Pulsara Blog

New study examines how Pulsara, an app used by paramedics, emergency rooms and stroke teams, can reduce the time it takes for a hospital to deliver clot-busting drugs to stroke patients.

Currently in the United States, someone suffers a stroke every 40 seconds, and each of those cases relies on getting treatment as fast as possible in order to assure best chances for recovery. Expediting care for these critical patients requires smooth communication between first responders in the field, the emergency room staff, and the specialty stroke team. Unfortunately, this delicate relay is not always well executed, as care teams are patching together archaic technologies such as pagers, faxes, emails, call lists, and other communication methods that do not integrate.

We’ve known for a while now that when EMS providers are properly trained, they perform at a high level when it comes to treating and assessing patients. For example, past studies have shown that paramedics who had formal training in identifying STEMI on a 12-lead ECG could do so with the same level of proficiency as most ED Physicians (1). The same goes for identifying stroke. A similar study showed that paramedics were on par with ED physicians when it comes to identifying stroke using simple stroke scales such as the CPSS or FAST (2). 

1.9 million neurons, 14 billion synapses, and 7.5 miles of myelinated fibers — this is what a brain experiencing an acute stroke loses every MINUTE that passes without treatment. Even more compelling, the brain ages 3.6 YEARS with every hour that a stroke goes untreated. It doesn’t require a medical degree to understand why reducing the treatment times of stroke patients is a vital priority for the healthcare community.

When the concept for EMS was born nearly 50 years ago, it was meant to be an integrated part of a smooth system of care beginning with the call to EMS dispatch and continuing through to definitive treatment. However, EMS-to-hospital communications have faced significant barriers including miscommunications due to archaic and unreliable technologies, issues transmitting ECGs and other patient data, inadequate training in STEMI recognition, and lack of access to patient outcome information for EMS. According to an article published in JEMS this week, recent studies have shown that prehospital notification by EMS improves time to treatment for stroke, however these notifications are not part of a consistent and standardized protocol, and in 25% of cases, EMS fails to alert the hospital of an incoming stroke patient.

With an estimated 25%, or 1 in 4 strokes considered "wake up strokes," where the patient wakes up to find they've suffered deficits and are unsure how long it has been since symptom onset, it's no wonder treatment of these patients is a hot topic of conversation. Without a known onset time, conventional wisdom suggests we should not treat with tPA. However, A recent prospective study published in Annals of Neurology, challenged this idea and examined the safety of treating wake up strokes with rtPA.

Who's on First is an original comedy skit that was made famous by Abbot and Costello back in the early 1940's. It's a classic illustration of two people talking, but it's as if they are speaking different languages. The longer the skit goes on, the funnier it gets. It's not that their understanding changes — quite the opposite in fact. They continue the conversation, but neither of them ever realizes where the breakdown in communication is happening.

When it comes to communication in healthcare, do you ever feel like you're playing a game of "telephone?"

One of the most challenging aspects of living in the technological age is the speed of change. There was once a day when the person armed with the most knowledge and information had the upper hand. That's not the case in today's world. Instead, the person or company that can rapidly learn and adjust to changing trends, information, and technology will now lead the pack. Your ability to adapt to a rapidly changing world will be the one skill that separates you from your competition.

Imagine this: It's a busy Saturday evening at the hospital. You are understaffed and overworked and it's one of those days where everything seems to be happening at once. The medics bring in a patient suspected of having a STEMI. You know that when time is tissue, every second counts, so you follow proper protocol and, when you need to consult the cardiologist, Dr. Smith, you simply send him a page and continue on with your seemingly endless list of tasks and patients that need your attention.

EDITOR'S NOTE: Special thanks to Cynthia Bradford Lencioni for writing today's blog post. You can connect with her on LinkedIn. 

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800 m freestyle
8:04.79 (World Record)
Katie Ledecky
August 12, 2016

400 m freestyle
3:56.46 (World Record)
Katie Ledecky
August 7, 2016

I’m a lot of things: a mom, a wife, a Chief Operating Officer … but one of my longest-standing titles is that of swimmer. I started competing in swimming at age 6 and continued on through Division 1 in college. And while I no longer compete, swimming is still a passion of mine, and my favorite way to exercise. So it’s no surprise that I love watching the Summer Olympics. In addition to the network coverage, it was especially fun to see former teammates and coaches broadcasting TV color commentary and posting behind-the-scenes photos with Michael Phelps and other medal winners.

