Obtain the patient’s last known “normal.” This may be difficult to obtain, especially if the patient presents with a ‘wake up stroke’ first thing in the morning. If the timeline is unclear, document the last time the patient was known to be at their baseline. Obtain history to include any recent trauma, anticoagulant therapy, and recent surgery.

A prehospital stroke scale, such as BEFAST, should be performed as soon as possible on all suspected strokes. If the scale is positive, transport to the closest stroke center or most appropriate facility without delay. If applicable, call a pre-alert to the receiving facility. Establish two large-bore IVs that are forearm or higher to facilitate the appropriate imaging.

Hypoglycemia and seizures can mimic strokes. Perform a detailed assessment to include a blood glucose level. If unsure, treat it as a stroke. Be aware of the potential for mental status changes that may require suction or airway control. Depending on local protocols, consider anti-hypertensive therapy that does not dramatically decrease the patient’s blood pressure.

The general inclusion time frame for “clot-busting medication” or thrombolytics such as tP-A is 4.5 hours after onset of symptoms or less, depending on surrounding circumstances. If the receiving facility is an IR-capable facility, they may attempt thrombectomy procedures up to 24 hours after onset of symptoms. A stroke scale should still be completed prior to transport if performing an interfacility transfer of a diagnosed stroke patient. This allows the provider to note and report any changes in the patient’s condition or presentation to the receiving facility staff.

North Dakota has established the BEFAST stroke assessment as the preferred state-wide prehospital stroke assessment. Information on BEFAST and the North Dakota Stroke System of Care can be found at: https://www.health.nd.gov/north-dakota-stroke-system-care-guidelines. EMS program directors have developed internal resources that align with BEFAST and the AHA recommendations for caring for suspected stroke patients. A North Dakota-based EMS system developed this BEFAST assessment tool; similar tools can be used to improve the care of stroke patients. This publicly accessible video provides an EMS-centric approach to completing the BEFAST stroke assessment.

Stroke- Blood Glucose Check Performed for Suspected Stroke

Description:

This report evaluates the percentage of adult suspected stroke patients that received a blood glucose evaluation. As a protocol adherence report, the provider gets credit for performing the assessment if a value is recorded or if it is documented that the patient refused the assessment.

NOTE: The Blood Glucose Check must be documented in the Vital Signs section of the ePCR. Specific filters for this report include:

1. Patient Age (in Years) ≥ 18

2. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient Cerebral Ischemic Attack (TIA)

3. Treatments Documented (per Patient) = Stroke Alert

4. Narrative Treatment Protocol = Suspected Stroke

Stroke- Last Known Well or Time of Onset Recorded by EMS for Suspected Stroke

Description:

This report calculates the percentage of records for patients with suspected stroke or TIA who had time of onset or time last known well (LKW) documented in the appropriate discrete data field as part of the stroke assessment.

Specific filters for this report include:

1. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient Cerebral Ischemic Attack (TIA)

2. Treatments Documented (per Patient) = Stroke Alert

3. Narrative Treatment Protocol = Suspected Stroke

Stroke- Stroke Assessment Performed by EMS for ED-Diagnosed Stroke

Description:

This report calculates the percentage of EMS responses originating from a 911 request for patients with an ED ICD10 diagnosis code indicating stroke, who had a stroke assessment performed during the EMS response.

This report is for EMS Agencies that receive information back from the hospital regarding the patient diagnosis and treatment at the hospital. The EMS ePCR is updated to reflect the ED and/or hospital diagnosis. If the hospital diagnosed the patient with a stroke, the report will flag the ePCRs that did not have a stroke assessment performed by EMS.

This is a learning opportunity for EMS. Knowing the hospital diagnosis allows EMS Agencies to review their assessment, training, and protocols and improve patient care.

Stroke- Stroke Assessment Performed by EMS for Suspected Stroke

Description:

This report calculates the percentage of EMS responses originating from a 911 request for patients with suspected stroke who had a stroke assessment performed during the EMS encounter.

Documentation of any part of a stroke screen will count towards “measure criteria met.” Performance improvement teams may wish to dive further into assessment to determine whether or not all elements of the screening instrument were completed.

