S2E5: “Feedback from a Comprehensive Stroke Center – An interview with Beaumont Royal Oak Hospital Stroke Team. - rec. October 7, 2020”

In this episode, we introduce our listeners to three key role players at Beaumont Hospital - Royal Oak, located in Oakland County Michigan.  Beaumont Hospital Royal Oak is a Comprehensive Stroke Center that served 1,319 patients in 2019.  Needless to say, that’s a lot.  In addition, Beaumont Royal Oak is a participating hospital in the OCMCA Stroke Study.  In this discussion, we’re joined by Dr. Rebbeca Grysiewicz, Comprehensive Stroke Program Medical Director, as well as Beaumont Royal Oak’s stroke coordinators Caitlin Woodruff and Wendy Carriveau.  They’re here to talk about the value of EMS when it comes to the recognition and treatment of stroke patients.  It turns out, EMS has WAYYY more of an impact on the decision-making process a stroke team uses to select a treatment plan for stroke patients.   In this episode, our guests will provide us with their perspective regarding the value of EMS and how we can make even more of a positive impact.

The OCMCA Stroke Systems of Care Special Study is rapidly expanding.  If you’d like to know more information about the OCMCA’s stroke study, or if your agency or hospital would like to participate, visit OCMCA.org/stroke.  There you’ll find all the information you need about the study and how your EMS agency or hospital can participate.  You’ll even find study data, as well as a few presentations that you can download.  You don’t have to be located in Michigan to participate.  The OCMCA would LOVE participants from all over the US help us to identify the strengths and weaknesses of implementing a stroke severity scale, so that we can share the knowledge amongst the entire prehospital community. 

Visit EMSonAIR.com for the latest information, podcast episodes and other details. 

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Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org.  

Transcript

Geoff Lassers: 0:08

Hello and welcome to the EMS on-air podcast. The mission of this podcast is to keep healthcare provider safe, informed and prepared. Today is November 9 2020. I'm Geoff Lassers, and I'll be your host. This episode was recorded on October 7. Originally, we intended to get this episode released as episode number 2. But after a lot of thought we felt that we needed to set the stage a bit more about the landscape of stroke and EMs over the last 15-20 years. We also saw a need to make sure to give the necessary context regarding the use of stroke severity scales and the OCMCA stroke systems of care special study. The previous four episodes provide a nice clean, 30,000 foot view of the current status of EMS and stroke. In this episode, we introduce our listeners to three key role players at Beaumont Hospital Royal Oak. Located in Oakland County, Michigan, Beaumont Hospital Royal Oak is a comprehensive stroke center that served 1319 stroke patients in 2019. Needless to say, That's a lot. In addition, Beaumont Royal Oak is a participating Hospital in the OCMCA stroke study. In this discussion, we're joined by Dr. Rebecca Grysiewicz, comprehensive stroke program medical director, as well as Beaumont Royal Oak stroke coordinators, Caitlin Woodruff, and Wendy Carriveau. They're here to talk about the value of EMS when it comes to the recognition and treatment of stroke patients. It turns out EMS has way more of an impact on the decision making process a stroke team uses to select a treatment plan for stroke patients. In this episode, our guests will provide us with their perspective regarding the value of BMS and how we can make even more of a positive impact. The OCMCA stroke systems of care special study is rapidly expanding. If you'd like to know more information about the OCMCA stroke study, or if your agency or hospital would like to participate, visit OCMCA.org/stroke. There you'll find all the information you need about this study and how your EMS agency or hospital can participate. You'll even find study data as well as a few presentations that you can download. You don't have to be located in Michigan to participate. The OCMCA would love participants from all over the US to help us identify the strengths and weaknesses of implementing a stroke severity scale so that we can share the knowledge amongst the entire pre-hospital community. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on-air podcast team by email at QI@ocmca.org. Also, check out our website emsonair.com for the latest information, podcast episodes and other details, follow us on Instagram @EMS_on_air and please whatever podcast platform you use, subscribe to our podcast and leave us a rating and a review. It really helps us to grow this podcast. Enjoy the episode. Well thank you very much for joining us Dr. Rebecca Grysiewicz, Caitlin Woodruff and Wendy Carriveau. Ladies starting with you Doc, can you kind of tell us what you do where you do it?

Dr. Rebbeca Grysiewicz: 3:09

Certainly, Good Morning! So I am the Medical Director for the comprehensive stroke program here at Royal Oak. And what that really means is that I oversee both the clinical and quality component of stroke at Royal Oak, and that has a lot of different elements. And I work very closely with our stroke coordinators on the quality side of that and providing care.

Geoff Lassers: 3:32

Thank you very much in your clinical time. Do you do do more clinical time or your role more managerial?

