How to optimize patient logistics in stroke

A stroke is a serious medical event. In the case of an acute situation the time to correct treatment is crucial. Through integrated care processes, like pre-defined and validated fast tracks, significant outcome improvements can be obtained.

Of fundamental importance in an acute stroke is to determine whether it is an ischemic stroke or a hemorrhage, i.e. a bleeding. In the case of an ischemic stroke the situation and the route to therapy is in many aspects similar to the situation when we have an AMI. The governing principle today is to start thrombolytic treatment as quick as possible, given that the patient don’t have any contra-indications and that to much time hasn’t elapsed since the clinical situation commenced. In general the time-window is said to be about 3 hours, however this period is constantly under re-evaluation by researchers. So far the trend has been that the time-window for positive effects on treatment expands for the good of the patient. Still a quicker correct treatment the better seems to hold.

Of fundamental importance in stroke is the possibility to discriminate between the ischemic stroke and hemorrhage. Approximately 80% of the stroke cases are ischemic and are therefore candidates for thrombolytic treatment, and ultimately this therapy should be commenced in the ambulance exactly as is the case with pre-hospital thrombolytic therapy in AMI. However, initiating this therapy without being sure that we have an ischemic stroke could lead to a very severe situation if dealing with a hemorrhage. The bleeding would likely be worse. Therefore there is a need for discrimination between the different types.

In contrast to ACS and AMI where we have the ECG, we today don’t have any simple and reliable methods to apply in the ambulance to do the needed discrimination. We have to rely on observations, checklists and in some cases what is known as stroke indices. The real discrimination has to be done at a hospital by for instance CT-scan. There is research and projects dealing with the discrimination issue, but so far nothing have reached further out in practice.

 What can be done is to use the checklists, observations etc. together with an established “stroke-protocol” to design a fast track for these patients, i.e. make sure that once the patient reach the hospital everything is set for a fast CT-scan and evaluation, and in the “right” cases initiate thrombolytic treatment.

Ortivus can through MobiMed provide the necessary tools and solutions to implement efficient stroke care processes, like implementing fast tracks, linking pre-hospital and hospital care together. Already in 2000 Ortivus was part of setting up such a solution in Uppsala County Sweden. In this solution Ortivus designed a stroke specific checklist for MobiMed which was communicated from the ambulance crew to neurological experts. After evaluation of the checklist together with other available information a pre-defined fast track protocol was initiated already during the transport. This protocol included for instance preparing for immediate CT-scan and meeting up with the patient at A&E.

Core Messages:
 Regionally implemented care plans or processes improves treatment outcome
 Time is important also in stroke – fast thrombolysis is the “remedy”
 Correct Pre-hospital processes improves call-to-treatment time
 MobiMed is the right platform for establishing and supporting the necessary plans and processes
 Good medical care is teamwork across stakeholder borders e.g. ambulance and hospital
 Today there are no methods available to discriminate an ischemic stroke from a hemorrhage in an ambulance; decisions have to rely on observations, checklists and stroke indices