Specific filters for this report include:

1. Patient Age (in Years) ≥ 18

2. Primary or Secondary Impression includes one of these values: 1) Stroke, 2) Transient, or Cerebral Ischemic Attack (TIA)

3. Treatments Documented (per Patient) = Stroke Alert

4. Narrative Treatment Protocol = Suspected Stroke

Aside from the unpleasant or even torturous experience of pain, pain stimulates a fight-or-flight response that is an additional physiological stressor on the acutely ill or injured patient. Effects range from elevated vital signs to impaired healing of injuries. Yet as many as 43% of EMS patients have inadequate pain relief, according to the Agency for Healthcare Research and Quality. Reasons include fear of adverse effects, masking of underlying conditions, and provider indifference. While data on analgesia-related adverse events is lacking, the availability of pulse oximetry, capnography, naloxone, and continuous 1:1 monitoring should make the prehospital environment a uniquely safe place for aggressive pain management.

The masking of symptoms and obscuring a diagnosis by relieving pain is a myth that has been thoroughly debunked. A physical exam is not impaired, but modern diagnostics such as CT are routinely used. Provider bias has been a well-studied problem throughout emergency medicine, with race, sex, age, and provider's perception of the legitimacy of complaints all associated with undertreatment. Patients labeled as "drug seekers" often have legitimate medical problems, and addiction or drug-seeking behavior is managed through a coordinated case management approach. In other words, you aren't going to create or solve addiction in the back of an ambulance. However, not all patients need opioids. Nonpharmacologic interventions, nitrous oxide and ketamine are possible alternatives. Pain assessment is subjective as vital signs are unreliable.

Assessing pain with different scales may be beneficial depending on the patient's age and presentation. Different scales include 1-10 numeric, Wong-Bakers, CPOTT, and Bloomsbury Sedation Scale.

The assessment of pain relies on subjective and objective information. As prehospital providers, it is essential to document all assessment findings related to the patient’s pain, including interventions and responses.

Subjective findings of a patient’s pain may include their description and rating of the pain. Everyone experiences pain differently, so all complaints should be treated as valid. Objective findings may consist of physical assessment findings and physiological changes. Document the patient's pain complaint as you would any other vital sign; for example, every 5 minutes for patients considered unstable and every 15 minutes for stable patients.

There are various treatments for pain ranging from BLS interventions to ALS medication administration. Choose the most appropriate means and document all responses and changes in the patient’s complaint. Simple interventions such as warming pads have been found to reduce pain from injuries, various abdominal conditions, and kidney stones.

Often overlooked by the ALS provider are BLS interventions that are synergistic with medication administration. Splinting and positioning are essential interventions that can profoundly affect the overall pain management.

When performing pain management with medication, remember that more medication can always be given, but a large dose cannot be taken back if adverse effects occur. Consider diluting drugs to make them easier to push over a more extended period. Consider a pain management drip for prolonged patient contact times depending on local protocol.

There are special patient populations for whom extra care should be exercised due to their ability or inability to metabolize medications. Pediatrics, geriatrics, renal insufficiency, and hepatic insufficiency patients should all be medicated according to local protocol, with consideration given to their specific presentations and conditions.

EMS providers often treat patients presenting with painful conditions and symptoms. This JEMS article is entitled, A guide to Prehospital Pain Management helps providers understand the physiologic mechanism that causes pain, the physiologic response to pain, and the methods to control it. This understanding makes providers well equipped to care for these patients.

Different approaches to the management of pain in the prehospital setting are discussed in this article entitled, 10 Things EMS Providers Need to Know About Acute Pain Management provided by EMS technology solution provider Pulsara.

Pain- Pain Management Intervention Performed for Pain >4

Description: The report calculates the percentage of patients with a pain score of five or greater from any cause (trauma, cardiac, other) who received some form of pain intervention and the percentage of patients with pain relief.

For the purposes of reporting the percentage of patients receiving pain intervention, the following interventions are considered: Toradol, Ibuprofen, Tylenol, Fentanyl, Morphine, Nubain, Versed, Versed Drip, Midazolam, Valium, Darvocet, Demerol, Dilaudid, Hydrocodone, Percodan, Stadol, Nitroglycerin, Nitronox, Nitroprusside, Nitrostat, Nitro Infusion, Nitro Paste, Nitro Spray. The following interventions when applied in the presence of a self-reported pain score of greater than 4 are assumed to be used in part to reduce discomfort; splinting, traction splint, cooling, bandaging, burn care and irrigation. That report requires documentation of at least two pain scores.

Specific filters to identify for this report include: 1. Highest Pain Value Gathered ≥ 5. [This value is documented in the vital signs section.] Pain- Pain Intervention Resulted in Pain Reduction for Pain >4 Description: This report calculates the percentage of EMS transports originating from a 911 request for patients whose pain score was lowered during the EMS encounter. Specific filters to identify for this report include: 1. Highest Pain Value Gathered ≥ 5. [This value is documented in the vital signs section.]

