Criteria for a stroke code?

[Mike123]

What exactly is the criteria of S/S that a Pt. must have to call a stroke code? I'm sure the nurses in the E.R. would love to chew me out If I called a stroke code when it wasn't necessary. I know to use the Cincinnati stroke scale but heres my question... so theres three things for the cincinnati stroke scale... facial droop, arm drift, and slurred speech, but how many of these things have to be present to call a stroke code? For example, what if my Pt. has arm drift but no facial droop and no slurred speech. Or what if theres slurred speech, but the other two are not present. Does there have to be all three things present to call a stroke code, or 2/3, or just 1? What are some other criteria? What exactly are the s/s that the pt needs to call a stroke code?

 

[SeeNoMore]

Typically a stroke "code" / alert is appropriate with any positive stroke scale finding not attributable to low blood glucose, head trauma with onset of symptoms within the last 5 hours. The harsh reality is that you may be chewed out justly or unjustly at various points over your career. The important thing is to make the best call you can and work to improve your assessment/decision making when you make a mistake.

 

[Clare]

FAST +ve and hx. of onset < 3.5/24

 

[SeeNoMore]

FAST +ve and hx. of onset < 3.5/24

How do you use Fast + ve? Do you consider all stroke mimics in the field? Are these criteria used to rule in or out a stroke alert?

 

[Clare]

How do you use Fast + ve? Do you consider all stroke mimics in the field? Are these criteria used to rule in or out a stroke alert?

A positive FAST test with a sudden onset (i.e. no history) of abnormalities means we consider the patient to be having a stroke until proven otherwise.

If they have < 3.5 hours since onset they must be taken to a hospital with CT and thrombolysis wherever possible.

Control will classify a positive FAST test and < 3.5 hrs since onset of symptoms as a red call i.e. emergency/immediately life threatening and we respond with lights and sirens. If it's > 3.5 hrs onset it's considered an orange call i.e. urgent/potentially serious but not immediately life threatening, immediate response at normal road speed.

From the triage perspective stroke with abnormal LOC is status one/immediately life threatening and is to be seen by a Doctor immediately upon arrival, stroke with normal LOC is considered status two/urgent and is to be seen by a Doctor within 10 minutes of arrival at hospital.

 

[DesertMedic66]

Called a stroke alert today for a patient who was unable to formulate words. MICN and the staff were completely fine with it (she ended up having a history of 1 stroke and was having another one).

 

[Gurby]

What exactly is the criteria of S/S that a Pt. must have to call a stroke code? I'm sure the nurses in the E.R. would love to chew me out If I called a stroke code when it wasn't necessary. I know to use the Cincinnati stroke scale but heres my question... so theres three things for the cincinnati stroke scale... facial droop, arm drift, and slurred speech, but how many of these things have to be present to call a stroke code? For example, what if my Pt. has arm drift but no facial droop and no slurred speech. Or what if theres slurred speech, but the other two are not present. Does there have to be all three things present to call a stroke code, or 2/3, or just 1? What are some other criteria? What exactly are the s/s that the pt needs to call a stroke code?

One thing I've learned from doing my hospital time in medic school is to not be afraid to call things in. I've never seen anybody get chewed out for making a bad STEMI or stroke alert call. The specialists may groan and roll their eyes, but really they'd much rather have you call it in and be wrong, than not call it in and be wrong. Obviously they might get angry if you're making a bad call every shift...

It's much easier for the hospital to prepare, clear the CT table, get the neurologist there, clear the trauma room, etc, if you give them 5 minutes warning. What they really hate is when you show up at triage with a critical patient after giving them a "pt stable see you in 5" type of radio report, and they have to scramble.

+1 to SeeNoMore, I'm calling any stroke sign not attributable to something else with sudden onset within past 5 hours. Your state protocols should specify when to call. In my state, they want us calling if onset is within 5 hours even though hospital likely won't give tPA if it's past ~3 hours or so.

 

[KellyBracket]

What exactly is the criteria of S/S that a Pt. must have to call a stroke code? I'm sure the nurses in the E.R. would love to chew me out ...

This should be addressed in your protocols, since there is no real national standard. Some places may want new neuro stuff for less than 4.5 hours, while some EDs prefer that EMS calls for everything < 6, 10, or even 12 hours onset.