Dr. Rebbeca Grysiewicz: 3:38

So I do both clinical and administrative time. I have a little bit more clinical time than I do administrative time. So I actually have boots on the ground in the hospital and I do take stroke call on a regular basis.

Geoff Lassers: 3:51

You know our buddy Steve McGraw says their doctors or their scrubs or suits. Are you a scrub or a suit?

Dr. Rebbeca Grysiewicz: 3:57

I would be more scrub than suit.

Geoff Lassers: 3:59

Caitlin Woodruff can you please tell everybody who you are, what you do and where you do it?

Caitlin Woodruff: 4:03

Yes, my name is Caitlin Woodruff. I am a stroke coordinator here at Beaumont Royal Oak. I'm also a nurse practitioner, part of my responsibility in our stroke program. We wear a lot of hats, but some of the main responsibilities that I have are quality assurance and performance improvement coordination of program initiatives with collaboration with many of the departments across our hospital in education.

Geoff Lassers: 4:28

Thank you. And Wendy.

Wendy Carriveau: 4:30

Hi, my name is Wendy Carriveau. I am a Nurse Practitioner and stroke coordinator. I work very closely with Caitlin we share our many hats, more specific is more data. I present data to the stroke stakeholders and stroke team. Also I work closely with nurses and do daily multi-disciplinary rounds, which includes nurses care management and social work.

Geoff Lassers: 4:57

Fantastic. So you're actually delivering the news, the facts, the hard facts, the data. Yeah. Cool. So give everybody listening. You know, most people that listen to this are located in Southeast Michigan and the name Beaumont Hospital Royal Oak. It's been around a long time. And it's got a pretty big name around here. Nationally, and we do have a fairly substantial national audience to kind of give them a background as to Beaumont Royal Oak in Michigan, because correct me if I'm wrong, were you guys the first comprehensive Stroke Center in Oakland County or Michigan?

Wendy Carriveau: 5:27

we were the first comprehensive Stroke Center in southeastern Michigan, can you

Geoff Lassers: 5:31

give us a little background on Beaumont Royal Oak, and as it stands right now is a comprehensive Stroke Center in 2020.

Wendy Carriveau: 5:36

So Beaumont Royal Oak, we are first accredited in 2012. As a comprehensive Stroke Center, we treat a very large volume of patients here at Royal Oak, we're a large hospital. And so our volumes reflect that. I think, in 2019, we cared for 1319 stroke patients, the large majority of that were ischemic stroke patients, and we also manage hemorrhagic strokes at our facility.

Geoff Lassers: 6:04

Out of all the data I've ever looked at teaching stroke, and I've been teaching stroke for a number of years now, especially specifically for EMS providers, we find that it's about 80-85% ischemic strokes. Do you find that at your facility as well being such a comprehensive center that sees a big volume? Is that consistent where you guys see it? Absolutely. Fantastic. Now, obviously, when you're talking about things like hemorrhagic stroke, a comprehensive centers, the best place for that hemorrhagic patient, and if you just look at the services that are offered, and that's typically and really generally speaking, but really there's four different levels of stroke centers found across the United States. And there seems to be a number of various groups that certify these the certifying bodies, and then some states have processes where the state is the certifying body, or you need to do both in some states, but in general, there seems to be four different levels of stroke centers. Caitlin, can you give us an overview of these four different levels of stroke center, starting with the lowest level of care, acute stroke ready hospital and work our way up to comprehensive give everybody a flyover what to expect at these different types of facilities.

Wendy Carriveau: 7:04

So acute stroke ready hospitals, there were actually a certification were introduced relatively recently, I think 2017 or 18, ballpark. These centers tend to be located in smaller, more rural communities, kind of our critical access hospitals, they provide emergency care and meet the initial needs of stroke patients, and they have the ability to administer IV thrombolytic agents for those patients who are eligible. In most cases, these patients will end up being transferred to the nearest primary stroke center thrombectomy, capable or comprehensive stroke center as appropriate.

Geoff Lassers: 7:41

So these acute stroke at hospital seem like they're in more rural areas that are available to patients to identify what the problem is, and then get them out to like a hub hospital. So it'd be like a satellite location where it's still a hospital, it's still an ED, it just serves an area that doesn't necessarily or wouldn't support a primary or Comprehensive Center because I think the volumes are necessary to get to that, right? So this serves as identifying the problem and then getting them to the correct location. And then these acute stroke readies I believe, is the term drip and ship where if they need TPA, they can get it going and then get them off to a center like yours.

Caitlin Woodruff: 8:16

That's the term we use.

