revolved neurologic patients, we believe the process. This meeting provided the around education, collaborasum of all parts of this endeavor outframework and springboard for movtion, and communication. weighs any individual aspect of stroke ing forward with a presentation to the care paralleled by other programs. Key hospital administration in December 2005. A crucial audience for this presentation also included to the development of this team is the integration of care on the members from our Joint Commission-certified primary all levels necessary to distinguish ourselves from the rest of stroke center stroke team. the country. Our goal would be to report, in a future article, Before assembling for this meeting, a series of emails our study findings as well as the ongoing progress of this was sent asking each member of the team key questions team. We are aware that assumptions do not always equate regarding individual perspectives on what a dedicated to fact, and we are committed to the ongoing assessment of stroke transport team would encompass, how it could be our influence on stroke care over time. beneficial, and how it should function. In a nutshell, agreeVision ment was sought on the scope of this proposed specialty team. Moreover, a pivotal piece of congregating as a group Our vision for a dedicated stroke transport team was inspired by the spirit of quality improvement and the search and presenting this concept was ascertaining whether the for an outcome study that reflected specific changes in hospital stroke team supported and believed in the concept process and their subsequent impact on patient outcome. of our flight program acting as an extension of them, Specifically, whether by coincidence or as a direct result of “bringing the stroke team to the patient.” Inherently suptransporting more stroke patients, our program was involved porting this concept also translated to their commitment to in several key transports that highlighted areas of needed the flight teams’ initial and ongoing education, collaboratimprovement in communication, consistency in stroke poling on policy/standards consensus, patient follow-up, and icy, and collaboration with the stroke team at our base of the ongoing evaluation of the general process. operations. It became apparent through case review and chart The support of the institution’s CEO paved the way for monitoring that a unique opportunity to provide enhanced presenting the concept to the flight team in the January stroke care was available to us because of our base location at 2006 staff meeting. The implementation of what we believe a comprehensive Joint Commission–certified primary stroke to be the nation’s first defined dedicated stroke transport center, including the innovative practice of interventional team for interfacility and scene transfers to a primary neuroradiologists, the advent of neurotelemedicine, and the stroke center would be a moot concept if it were not commitment of both the flight team and the hospital’s stroke embraced by team members actually transporting those team to raise the standard in stroke care. patients. Team willingness to participate in an ambitious In the global assessment of identified areas of improveundertaking requiring effort above and beyond the status ment, we struck on the three basic tenets of how a dediquo would be the most crucial piece in this mission. 134
Air Medical Journal 28:3
Development As described, the three underpinnings for the creation of a stroke transport team have revolved around education, collaboration, and communication. Each has been central to building a team with substance. Labeling a team as such does not instantly translate to a vision brought to fruition. Although our goal is to provide a service to stroke patients not otherwise offered, we realize reaching that endpoint requires constant scrutiny of what we have defined as necessary requirements to providing this service. That being said, we have focused heavily on these criteria to satisfy what we believe differentiates a “specialty” team from one that is not. Education Critical to being specialized is the level of knowledge that can be brought to the described patient population and, furthermore, translating that knowledge into practice. We approached our goals for education by first assessing our educational needs through a stroke knowledge pretest. This pretest identified several areas of educational focus, which then allowed us to create an initial educational plan that simultaneously defined our ongoing educational plan. The following is a description of that plan: National Institute of Health Stroke Scale Certification One area of focus we identified was establishing consistency in the assessment of the stroke patient. We believed the most efficient way to accomplish this would be to use the same tool each time we encountered the stroke patient. Although not sensitive for all types of stroke, it was determined that each member of the team should be certified in the National Institute of Health Stroke Scale (NIHSS) tool. By speaking the same language, so to speak, and consequently assessing the stroke patient with a common tool, we believed we also could most concisely control interrater reliability. Becoming NIHSS certified required an in-depth 3 hour lecture from the stroke nurse practitioner, an online study course, and finally, an online certification, which took approximately 2 to 4 more hours to complete. We set a deadline for completion of this certification by March 1, 2006. All team members, including administration, completed and passed this certification successfully. Additionally, required reading before the March 1 goal date was assigned by the director of the hospital’s stroke program and the stroke nurse practitioner. Establishing Competency Staying competent in completing stroke assessments via the NIHSS certification was one of the challenges identified early in the process. In discussions with the hospital stroke team and our medical director, we chose the goal of completing four NIHSS assessments within the first three months of the inception of the team (and for new orientees) through stroke alerts in the emergency department (ED) and in-flight transfers. In dialogue with the stroke team, it was deemed that this May-June 2009