In general though, I think most EDs prefer that EMS be fairly liberal in calling a "stroke code."

 

[Tigger]

Here the ED has no issue with us saying "hey this might be stroke/whatever alert, these are our findings, what do you think?" It's not like you have to patch in with "Med 16 here, we need a stroke alert STAT." It's ok to have a discussion.

 

[OnceAnEMT]

Here the ED has no issue with us saying "hey this might be stroke/whatever alert, these are our findings, what do you think?" It's not like you have to patch in with "Med 16 here, we need a stroke alert STAT." It's ok to have a discussion.

I agree with this. Especially since strokes don't call for summoning such a team that a STEMI alert does, we are fairly liberal. We have a good relationship with the services that deliver to us, and I would argue that their criteria is more conservative then ours in some cases, so when they call it we will call it preemptively. If we cancel on arrival, then we cancel on arrival. The CT tech will get over it.

And to agree with other things said, I've never seen someone get chewed for calling a cautious or preemptive STEMI, trauma, or stroke alert. I have seen some major chewing (and been on the business end of some) for late calls. The specific event I am remembering is a STEMI that wasn't called by the physician until 45 minutes after bed and 30 minutes after the first EKG (it was called after a second EKG).

 

[Bullets]

We will call a patient Cincinnati Positive if they have one criteria.

 

[SeeNoMore]

A positive FAST test with a sudden onset (i.e. no history) of abnormalities means we consider the patient to be having a stroke until proven otherwise.

If they have < 3.5 hours since onset they must be taken to a hospital with CT and thrombolysis wherever possible.

Control will classify a positive FAST test and < 3.5 hrs since onset of symptoms as a red call i.e. emergency/immediately life threatening and we respond with lights and sirens. If it's > 3.5 hrs onset it's considered an orange call i.e. urgent/potentially serious but not immediately life threatening, immediate response at normal road speed.

From the triage perspective stroke with abnormal LOC is status one/immediately life threatening and is to be seen by a Doctor immediately upon arrival, stroke with normal LOC is considered status two/urgent and is to be seen by a Doctor within 10 minutes of arrival at hospital.

Yeah I'm familiar with a FAST test, I was just curious what you meant by + VE. I was under the impression that referred to a set of stroke mimics , many of which are not well evaluated in the field.

 

[Clare]

(+VE) is shorthand for "positive" whereas (--VE) is shorthand for "negative".

 

[SeeNoMore]

Ah OK. Thanks

 

[Christopher]

I'm partial to the MEND exam.

Anyways, Clare and SeeNoMore nail it:

1. Positive findings on <Insert Your Agency Stroke Exam Here>
2. Last seen normal less than <Insert Your Stroke Center Criteria Here>
3. Blood glucose between 40 and 400 mg/dL (or <Insert Your Stroke Center Criteria Here>)
4. No absolute contraindications on Thrombolytics via Check List (if applicable, perhaps they do angioplasty/endovascular work at your center)

North Carolina mandates systems have a destination policy for Stroke patients, so if they meet our criteria we're going to one of the designated facilities. The ideal flow includes going right to CT on our stretcher, then back to the ED on our stretcher before doing patient handoff (much like STEMI patients).

 

[OnceAnEMT]

I am curious, what are y'alls transport decisions on these? Lights & sirens or no? Vary by onset time (how close to the criteria)?

 

[DesertMedic66]

I am curious, what are y'alls transport decisions on these? Lights & sirens or no? Vary by onset time (how close to the criteria)?

Strokes get a lights and siren transport for us. It's either company or county protocol.

 

[SeeNoMore]

911 around here it's expected you go lights and sirens for stroke calls. For ground transfers of acute CVA patients I have instructed the EMT to use them to get around standstill traffic , really only if their condition is deteriorating or if they are being transferred for a time sensitive interventional procedure. If you are attempting to manage B/P the lights and sirens and bumps add some stimulation.

 

[Brandon O]

(+VE) is shorthand for "positive" whereas (--VE) is shorthand for "negative".

Eh?

 

[OnceAnEMT]

Eh?

Yeah, I was curious too. Google says it is math/physics related. Personally if I am documenting positive or negative it is (+) and (-).