Geoff Lassers: 8:17

Fantastic. So you drip and ship them out. So let'ssay you take them to a primary Stroke Center. What's the the next level up? What is that primary stroke center offering that the acute stroke ready hospital is not?

Caitlin Woodruff: 8:28

Primary stroke centers were kind of the mainstay in the development of certifications for stroke centers, they came about in about 2003. Primary Stroke Centers, in addition to having the same capabilities as an acute stroke ready hospital have additional imaging capabilities in most cases, and they're also able to hold on to those patients and provide post treatment care, provide the necessary rehab services, education, and help with discharge planning, where are these patients going to go after they've been treated for their stroke in the acute setting.

Geoff Lassers: 9:01

So these primary stroke centers do have the ability to treat and then maintain the care for that patient throughout the duration of their treatment. However, there are some cases where they might not be able to handle. However, at this point, I am aware that there are hospitals that are designated as primary but also offer some of the services that are offered at things like a thrombectomy capable stroke center or comprehensive Stroke Center. But if they don't have those services, they're going to bring them up to another level of care. Correct, right. If my hospital is a primary Stroke Center, and I don't offer any type of comprehensive services to these patients for neuro, what would get me to send this patient or from that primary location either in the field or for my acute stroke ready hospital. What gets you to say, we need to get this patient to either a thrombectomy capable stroke center or a comprehensive stroke center.

Caitlin Woodruff: 9:56

So the presence of a large vessel occlusion in most cases will earn a patient trip to kind of the next level of care here. So, LVO large vessel occlusion indicates that there could be a clot or thrombus in one of the large vessels in the artery that might be amenable to treatment with thrombectomy endovascular reperfusion. So at the thrombectomy capable stroke centers, that's kind of the next level up from a primary Stroke Center. These centers offer endovascular treatments and can manage patients post procedurally. So in most cases, this means they have dedicated IC, that's for the management of those patients. They also have additional advanced imaging capabilities. So we have to have the ability, if we're going into pull out a clot, we have to be able to see what the vasculature looks like. So availability of something like a CTA or CT perfusion, an MRI.

Geoff Lassers: 10:52

Yeah, like we've said in previous episodes, large vessel occlusions, are exactly what they sound like. They're a large vessel occlusion, it's a big giant clot in a big giant artery. And the problem with clogging up a big giant artery is it stops a whole lot of blood, the bigger their artery, the bigger the blood, the more blood you stop, the bigger the problem. And some hospitals have the capability of removing that clot through a process called mechanical thrombectomy. If a hospital doesn't have the ability to remove that clot, the lowest level of care for certification of that is thrombectomy capable, which is a fairly new designation that we're finding throughout the United States. You know, in 2003 primary stroke centers came out 2012 comprehensive stroke centers, and now we have thrombectomy capable, because the amount of data that's come out over the last 8-10 years, about LVO recognition in the field and LVO care in the hospitals has become so great. Now, you said it was going to be an LVO that gets that patient buys them a ticket out of that primary stroke center would hemorrhagic also buy them a ticket out of that center?

Caitlin Woodruff: 11:53

Absolutely. Some primary stroke centers can manage some hemorrhages, but the requirement for neurosurgical services is that they're able to be evaluated in two hours. At a comprehensive Stroke Center, we have 24/7 neurosurgical services. So any neurosurgical emergency will require that patient to be transferred to a comprehensive stroke center. So in addition to being able to offer things like thrombectomy like a thrombectomy capable center would be one additional thing we can offer in a comprehensive Stroke Center is neuro-surgical services. We can offer endovascular coiling for endovascular subarachnoid hemorrhage, clipping where necessary and other neurosurgical options.

Geoff Lassers: 12:36

Okay, so that kind of comparison contrast the difference between those thrombectomy capable and comprehensive, I think, and please, Dr. Grysiewicz Tell me if I'm wrong, the increase in availability of thrombectomy capable hospitals is based on the data that shows that LVO's can be managed with mechanical thrombectomy. And so they wanted to make it more available. And because ischemic strokes are obviously the predominant type of stroke, making that level of care available made sense. However, with hemorrhagic strokes being much less incidence, the comprehensive centers seem to be the best place because of that neurosurgical care, correct?

Dr. Rebbeca Grysiewicz: 13:16

Absolutely. I think you summarized it very well, Geoff. So we know that many primary centers were capable of performing mechanical thrombectomy. But they didn't necessarily have that 24/7 neurosurgical coverage for hemorrhagic stroke, as you mentioned. So having this additional designation really helps to make sure that there are more centers that can provide those services and have a certification to do so.

