I. Ambulance transfer process
(i) Objective.
1. to transfer the patient quickly and accurately to a hospital where emergency intravenous thrombolysis is feasible, with the informed consent of the patient or family.
2. pre-hospital emergency treatment.
3. Advance telephone notification of pre-hospital information (including pre-hospital stroke score, e.g. Cincinnati Pre-Hospital Stroke Score or Los Angeles Pre-Hospital Stroke Assessment) to the target hospital.
(ii) Technical points.
1. The emergency dispatch command center should dispatch an ambulance with appropriate equipment and personnel in the shortest possible time for patients suspected of having a stroke.
2. instruct the patient to help himself/herself and the ambulance to arrive as soon as possible
3. assess vital signs and administer on-site first aid
4. complete a pre-hospital stroke score within 10 minutes of arrival
5. maintain stable vital signs, monitor blood pressure, measure blood glucose, perform ECG, record final visual assessment of normal time, administer oxygen, cardiac monitoring, keep airway open, open intravenous access to saline, etc. if necessary.
6. Give priority to the nearest hospital with funding for emergency intravenous thrombolysis
7. Pre-notify the hospital of emergency care, and transmit pre-hospital information such as pre-hospital stroke score to the target hospital using the relevant WeChat public platform, in-vehicle system, MMS, etc.
8. Call the hospital for confirmation, inform them of the estimated arrival time and basic information of the patient, prepare for the appointment of CT, thrombolytic drugs and stroke team consultation, and transfer the patient to the emergency clinic.
9. Complete the handover procedures of the patient and information and sign for confirmation.
(iii) Assessment points.
1. the time from the patient’s call to the answer of the emergency system.
2. the time from the emergency system answering the call to the dispatch of the ambulance.
3. the time from the ambulance team receiving the dispatching instruction to the departure.
4. the time from the patient’s call to the arrival of the ambulance
5. pre-hospital stroke score, the proportion of last seemingly normal time records completed within 10 minutes.
6. the proportion of hospitals sent to feasible emergency intravenous thrombolysis treatment.
II. Hospital emergency department treatment process with intravenous thrombolysis
(I) Objectives.
1. to establish a green channel for in-hospital intravenous thrombolysis
2. confirm/exclude stroke diagnosis.
3. Early initiation of early intravenous thrombolytic therapy and improvement of the preliminary preparation.
(ii) Technical points.
1. complete handover and keep proper records of pre-hospital emergency information of patients delivered by ambulance.
2. Immediate general assessment by the emergency receiving physician within 10 minutes of arrival: vital signs; take medical history and precise physical examination, including the last seemingly normal time; blood specimens for routine blood, blood type, coagulation function, glucose, electrolytes, renal function; electrocardiogram; prescribe emergency head CT; immediately notify the stroke team; ensure that intravenous access is open and give saline.
3. Other symptomatic emergency treatment, maintain stable vital signs, transfer to emergency resuscitation room if necessary.
(C) Assessment points.
1. the pathway and proportion of patients with suspected stroke.
2. Time from emergency to cranial CT report, and proportion of cranial CT <25 minutes; < span="">
3. The proportion of emergency department visits to lab report time <35 minutes;< span="">
4. arrival time of the stroke team, and the proportion of stroke team arrivals <10 minutes;< span="">
5. mean time to initiation of intravenous pharmacological thrombolysis.
6. time to emergency room treatment.
III. Hospital emergency department procedures for infeasible intravenous thrombolysis
(i) Objectives.
1. Confirm/exclude stroke diagnosis.
2. Early initiation of transfer of patients requiring intravenous thrombolysis and improvement of the transfer process.
(ii) Technical points.
1. complete handover and keep proper records of pre-hospital emergency information of patients transported by ambulance.
2. Immediate general assessment by the emergency receiving physician within 10 minutes after arrival: vital signs; take medical history and precise examination, including the last seemingly normal time; blood specimens to check blood routine, blood type, coagulation function, blood glucose, electrolytes, renal function; electrocardiogram; prescribe emergency cranial CT; ensure that intravenous access is open and give physiological saline.
3. Combine with cranial findings: CT and history suggest non-stroke, stop vascular neurological evaluation; CT suggests intracranial hemorrhage, enter hemorrhagic stroke process; cranial CT and other images combined with history and symptoms suggest acute ischemic stroke, evaluate contraindications and indications for intravenous thrombolysis of patients, if suitable for intravenous thrombolysis, transfer to the nearest hospital with intravenous thrombolysis in combination with transfer time.
4. Other symptomatic emergency treatment to maintain the stability of vital signs, if necessary, transfer to emergency resuscitation room.
(C) Assessment points.
1. the route of consultation and proportion of patients with suspected stroke.
2. The time from emergency consultation to cranial CT report, and the proportion of cranial CT <25 minutes; < span="">
3. time from hospital visit to transfer out (DI-DO).
4. the proportion of patients suitable for intravenous thrombolysis, transferred to the nearest hospital with intravenous thrombolysis.
5. standardized written procedure for cooperation with hospitals with IV thrombolysis.
Stroke team assessment process
(i) Objectives.
1. To establish a green channel for in-hospital intravenous thrombolysis.
2. confirm/exclude stroke diagnosis.
3. Early initiation of early intravenous thrombolytic therapy.
(ii) Technical points.
1. Arrival of stroke team and immediate neurological assessment: review history; determine time of onset; general neurological assessment; neurological examination: determine degree of coma (Glasgow Coma Scale); determine stroke severity (NIHSS score); emergency CT (Door – CT completion: less than 25 minutes).
2. Define stroke subtype based on CT and symptoms and history: CT and history suggest non-stroke, stop vascular neurological evaluation; CT suggests intracranial hemorrhage, enter hemorrhagic stroke process; cranial CT and other images combined with history and symptoms suggest acute ischemic stroke.
3. rapidly assess the indications and contraindications for intravenous thrombolytic therapy.
4. signing the informed consent and initiating the green channel for intravenous thrombolysis with one click.
5. shorten the time of delay in family conversation and informed consent signing and hospitalization procedures for intravenous thrombolysis, allowing in situ intravenous thrombolysis to be carried out in a dedicated bed in the emergency department, and allowing hospitalization procedures to be carried out at the same time.
6. Income stroke unit or general ward or intensive care unit, etc.
(c) Assessment points.
1. the time between the stroke team receiving the emergency call and contacting the patient.
2. the proportion of patients contacted by the stroke team to the administration of intravenous thrombolysis
3. the average time to initiate intravenous drug thrombolysis, the proportion of the time from receiving to intravenous thrombolysis less than 60 minutes.