Vital signs provide objective patient condition data, contributing to the diagnosis, treatment and transport decisions, and triage. Measuring and documenting at least two sets allows trending of the patient's condition and provides medical-legal evidence that you were monitoring the patient for changes. Finally, reporting vital signs to the ED helps them appropriately triage the patient. Respiratory rate and oxygen saturation are important vital signs that deserve special mention because they are often neglected or inaccurately measured. Pulse oximetry is an indispensable tool sometimes met with skepticism in EMS. While undeniably useful, do we know when it is accurate, and are we aware of its pitfalls? Poor perfusion, hypothermia, patient movement, carbon monoxide, and cyanide poisoning (e.g., smoke inhalation) can all prevent accurate assessment of proper oxygenation.

Additionally, pulse ox lag or latency refers to the delay between actual blood oxygen levels and pulse oximetry readings. This delay can be 30 seconds to a few minutes. This can lead to continuing intubations attempts when the patient is more hypoxic than indicated by the pulse oximeter, extubating when the patient is properly intubated, and overly aggressive bag ventilation. The respiratory rate is notoriously estimated or not assessed. Yet changes in respiratory rate are often the earliest indicator of shock, sepsis, respiratory insufficiency, and other severe conditions. It is the most critical predictor of subsequent cardiac arrest. So, is your patient’s respiratory rate 16?

Obtain and document at least one set of vitals on all patient contacts, even if it does not result in a transport. If a patient is transported, a minimum of two sets should be obtained to show continuous monitoring. Vital signs should be obtained and documented in intervals appropriate for the patient’s clinical presentation. (I.e., Critical Every 5 Minutes, Routine Every 15 Minutes)

EMS programs should be familiar with all current guidance on field triage about the care of patients suffering from traumatic injuries. Numerous informational resources are available from the State of North Dakota’s Trauma System via their website. GCS capture remains a critical element of EMS’s evaluation and management of trauma patients. https://www.ems1.com/ems-products/medical-monitoring/articles/patient-vital-signs-5-tips-for-emts-paramedics-ppfyyuFnCZKWxTsV/

The six Vitals Sign reports are for all patient contacts. All Vital Signs must be documented in the Vital Signs sections. The Vitals Reports exclude the following disposition values: 1) Cancelled (No Patient Contact), 2) Cancelled (Prior to Arrival at Scene), 3) Cancelled on Scene/No Patient Found, 4) Standby - No Service or Support Provided, 5) Patient Dead on Scene - No Resuscitation Attempted (With Transport), 6) Patient Dead on Scene - No Resuscitation Attempted (Without Transport), 7) Patient Dead on Scene - Resuscitation Attempted (With Transport), 8) Patient Dead on Scene - Resuscitation Attempted (Without Transport), 9) Transport Non-Patient, Organs, etc., and 10) Wheelchair Transport.

Vitals- Glasgow Coma Scale Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one Glasgow Coma Scale score gathered and documented in the appropriate discrete data field.

Vitals- Pulse Rate Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one pulse rate gathered and documented in the appropriate discrete data field.

Vitals- Respiratory Rate Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one respiratory rate gathered and documented in the appropriate discrete data field.

Vitals- Set of Vital Signs Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one set of vital signs gathered and documented in the appropriate discrete data fields. For this measure, a set of vital signs consists of: Glasgow Coma Scale score, pulse rate, respiratory rate, systolic blood pressure, and pulse oximetry.

Vital- SpO2 Documented Description: Assessing and monitoring vital signs is critical for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one pulse oximetry reading gathered and documented in the appropriate discrete data field.

Vitals- Systolic Blood Pressure Documented Description: Assessing and monitoring vital signs is a critical component for ensuring appropriate and timely out-of-hospital care. This report calculates the percentage of all records with at least one systolic blood pressure reading gathered and documented in the appropriate discrete data field.  

Operating with lights and sirens (L&S) has long been an EMS industry norm. Still, this practice is increasingly questioned as it increases the risk to the provider and patient while providing minimal benefit. According to NEMSIS data, 74% of 911 responses and 27% of transports used L&S. Yet studies have found less than 4 minutes saved by L&S. It is estimated that only 5% of patients benefit from the use of L&S. Meanwhile, there are around 12,000 EMS vehicle crashes every year. Over 90% of these occur during L&S driving. One study found 67 EMS providers killed during ground transport crashes in five years. Recognizing the folly of everyday L&S driving, EMSA which is Oklahoma’s largest EMS provider now responds to only 33% of 911 calls with L&S and has done so without increased morbidity or mortality. L&S is a patient care intervention, and like any intervention, the benefit must outweigh the risk.