Geoff Lassers: 13:42

Yeah, and it can be a little bit confusing. When I started out understanding the different levels, I tried to liken it to trauma centers. However, when you're talking level one, level two, level three level four trauma centers, there are so many protocols that dictate exactly where patients go based on what we're finding in the field. The difference is nationally, we are seeing little pockets do the same thing with stroke centers. But it isn't such a nationally accepted thing. You know, even the CDC accepts the ACS guidelines for trauma patients. It's not as widely accepted yet for the stroke identification in the field in the measurement of an LVO. So what we find in many cases that this closest Stroke Center is the most appropriate in most EMS protocols. That's certainly not the case. Everywhere. There's places in Ohio, there's places in Florida and in Massachusetts that are currently bypassing certain facilities to take specific types of stroke patients to specific types of hospital based on their capabilities. So what I'm getting at is, know what your protocols are, follow them. And if you need to know more about the hospitals get in contact with people like Dr. Grysiewicz and Caitlin and Wendy. So we've touched on just briefly on ems identification in the field. So it's a good point to kind of stop remind everybody That there is the difference between stroke identification tools that identify the presence of neuro deficits like the Cincinnati pre hospital stroke scale or the Los Angeles pre-hospital stroke scale. But then there's stroke severity scales like FAST-ED and RACE that are designed to quantify or specifically identify how severe a stroke is, based on their findings, no matter what ems since about the 1990s, has focused more on stroke, because we've learned more about stroke. You know, we got TPA came out in the 1990s, which shifted the use of the Cincinnati pre hospital stroke scale to allow ems to identify potential candidates for TPA. And we've built on that over the last 20,30,40 years. And now we're at the point we could do a lot more for patients in the information gathering so that when we bring them to hospitals like Beaumont Royal Oak, we can deliver more information and they can make quicker decisions. So my on-scene assessment, recognition of a stroke is huge. And if my agency uses a stroke severity scale, it's really important I do that right. But what's most important is I convey all that to the hospital. And the first thing I do is I contact the hospital as soon as possible once I have all my information and let them know that I have a stroke alert and what I have. Can you guys tell me how important is it to you the agency that receives my stroke patients, if I'm constantly delivering really good stroke alerts, how important is that?

Caitlin Woodruff: 16:28

It definitely matters. It's very, very important. And the reason why is because when we're working with patients that are potentially stroke, we have what we call the stroke golden hour, which is 60 minutes, which was originally the goal but we at home at Royal Oak, our expectations are closer to less than 45 minutes for treating these patients that are candidates for IV TPA, or thrombolytic therapy in less than 45 minutes is our goal. So how the stroke alert notification prepares us in the emergency room is that we are preparing for the arrival of the patient. Even if that arrival notification is moments, it really makes a large impact in preparing our emergency center. When it comes to the ED provider is aware of the patient's coming. The CT tech anticipates the patient's arrival directly to the scanner for appropriate diagnostic testing, whether it's just a head CT or a CTA. Also, a pharmacist reviews the patient's chart for any past medical history he may have and current medications, the stroke team advanced care provider arise at the bedside for prompt evaluation and additional communication between all members that I mentioned in also the on call stroke neurologist impossible neuro-interventionalist. That makes a huge impact.

Geoff Lassers: 17:48

You receive a lot of stroke alerts because you receive a lot of stroke patients. So it's safe to say that you could probably give us some feedback. Is there anything that EMS delivering to you that you want to hear them keep doing their strengths? Is there anything that we can improve upon, maybe there are opportunities for learning there?

Wendy Carriveau: 18:05

I think one of the most important things for us is for them to be very clear that this is a stroke alert. There are a number of times where we're given symptoms, which is wonderful. But I think processes we have in place here, the minute you hear "STROKE ALERT" coming over that radio, it's not optional, you have to do your part as the person on the other end of that line and activate the stroke team. So being very clear that this is a stroke alert, if we're able to get a last known well and have that reported before the patient arrives. That's also extremely helpful, because it helps us to determine is this somebody who is within a treatment window? Is this somebody who might be eligible for TPA? Is this somebody who we might need to look at advanced imaging to determine if there's an LVO, and they're eligible for thrombectomy versus somebody who is a wake-up stroke? And we're not sure when they were last seen well.

Geoff Lassers: 19:02

it seems that all of the information I've seen is that many of the treatments based in stroke are time based. So if we don't know the last time they were normal for them, it seems like it takes away a lot of options. Is that safe to say?

Dr. Rebbeca Grysiewicz: 19:15

Absolutely. So we need to know when they weren't last known. Well, sometimes that gets misconstrued as when someone found them which can be important information. But again, when they were last well really dictates the care and what they're eligible for. A lot of the decisions we make very early on are dependent on that information.