would set the stage for an acceptable level of “competent.” Throughout this initial competency phase, each assessment was mentored by either an ED physician participating in the stroke alert, the stroke neurologist, or the stroke nurse practitioner, or it was reviewed by appropriate stroke team members if the assessment occurred on a transport. After initial competency, we further defined different levels of competency, as described in the following sections. Continuing Education/Maintaining Competency In staying with the standards set by Joint Commission for all stroke team members of a Joint Commission certified stroke center, a minimum of 8 hours/year of continuing education was established to maintain competency as a dedicated stroke transport team. Our plan includes any combination of opportunities listed below, which includes a required number of NIHSS assessments. Level of competency was stratified, ranging from proficient to mentor level as determined by the hospital Stroke Team, flight program Education Advisor/Administrator, and the hospital’s Education Committee. Each level of competency has been defined and based on how many hours of continuing education each flight crewmember has accrued: competent. 8 hours; proficient, 8–12 hours; mentor, 12 hours or more. Continuing Stroke Education Hour Accrual Combinations: a. Annual required NIHSS certification b. Four Stroke Alerts or NIHSS examinations within first 3 months of orientation, then one Stroke Alert or NIHSS examinations quarterly to maintain competencies for a total of four/year (can include patients being transported who are also Stroke Alerts, as well as participating in assessment with designated Stroke Team member, obtaining NIHSS, and following to CT/IR). c. Time spent participating in Stroke Alert with ED physician, neurologist, stroke NP, or interventional neuroradiologist. d. Minimum of one stroke article beyond deemed required reading for stroke awareness as determined by flight program Medical Director/Education Committee and hospital Stroke Team (1 hour) e. Stroke Case Conference given monthly by Stroke NP (1 hour) f. Stroke Council meeting (1 hour) g. Attendance of designated “Stroke Month” flight program education meeting (ie, neurology lecture from hospital Stroke Team: 1.5 hours) h. Attendance of annual Joint Commission-certified primary stroke center stroke conference (8 hours) i. Participation in neurovascular educational monthly case conferences presented by interventional neuroradiologist (1 hour) j. Other neurovascular/CVA educational opportunities as they arise Annual Stroke Competency Separate from NIHSS Certification, Written in Collaboration with Hospital Stroke Team 135
Collaboration Collaboration has been a fundamental philosophy in the creation of a dedicated stroke transport team and is inextricable from the related precepts of education and communication. Without the alliances of many people and departments, it would be difficult, if not impossible, to provide our vision of enhanced stroke care in the setting of the air medical environment. First, as discussed, partnering with the hospital stroke team in our education has been a key piece of building the foundation for this undertaking. Moreover, their participation in the review, revision, and implementation of stroke policy that reflects the unique practice of a Joint Commission-certified primary stroke center was a standard we endeavored to attain. Since the inception of this team, our stroke policy has been revised twice, as we have progressed and reevaluated our process. This stroke policy has included guidelines regarding the care and management of both the ischemic and hemorrhagic stroke patient. Dovetailed to our stroke policy is a “stroke packet” created to include symptom history, intravenous t-PA inclusion/exclusion criteria, triple computed tomography (CT) screening criteria, blood pressure goals, t-PA precautions, and an NIHSS documentation form that becomes a part of the patient’s medical record. Of significance also is a t-PA worksheet created by the pharmacy to enhance the safe and accurate administration of thrombolytics. Along with the decidedly important role of the hospital stroke team has been our partnership with the ED, pharmacy, radiology department, neurosciences department, our communications center, and telemedicine services. Specifically, the ED is pivotal in recognizing the transport team’s request for stroke alert, CT direct admit, and the communication of updated stroke scores to the stroke team. Pharmacy has assisted in the specific tailoring of a tPA policy that allows for rapid acquisition of the drug for patients requiring thrombolytics in rural communities without appropriate access to this treatment (and, as mentioned, a standardized t-PA administration worksheet). Radiology, by previous practice, has continued their coordination with the ED to accommodate for “CT direct,” a request by EMS that allows for the stroke patient to move directly to CT, with the stroke team meeting the patient there. Our communications center has been crucial in many aspects of collaboration and is discussed in further detail later. Telemedicine service is a breakthrough offered to patients in specific areas of remote Colorado who would not otherwise have the benefit of stroke care from a primary stroke center. Coordinating transport with the telemedicine neurologist offers key time savings, which can make the difference in whether a patient falls within the recommended window for thrombolytics or interventional radiology practices.