Consider that use of L&S is a medical intervention. Performance Measure Benchmarks are:

1. L&S during Response to Scene: <50% [For the measure the goal is >50%]

2. L&S during Transport: <5% [For the measure the goal is >95%.]

Regularly review a sample of L&S responses and transports and discuss whether L&S ultimately benefitted the patient. Was the lack of benefit predictable at the time? Are there times when L&S should have been used but was not? Refine dispatch protocols to use L&S when most likely to benefit. These might include: o Cardiac or respiratory arrest o Airway problems o Unconsciousness o Severe trauma or hemorrhagic shock o True obstetrical emergencies Consider Implementation of a “sterile cockpit” policy of no unnecessary conversation or interruptions during L&S operations. Provide formal EVOC training or an equivalent course and annual refreshers.

Kupas DF. Lights and Siren Use by Emergency Medical Services (EMS): Above All Do No Harm. NHTSA 2017. https://www.ems.gov/pdf/Lights_and_Sirens_Use_by_EMS_May_2017.pdf

Safety- Lights and Sirens Not Used During Response to Scene

Description: This report calculates the percentage of EMS responses originating from a 911 request in which lights and sirens were not used during response.

Safety- Light and Sirens Not Used During Transport

Description: This report calculates the percentage of EMS transports originating from a 911 request during which lights and sirens were not used during patient transport. Specific filters to identify for this report include: 1. Disposition is any of these values: 1) Transported Lights/Siren, 2) Transported Lights/Siren, Downgraded, 3) Transported No Lights/Siren, upgraded, 4) Transported No Lights/Siren  

Unrecognized misplaced intubations are preventable tragedies that should never occur, yet reported rates in EMS range from 7%-25%. The square wave of the capnograph is real-time proof that the lungs are being ventilated and can virtually eliminate this catastrophic error. Other approaches, such as colorimetric EtCO2 detectors, esophageal detection devices, and auscultation, do not replace continuous capnography which is the standard of care for several years. Colorimetric EtCO2 sensors are poorly sensitive during hypoperfusion with low EtCO2; they do not provide a numeric CO2 level, can be positive despite esophageal or hypopharyngeal tube placement, and lose their color change shortly after placement, so they do not provide continuous confirmation.

Aside from ET tube placement, capnography offers additional information about ventilation and perfusion that can improve care for respiratory, cardiac, brain injury, and shock patients. Reasons for hypocapnia include hyperventilation, hypoperfusion (CO2 does not return to the lungs), hypothermia (CO2 is a byproduct of metabolism and metabolism is slowed), and metabolic acidosis (e.g., DKA and sepsis; CO2 is lost as bicarbonate, which is buffering the acidosis). Capnography prevents hyperventilation and associated harm (cerebral vasoconstriction, decreased cardiac output, the inability of oxygen to dissociate from hemoglobin, and vomiting) from bagging with excessive rate or volume. Reasons for hypercapnia include ventilatory failure (e.g., asthma exacerbation), chronic CO2 retention (e.g., COPD), and respiratory acidosis.

Other clinical applications of capnography include titrating naloxone, monitoring the effectiveness of CPR, identifying ROSC without pausing compressions, termination of resuscitation, and recognizing severe sepsis/septic shock (EtCO2 less than 25 correlates with a lactic acid greater than 4), identifying bronchoconstriction, and assessing whether interventions are working or whether the patient is deteriorating.

Set up the capnography while preparing for intubation. For initial confirmation, the capnography can and should be used instead of the less reliable colorimetric device. Look for “squares” on the capnography display. Use capnography inline between the mask and bag (with continuous mask seal) for breath-to-breath confirmation of adequate ventilation and to avoid hyperventilating.

Patient Safety Clinical Check List

Assure Waveform Capnography – Invasive (EtCO2) on all patients intubated or with advanced airway

Use Waveform Capnography – Non-Invasive (EtCO2) on patients meeting local protocol including diabetes, seizure, metabolic, ALOC, respiratory, cardiovascular, or other acute illnesses or injuries that could benefit from capnography.

https://www.ems1.com/capnography/articles/5-things-to-know-about-capnography-in-cardiac-arrest-YipMTGQ2yTt5mTub/#:~:text=A%20higher%20ETCO2%20reading%20during,the%20chances%20of%20survival%20are.