Geoff Lassers: 19:33

Totally. You know, in our EMS protocol here in Oakland County, it spells out specifically what should be delivered over a Stroke Alert and a Stroke Alert should also always start with "STROKE ALERT". One thing we've tried to convey in 2019 and 2020 to our EMS providers is that if you're calling a patient a stroke, call the patient a stroke if your primary impression your PCR stroke, you should say Stroke Alert on the radio. If you're not not confident, then you're not confident. What we're trying to get at here is you need to identify the fact that there's new onset neuro deficits, you've ruled out potential mimics, if it qualifies as a stroke, it qualifies as a stroke. If EMS calls and they have this unclear, semi-vague, but they do say there are neuro-deficits, I'm a little confused on why you didn't say stroke. Now, there's many diseases and disease processes that do cause neuro deficits. But when you say Stroke Alert, we're on the same page. That's a big deal. The next thing we tell them to do is list what those deficits are. And if their agencies using a stroke severity scale, give them the FAST-ED score, right? It goes on last known well, symptom onset, anticoagulant use if applicable with the last date, time and, and dose of that medication, as well as applicable vital signs, including their blood sugar, a GCS, and an estimated time of arrival. Now, that's what you guys should be getting, would you say it's common to receive that amount of information? That is the collective laugh of every Stroke Center Coordinator ever in the history of the United States. And it's okay, because it's fairly new to EMS providers to be so confident about stroke. And it wasn't up until this year that they even had a checklist of exactly what they should say. So what I'm hearing you say is there's some that are good, but it's not always common to have a dialed in Stroke Alert with all of the things they need to hear.

Dr. Rebbeca Grysiewicz: 21:28

Exactly. I think that what you outlined sounds exceptional, maybe we don't receive that amount of information on every call. But I really just want to echo and stress the importance that even just a stroke alert is coming and that last known well are so vital. If we get additional information about anticoagulation use, last administration, those additional pieces are wonderful. But again, that initial stroke alert is really the pivotal key component to this.

Geoff Lassers: 21:59

I totally agree. And you know, there's always the rule and what you should aim at, and it doesn't always get hit. But if we do get all that information, she it seems to work now, anecdotally, the feedback you get from your providers in the ED that receive a stroke alert, have you ever gotten feedback from them? Is it is it seem to be in-line with what your feelings about your stroke alert your hospital receives?

Caitlin Woodruff: 22:23

I think so I think our emergency room, we've worked with them at length taken great effort to remind them that if they are getting a stroke alert, it is their responsibility. They need to trust our colleagues, our ems colleagues that what they're seeing in the field is real. And we need to do our part as a hospital. And so I think we've had great buy-in from our staff in the emergency room. And I think they do really appreciate the amount of information, particularly during COVID when we didn't always have family members able to get to the hospital with patients. EMS having that contact so that we as a hospital can start those conversations about treatment options and confirming the last known Well, I think EMS has been an incredible asset in that regard. And I think our emergency room colleagues would agree with that.

Geoff Lassers: 23:13

Totally agree next to kin that's another one that we've been hammering and making sure that the providers that deliver to you give to you especially during COVID. We've been transporting the historian to the hospital for the last couple years so they can give you that information directly face to face. Well guess what? It can't bring them there anymore. Oh pandemic stop that so yes leaves next to kin information is so important to stroke patients and their outcomes. This quick commercial break is brought to you by American CME, If you or your EMS agency need to catch up on your stroke knowledge go on over to AmericanCME.com. There you'll find multiple courses approved for EMS CE's that focus on stroke. I highly recommend the course "Identifying large vessel occlusion strokes with FAST-ED" Hmm, kind of applies to this. This course walks you through the FAST-ED stroke severity scale step by step shows you how to score the criteria of the scale and provides additional details to successfully guide EMS through the process. Or, if you want to focus on the fundamentals of stroke, check out the course "Anatomy and pathophysiology of stroke" which breaks down each region of the brain. Or check out the "large vessel occlusion stroke" course which introduces EMS to LVO stroke and provides great detail and information. All three of these courses are approved for 0.5 EMS continuing education credits in the medical category. Did I mentioned that you can access all of American CME's content for free? Yeah. Free. and now back to the show. And when I deliver that stroke alert, I then transport and then when I get to your facility, we're doing a face to face handoff and we always let our EMS providers know it's always best to kind of re-iterate everything you said on the stroke alert with a little bit more nuance. Because on that radio, you kind of want to give a confident, clear, concise report, get off the radio, they know what's coming. Now that I got your face to face, here's what I found. With that face to face interactions are you guys at your hospital? does it occur on the way to CT? Do you go direct to CT, what are your feelings on that?

Wendy Carriveau: 25:22

It does happen when the patient is rolled right into CT. Often, we find EMS in the CT office giving report to providers while the patient's receiving their head CT.