Communication: Linking Partners in Stroke Care A crucial piece of the organization, facilitation, and streamlining of the transport of the stroke patient is accom136
plished from our communication center. By defining ourselves as a specialty team, we believe it is imperative that we can consistently provide our services for enhanced stroke care, while also navigating multiple calls such as trauma, pediatrics, and other specialty requests. Built in 2002, it is integral to linking the transport team to the sending facility stroke neurologist, interventional neuroradiologist, or receiving primary stroke center facility. Specifically, the dispatcher guides the conference call between sending and receiving physicians, collecting pertinent information at the same time by also participating in the same phone call. In turn, the stroke transport team is suggested based on an algorithm reference stroke book if the team has not already been requested. This reference book details transport times for all programs in the region, comparing total round trip times from respective bases, all with the intention of providing for the stroke patient the fastest available transport. Add to that the ability of dispatch to launch an airborne standby for those patients being transported by helicopter. For example, a facility that suspects but may not be sure of a patient requiring the services of a primary stroke center may choose to initiate the stroke transport team with the option of canceling the call if appropriate. The option of initiating the team based on clinical findings without waiting for diagnostics satisfies closing the distance, simultaneously saving valuable time when traveling to rural settings while providing the patient with a transport team specializing in stroke care. There is no charge to the patient, facility, or EMS agency if we are canceled. If we are used, the time most programs would traditionally be on the ground while all information is gathered, or waiting on tests completed, has been carved out of the equation. Thus, the adage, “when minutes count…time is brain.” This same process can also be initiated by the stroke neurologist, who assesses the patient via telemedicine technology. Through an entity entirely separate from our hospital base, several telemedicine cameras have been set up for the specific purpose of improving stroke care to remote patient settings. Of these locations, approximately half could benefit from an airborne standby while the telemedicine conference call and assessment by the stroke neurologist are being completed. Ultimately, it is the goal to shave off time that is otherwise lost in the logistics of transport by providing a streamlined process that is managed and executed by our communications center. This process continues throughout the transport, with dispatch communicating with the stroke team and providing information such as NIHSS, activation of stroke alert, or request for CT or IR directly, based on the stroke transport teams’ patient assessment. Furthermore, communication can be directed to the stroke neurologist at the flight crew’s discretion if further guidance is sought. Lastly, the loop of communication is completed when follow-up is provided by the hospital stroke team to the flight team, and visa versa, with real-time feedback regarding issues that may arise during the course of a stroke transport. This dialogue provides the foundation for improvement in the process and the setting for evaluation, Air Medical Journal 28:3
which is necessary in scrutinizing the methods and practices of this specialty team. By closing the loop, so to speak, each call allows for the fine tuning of care provided based on the standards of a Joint Commission-certified primary stroke center. It is also worth mentioning that our program covers four bases currently. Because of our wide coverage both logistically and as a dedicated stroke team, it is the rare occasion that simultaneous calls involving a stroke patient and a non-stroke patient creates a situation in which a decision would have to be made on which call to take. That being said, our philosophy is to refer the nonspecialty call to another program in the event that this would occur.
encountered. These experiences have paved the way to better logistics, improved practice guidelines, and outreach opportunities that we otherwise would not have had. Lastly, because any program is only as good as the education provided, one of the most significant changes can be seen in the total number of hours of stroke education before and after the development of the stroke transport team. In 2005, the total number of hours for stroke education for the team was 65 hours. In 2006, total hours increased to 330, and in 2007, team totals approached 400 hours. The average stroke education hours for each flight nurse have increased by almost five times the amount in 2005. Although it is rewarding to describe specific examples of the benefits from the development of the stroke transport Evaluation team, we know that the idea needs to be measured to define Evaluation of the Stroke Transport Team includes both its effectiveness in different areas. Our program is in the patient care, which is evaluated against the developed process of evaluating the efficacy of the stroke transport standards, and the evaluation of the effectiveness of the team and how it has impacted a wide range of variables such program itself. Evaluation initially is handled through our as transport times, interventions, time to CT on landing, as quality improvement (QI) process. well as 3- and 6-month modified Each transport is reviewed by a flight Rankin scores to look at functional In improving the life of one nurse and then the QI committee outcomes of stroke patients transstroke patient, we hope to chair. Although not all transports are ported by our program. Additionally, transform the lives of many. taken to our hospital base (and priin our most recent CAMTS survey, the mary stroke center), each transport surveyors made the point