Rhode Island State Breakout
Dr. Ken Williams
Stroke Legislative Update
- Acute stroke ready designation passed, we now have a 3-tiered system in Rhode Island’s State Law.
- Stroke Prevention and Treatment Act: In 1.5 years it will be the 10-year anniversary. Opportunity to plan a media event, release data and highlight accomplishments.
- The New England Council for EMS: Sunday, Nov 19th – Monday, Nov 20th 2017 at Gurney’s Resort and Marina in Newport
- NASEMSCO 2018 in Providence, RI: May 21-24, 2018
Review of GWTG-Stroke Data
Note: This data is a reflection of hospital documentation of pre-hospital care, and may not be a true reflection of care provided by EMS.
- Stroke Diagnosis by Type: RI has half as many TIAs compared to the rest of the Northeastern States (7.1% in RI vs. 12.5% in NE)
- Arrival Mode: 51.4% of patients arrive by EMS (similar to rest of NE). RI has a higher % of transfers, as expected.
- LKW to Arrival Times: RI has similar numbers across the board for all time groups, compared to other NE states.
- Pre-notification by EMS: all states have lower percentages than we’d like to see (RI hovers around 50% but with a dip down to 40% in 2015). For 2016, RI had 44.4% had pre-notification by EMS.
- Door to CT – Ischemic Stroke patients who received IV tPA: Similar to NE (RI: 11.5% vs. NE: 10.1%)
- Ischemic Stroke patients who received IA catheter-based reperfusion: RI had more than 2x as many compared to other NE states (8.4% vs. 3.2%).
- Time to IV tPA – 60 min: RI is doing great (82.1%)! For those eligible, we’re getting tPA to them quickly. Within 45 min: RI is 49% vs. 41.7% in Northeast.
How is RI doing with the Severity-Based Stroke Algorithm for EMS?
- Response time from call to patient is quite good but we don’t have a lot of high level education for those who are dispatched (e.g., for screening)
- We’re getting LKWT most of the time when we suspect a stroke. We’ve also been good at collecting contact names & numbers as well (which is important for consent).
- Using LAMS in RI: Might be interesting to do a study on what EMS thought the LAMS score was vs. what the hospital thought it was.
- Algorithm says direct transport to CSC if it won’t add more than 15 minutes, but in RI we use a 30 minute cutoff point.
In 5 years, how long after the onset of stroke symptoms will we consider clot retrieval after CTA/MRI evaluation of ischemic vs. infarct size?
(This discussion ended up focusing more on what we would expect to see in 5 years from now)
- We’ll see more efficient routing as we get better at using stroke scales in the field and as the scales get refined through research & practice
- Focus more on interrater reliability
- Begin using video documentation in hospitals (currently not many are using video documentation, but would be helpful to have before/after videos and pictures; EPIC allows this).
- If there are questions about interrater reliability, having video documentation would be helpful.
- Mobile stroke units being used more effectively in large geographic regions, not currently one in RI. There will be a focus on what can be done ahead of time, with EMS taking more responsibility of patient care
- Stroke diagnostic unit with a specialized team to go with that unit
- Patients should go to CSC for stroke but then go back to their community hospital after treatment to be near family and to prevent overcrowding
- Biggest barrier is insurance – who will transport them back to regional hospital? Insurance or the State likely wouldn’t cover that (needs to be tied into reimbursements).
Do you anticipate that EMS as a system evolves? Centralization, a certain standard set for all professionals?
- Given the landscape (39 diff municipalities, 86 licensed services); level of service may be different within one town. Probably further out than 5 years before we see the system change.
- We would more likely see folks advancing towards the paramedic level. It’s more difficult in the private sector (esp. in interfacility transport) because Medicare reimbursement rates are lower than surrounding states so RI loses a lot of people to that.
- Viewing EMS as healthcare professionals rather than first responders is important; having EMS being brought into the triage, transport and care process and have it be more of a partnership.
- Move toward idea of “Community Paramedicine”
Open Discussion Notes
- Volume of stroke type patients have been the same, but the type of patients presenting to hospitals has changed: seeing more low scores, because more severe strokes are sent to CSCs.
- We may want to build out something similar to STEMI where we can call medical control and ask where to bring patient
- Information on where and why patient was transported to a certain facility needs to be documented: was the decision protocol-driven, patient preference, distance, etc.?
- FirstNet – patient tracking system is great but it’s mostly one-way. We need to get a committee together of physicians doing medical control who understand EMS. Every hospital should have a designated EMS person who can decide on what’s best for the patient.
- Better data collection & data sharing – GWTG/hospital data needs to be linked better from EMS
- The New England region agreed to work similarly in creating protocols and follow the New Hampshire format
- It could be confusing for providers to report to one region, transport to another region and have different protocols, so we’re trying to achieve uniformity in protocols, training, practice, and communication in New England. Already using the same software product for data collection and abstraction. Massachusetts uses a radio and CMED, RI uses the patient tracking system.
- Need for advance training and communication with providers in the field so better triage decisions are being made
- Re-patriation – bring people back to their hospitals in their communities after treatment at the CSC
- In 5 years, we hope to see Mobile Stroke Units in RI, better testing
- Keep people engaged in stroke care from the whole state (EMS, ED, etc).
- We have a good system going in Rhode Island; our numbers are better in almost all areas compared to the rest of the Northeast – keep up the great work!