Geoff Lassers: 25:34

They show up at your hospital at that stroke alert, they're going right back to CT, and then they're going to finish their patient care reports. And this is so vital to me, I'm a quality improvement coordinator. And to me the information that enters into that PCR is so important because it's going to carry on the legacy of what actually happened. And it might be obvious to those that were there. But it's not obvious to those that are reading it unless you clearly depict that. So I have a question. Do you guys actually read my patient care reports for stroke patients that are delivered to your hospital? Yes, we do. And what is your general impression of MS patient care reports in regarding stroke patients, and Please be honest, and nobody's listening. So don't worry.

Caitlin Woodruff: 26:16

I think we have actually made more of an effort recently, within the last year to look at those reports. And I think we're finding more and more that there's really valuable information included in those reports, things that you don't necessarily get when you look at the patient chart when they get here, some things that can really fill in gaps and holes in our patient record. And so I think it's an invaluable piece of information for us as a hospital and as a program. And I think it really helps to have a better picture of what that continuum of care looks like for that sort of patient, where we started and how we progressed through our decision making process.

Geoff Lassers: 26:59

And how big of an impact has it been making on your decision making process? Are these PCR something that you're reviewing after the patient care decisions, during the process? And what I mean by that is, do you go back and look at them to glean what information could we have gotten? Or are you using it in real time as you receive them?

Wendy Carriveau: 27:17

we're really not using them specifically in real time, because we're at the patient's bedside, we're talking to the crew that's come in with a patient, we can glean a lot of our information for decision making on those conversations, we are not receiving the PCR necessarily instantaneously, or looking at it. But we are using the PCR when we're extracting data from the charts, gleaning information for our data and practice improvement.

Geoff Lassers: 27:44

So here's a new term it just popped in my head we call them EPCR's, (electronic patient care records). But I think we have a new one OPCR's(oral patient care records), you just gave it at the bedside to the nursing staff or the ED physicians or the neuro team that showed up. So you've given them the patient care record. And in all reality, we need to make sure it's reconciled in writing, so that we can assure what you actually did what you actually said when you actually wrote down were the same so that that data can let us know, what is something we need to continue and what is something that needs to be improved upon? That's huge.

Dr. Rebbeca Grysiewicz: 28:19

Absolutely. And Jeff, I just want to share that I do read them as well. So when I get to the patient record, I always look at the PCR. I agree with what Caitlin was saying that you get valuable information that sometimes is unexpected, that helps you and again, this really, really aids in our audit when we're going back and looking at the patient record. So so vitally important.

Geoff Lassers: 28:43

When you're looking at patient care records for the Bloomfield township Fire Department who's delivering FAST-ED scores along with their stroke alerts in their patient care record, in their radio reports, and in their face to face. How is that impacting your decision making is queing you in on anything more? Is it making things better? What's your opinion on the differences you see between the stroke patients that are in the current stroke study versus the ones that are not?

Wendy Carriveau: 29:08

I think the information that we get in our radio calls and within the report is streamlined. I think there's a special attention to stroke symptomatology and onset and so I think that has been really helpful on our end in teasing out is this somebody who's an LVO and we've gone down the perfect path, once they get here and done everything that we needed to do. Was this somebody who wasn't eligible or maybe outside of a window, but we got them to the right place for evaluation. I think those pcrs have been, I think, the first one I opened and looked at and saw a FAST-ED report and, you know, very clearly outlined symptoms. Wow, this is above and beyond. This is amazing. So I think the quality of those reports has been excellent. We appreciate the information provided in those reportsimmensely.

Geoff Lassers: 30:01

One of the side effects we think we're obtaining through this study is teaching about FAST-ED and stroke severity scales isn't so much that we're teaching them the stroke severity scale is that they're learning so much more about what they could have been doing for the last 10 years. And I hope and what I'm hearing for you, as it's kind of being conveyed in the stroke alert, you're getting more nuance to the stroke patient, probably a little bit more confidence when they're calling a stroke alert. You know, when I learned about stroke in my first interactions in my initial education for EMS, it wasn't very much, here are what neuro deficits are, check a blood sugar, take them to the hospital and shake their hand that still works, wish them luck and go away. Well, it's been 20 years. And since then, you neuro teams have done a great job of increasing the abilities for these people to have a good outcome. And we hope that that information we're clearing is making it even more options for those patients.

Dr. Rebbeca Grysiewicz: 30:56

Geoff, I just want to share with you this information in the last quarter of 2019 patients that arrive via EMS versus car had a faster door to needle time by 10 minutes. So just to share with you what immense difference that makes, particularly as you said, with more education, that competent, streamlined information is so important in how rapid we can administer intervention.