Just for grins and giggles, I signed in to Netflix recently and watched a few episodes of the medical drama from the 70's, "Emergency!" I'm a little young to remember the show when it was on the air, but when I started in EMS, my paramedic partner insisted that I watch some of it. It was a rite of passage. Of course, there was also Bringing Out the Dead starring Nicholas Cage and Mother, Jugs & Speed with Bill Cosby, but those are for another post.

We all know that for any complex problem, there is rarely a simple solution. Endovascular stroke, with its many moving parts, is no exception. Trying to mobilize multiple disciplines and processes simultaneously (like a pit crew does in a NASCAR race) during one of the most time-sensitive emergencies is no easy task. But, as you may remember from a previous blog post I wrote, parallel processing of tasks is a key element to reducing treatment times.

The August issue of the EMS World Magazine features a photo of three key players who are leading the transformation of stroke care, particularly with regards to Large Vessel Occlusions (LVO). This transformation is crucial to improve patient outcomes by getting stroke patients the treatment they need in as little time as possible - especially since 2 million brain cells die each minute a patient is having a stroke. Part of this effort includes establishing regional systems of care, which help first responders and other members of the care team decide which facility a patient should go to for the best treatment; currently many patients are initially brought to hospitals that are not equipped to deliver the level of stroke care needed and must then be transferred. In fact, according to the Joint Commission Center for Transforming Healthcare, 80% of serious medical errors involve miscommunication between caregivers when patients are being transferred. 

Last week, I talked about the root of all evil in STEMI care (variability) and then about some sources of variability in STEMI care and how to identify and reduce them in your facility. When it comes to variability, stroke programs have their challenges too. Today I will share with you the top four questions I ask that reveal when the "V word" has snuck into your stroke systems.

Geographic Information System (GIS) software has long been employed by public health agencies to assess the health of populations in various locations. But now, healthcare providers are starting to turn to GIS too, in efforts to better identify health risk based on location; as a recent article on the subject points out, there is a strong relationship between people's health and the particular communities they live in. 

How do you solve care management problems at your hospital?

I think that's a fair question. I was talking with a nurse from reputable a STEMI receiving center just a few days ago, and he told me "our times are amazing!" In my role, anytime I hear that it makes me ask lots of questions. I want to learn what the leading hospitals are doing to solve the problems that we all face.

As Pulsara employees, when we meet with prospective clients we hear a lot of different stories about how well their facilities are already doing. Most of the time they tell us what their mean time for Door-to-Balloon (D2B) is. Many of them sound good on the surface, but there's usually more going on under the hood that they aren't proud of or willing to show you.

Well, the time is upon us once again. It is nearly our country's Independence Day, and while the holiday generally brings with it plenty of camping trips, music festivals, family barbeques, etc., it also tends to be a time when many Americans find themselves indulging in lots of fatty, salty, and simple carbohydrate-rich foods from all of those post-river 4th of July cookouts. 

Don't worry! I'm not here to chastise you for that. It's necessary to indulge once in awhile! Instead, I wanted to share the results of an interesting study that examined the diets of people with heart disease to see what effects a Mediterranean style vs. a Western style diet had on their likelihood of experiencing a stroke or heart attack. 

Montgomery County Hospital District (MCHD) EMS is just one of thousands of operations across the country working tirelessly to find the best solution to the issue coined the "pre-puncture problem." As alluded to by its name, this problem concerns determining the most effective course of action for getting large vessel occlusive (LVO) stroke patients to the best possible treatment center in the very limited time frame afforded to them.

MCHD personnel have recently chronicled their experiences and insights from managing this issue in an article published on EMS1 last week, titled "LVO stroke: How to improve EMS response and patient survival." 

Stroke care protocols and best practices are rapidly changing thanks to recent research that demonstrates the efficacy of intra-arterial interventional treatments over tPA in large vessel occlusion (LVO) stroke patients. 

And as these new techniques become the standard of care, they also necessitate a change in the way care teams approach stroke treatment beyond the technique itself:  there is an "urgent need for integrated regionalized stroke care networks," according to a recent article siting experts Louis Caplan, MD, Anthony Furlan, MD, and Werner Hacke, MD, PhD.

To meet this aim, updates will be needed in the way stroke care is delivered at every stage of treatment. "The thrombectomy studies have created an ethical and practical mandate to upgrade stroke care," the physicians stated in a recent JAMA Neurology article. "This mandate will require changes in systems of stroke care delivery at all levels of care."