of acknowlbrought to this facility gets follow-up of interventions and edging their belief that no other program had defined and results from the stroke team nurse practitioner. Cases also developed a dedicated stroke transport team unique to can be reviewed at the monthly flight staff meeting, with stroke care. We believe that this is only the beginning of the our program’s medical director, or specifically with the process and that our commitment to scrutinizing our impact interventional neuroradiologist. Additionally, the flight on all levels is of the highest importance. crew has the option to participate in the monthly hospital Taking It Beyond Stroke Council meeting, which includes case reviews presented by the stroke neurologists. In conclusion, our dedicated stroke transport team’s Evaluating the effectiveness of the program also can be mission is to provide streamlined, seamless care to neuviewed through the lenses of positive patient outcomes and rovascular patients from point of contact to destination obstacles encountered, as well as a comparison of the numthrough collaboration, communication, and education. ber of stroke education hours since the inception of the Our purpose is to practice as an arm of the hospital-based team. First, we know there are specific cases in which the stroke team, extending stroke services to patients, decreasstroke transport team has been effective in the ultimate ing out-of-hospital time, and enhancing a patient’s opporgoal of improving patient care and patient outcomes. One tunity for timely intervention. The benefits to this are example is a patient being transported from a rural commany, not the least of which are improving patient munity on the eastern plains of Colorado. The patient was care/outcome and addressing community need. Utilization a young man in his late 30s who presented with an initial of available resources such as a rapid transport team partNIHSS of 12. The facility contacted the stroke neurologist nered with a comprehensive Joint Commission–certified through a “ONEcall” line, which is managed by our comprimary stroke center, and collaboration with telemedicine munications center. During this conference call, the stroke services at a patient’s bedside, impart the highest level of neurologist recognized the potential benefit of thrombolytcontinuity of care. The development and success of this ics. On his request, which was relayed through dispatch, specialty focus revolves around a lasting coordination with the JCAHO-certified primary stroke team, defining, revisthe stroke transport team brought t-PA to the patient, ing, and improving criteria supporting requirements for a because this particular hospital did not keep any in stock. “dedicated stroke transport team”; ongoing development The transport team was able to initiate the t-PA bolus and of an aggressive flight team education plan beyond merely infusion with 1 minute to spare in the 3-hour window of being NIHSS certified; a current community outreach administration of thrombolytics. The patient’s symptoms plan; and a refined logistical plan for the transport of improved dramatically, and he was ultimately discharged local, rural, and out-of-state patients. from the hospital without any neurologic deficits. Scrutinizing our collected data for the most objective As with any process or significant endeavor, some of the evaluation of our impact on stroke care peritransport is most fruitful experiences in retrospective evaluation are crucial. We will aspire to review and publish our results at those in which obstacles and/or challenges have been May-June 2009
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7. Marler J, Tilley B, Lu M, Brott T, Lyden P, Grotta J. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 2000;55: 1649-55. 8. Silbergleit R, Scott P, Lowell M, Silbergleit R. Cost-effectiveness of helicopter transport of stroke patients for thrombolysis. Acad Emerg Med 2003;10:966-72. 9. Silliman S, Quinn B, Huggett V, Merino J. Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34:729-33. 10. LaMonte M, Bahouth M, Hu P, Pathan M, Yarbrough K, Gunawardane R. Telemedicine for acute stroke, triumphs and pitfalls. Stroke 2003;34:725-8. Epub 2003 January 30.
5 years. If we can show a positive impact, we would venture to propose that having a dedicated stroke transport team would be a worthy criterion for those primary stroke centers applying for comprehensive JCAHO-certified stroke center designation. It is our vision to offer our program’s experience to other transport teams across the country in an effort to reach beyond past and present limitations unique to the stroke patient based on access to timely care and intervention. In improving the life of one stroke patient, we hope to transform the lives of many.
Elizabeth Ahl, RN, BSN, and Roderick Wold, RN, ND, are flight nurses with Airlife Denver at the Swedish Medical Center in Englewood, CO.
References
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1. The Joint Commission. Certification master mailing list, revised 070108. Available at http://www.qualitycheck.org/Consumer/SearchQCR.aspx. Accessed July 17, 2008. 2. Smith D, Nettro P. A report to the Colorado Legislature from the Colorado Stroke Advisory Board. Colorado Department of Public Health and Environment. 2003 November. 3. Colorado Department of Public Health and Environment. 2004 Colorado Population Data and Statistics. 2005 May. Available @ http://www.cdphe.state.co.us/hs/vs/2004/ 2004population.html. Accessed April 26, 2008. 4. Silbergleit R, Blumstein H. Revascularization options: Implications for critical transport. Acad Emerg Med 1995;2:568-9. 5. Conroy M, Rodriquez S, Kimmel S, Kasner S. Helicopter transfer offers a potential benefit to patients with acute stroke. Stroke 1999;30:2580-4. 6. Chalela J, Kasner S, Jauch E, Pancioli A. Safety of air medical transportation after tissue plasminogen activator administration in acute ischemic stroke. Stroke 1999;30:2366-8.
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