Geoff Lassers: 31:20

And I always say intervention now because I don't want to say mechanical thrombectomy. I don't want to say thrombolytic. I don't want to say coiling, because there's so many options, depending on what you have now, it's the right intervention for you. You know, even though mechanical thrombectomy is here, that doesn't mean that thrombolytic therapy isn't around still and doesn't have a place. So I think you're bringing up another great point is we're not just benefiting mechanical thrombectomy patients are benefiting anybody that is having a stroke that we can get the information to they get a lot of different options. Very cool. One of the things you guys brought up a little bit earlier, if I could kind of backtrack a second isn't just the various procedures that can be offered to a stroke patient, I'd like to go back a second and talk about that imaging, because imaging is such a big deal to a stroke center. That type of imaging CT is something that's very commonly understood amongst pretty much anybody who understands what a CT is. And a head CT is a stick your head in the big doughnut and take a picture head and they can look at it but their CTA, their CTP. And there's different things that can identify the precise location of a problem. Can you guys give us just a quick flyover as the application of imaging and how important is that stroke patient beyond all the treatments that you do?

Dr. Rebbeca Grysiewicz: 32:34

So a CTA looks at the blood vessels, the arteries, and this is additional vascular imaging to determine if there is a large vessel occlusion. So this would be a image that we would obtain when we have last on well between zero and six hours. So we could make a rapid decision about a patient going for mechanical thrombectomy or additional intervention. A CT perfusion can be immensely helpful when you have a patient that's outside of that last known well of zero to six hours when you're trying to decide if there is viable tissue for intervention. And what I mean by that is the perfusion study looks at the blood flow in the blood volume. And we can see if there is already established infarct of tissue or if there is enough Penumbra or surrounding tissue that could be salvaged to intervene upon. So we use that information to make a decision. For example, with a wake up stroke, if somebody comes in and we say their last one well was the evening prior at 10pm. And they woke up with symptoms, we don't really know when it occurred. So if we look at a perfusion study, we can determine the amount of infarct it or dead tissue and the amount of potential salvageable tissue to treat so that that additional vascular information can be very valuable when we're making these higher level two treatment decisions.

Geoff Lassers: 33:58

And you're making these decisions very quickly. So not only do you need to have the information of what happened leading up the stroke, when it happened, how it happened, how it presented, how long has it been? What is their medical history? Have they had previous strokes? Are they on anticoagulants? What's in their blood? and then you got to take at least one set of pictures of the inside of their head, and then follow that up with a couple more and then I hope you have an IV because there's going to be a contrast dye. And then you got to take all that data and say okay, and all this data, what's best for this patient? So it sounds pretty cut and dry and simple. No?

Dr. Rebbeca Grysiewicz: 34:32

Try to make it as streamlined as possible. But yes, there are a lot of components that go into the decision making for stroke treatment.

Geoff Lassers: 34:40

So with that you have a situation where you got many departments coming together, you got an EMS agency, bringing a patient working with your EDI physicians and nurses calling a stroke team then working with your imaging and then maybe interventional teams. That's a lot of teams to get together in a lot of separate different division expectations. As well as the expectations of your entire system. So how important is it to you, doc and your team to always inspect what you expect? And what I mean is when you how do you? And do you feel it's necessary to constantly monitor, measure and evaluate? Because it sounds like you got a lot of moving parts, and they probably need a lot of attention.

Dr. Rebbeca Grysiewicz: 35:18

Absolutely. So I think to have a successful program, you have to constantly be evaluating the quality of your program, and you have to provide feedback, it's better if you can do that in real time. And there are always opportunities for improvement, even in a system that is working very well, there is always an opportunity to shave off a minute here and there and potentially deliver intervention faster. And that's always what we're striving towards. So this is something that we do on a daily basis, all the time, we're evaluating the quality of the program. And hopefully, that feedback is being delivered as quickly as possible to everyone in all the different multidisciplinary groups involved in stroke care. As you said, there are many components, and just having opportunities for improvement in one area. Sometimes we'll help everyone else in what they're able to do and how they're able to be successful.

Geoff Lassers: 36:17

Yeah, just looking at it. From my perspective, if I'm the first person to put hands on the patient, man, I feel like I can hack out a lot of wasted time and energy by just grabbing that list. That checklist. That's right in my protocol, and I'm sure it exists in stroke protocols across the United States, just grabbing all that info because to me, EMS providers are investigators before practitioners, our information gathering is what is so necessary to the next level of care. And I think it's so underappreciated, and every time I talk to an agency or hospital or something about process improvement I learned about man, it all comes back to the fundamental things, what did you find that's going to help out a lot? So I deliver those patients to you, can you give me a flyover of how you perform that process improvement internally? And what I mean is do you do you just like meet all the time? Or do you find a problem and just email Bob down in imaging and say, Hey, Bob, you screwed this up. Like, what does that kind of look like? Is it a team aspect? Is that a Dr.G thing is that a Beaumont thing?

Wendy Carriveau: 37:21

Well, specifically for our stroke treatment patients, we do a more real time evaluation and audit of the chart. And it's sent to the stroke team members that were involved in the case and the stroke team itself. And it details the patient's care everything from how the patient arrived, whether or not we had EMS pre-notification of the Stroke Alert. It also talks about diagnostic testing and treatments and the timing of those very specifically so people can understand when they read it, their portion of the process, and whether or not they performed within the expectations.

Caitlin Woodruff: 37:59

For those patients who aren't necessarily eligible for treatment. We have process too, we actually review every single chart of every discharge stroke patient, because you can't fix problems if you're not looking at every case. And so every month we get a coding list together, we look at each of those cases, doing essentially the same thing Wendy outlined looking at their mode of arrival, how quickly did we get a head CT, how quickly did an ED provider see them, we use all of these details to drive our process improvement plans. So just because a person didn't get treatment doesn't mean that we shouldn't provide them extraordinary care. And so we use all of the cases for of all of our patients to help even the ones that went exceptionally well. There are things to be learned from cases that went exceptionally well. We use all of those cases to drive our quality and process improvement initiatives here at our hospital.

Geoff Lassers: 38:53

Sounds like you guys got it dialed in. That's awesome. With the feedback you provide to your stroke team, I'm sure it's also shared with other teams throughout like imaging, and I'm sure your neuro team is a part of other teams as well as their feedback loops. But as the guy who delivers the patient to your hospital, what is your mechanism to give the strengths and weaknesses, opportunities and threats from the data you've gleaned to theEMS agencies that deliver those patients?

Wendy Carriveau: 39:20

We do have our EMS coordinator follow up with documentation specifically for the stroke treatment cases. But he does give feedback immediately to the crews when they bring a patient in. What is going on with the patient. The patient's being taken directly to head CT and the documentation that's received by EMS includes that crew member list. It also includes everything that we've been told about the patient it might include some information in the PCR, which includes the presenting stroke symptoms. The patient's last known well, if the stroke alert was called into the hospital and it also includes information derived directly from our process improvement and quality review that is reported internally for process improvement. It's everything that our EMS coordinator provides within that documentation. And then he also takes requests from EMS companies. So if you have a EMS company that has specific request and find out what happened to a patient, he takes those requests and gives feedback on those case.

Geoff Lassers: 40:24

It sounds like it's a fairly substantial program that gets back to EMS. And one of the things I'm trying to do is learn how to get back an automatic process with hospitals and agencies, because that experiential learning is such a big deal. And you know, hospitals, and any system isn't really set up to be like, Oh, this is a great idea, let's just go do that you don't have personnel that can give the feedback directly to every single agency for every single stroke. But that doesn't mean that we can't leverage technologies to eventually get there. So please keep at it, and identifying the best way how to tell these providers what they're doing well, and what we need to improve upon, so that when we get to the phase where we can actually deliver to them quickly, we're ready to go.

Wendy Carriveau: 41:04

We want to do a amazing job of treating patients and with EMS doing the great job they do we're able to be successful.

Caitlin Woodruff: 41:11

I think, too, you know, we, on our end, want to do our best for EMS. So what things can we provide as a stroke center? What things can we provide, whether it's education, increased feedback, or more directed feedback about how things are going, the work doesn't stop when the patient gets here, it needs to be a reciprocal relationship, we need to be providing EMS with the things they need as well.

Geoff Lassers: 41:37

Absolutely. And we'd love to have you back. And maybe the next one, we do a couple case studies to highlight some of the great things that EMS has done and maybe some other ones or there's some learning opportunities, and maybe we can get you back in the next month and talk about that.

Wendy Carriveau: 41:49

Sounds good.

Geoff Lassers: 41:50

Perfect. Well, you ladies, have a great day. Thank you very much for your time. And thanks for coming on the podcast.

Dr. Rebbeca Grysiewicz: 41:56

Have a great day!

Geoff Lassers: 41:57

You guys have a good one. Thanks. That's all for the show today, everyone. Thank you for listening. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on-air podcast team by email at QI@ocmca.org. Also, check out our updated website emsonair.com. For the latest information, podcast episodes and other details. Follow us on Instagram@ems_on_air and please whatever podcast platform you use, subscribe to our podcast and leave us a rating and a review because it really does help. Thank you for listening to the EMS on-air podcast. Stay safe and have a great day.