Introduction: In predominantly rural states, effective and efficient response of Emergency Medical Services (EMS) to stroke cases is often delayed by geographically large, sparsely populated service areas and limited access to healthcare professionals and services. North Dakota is a rural state with 36 of 53 counties designated as Frontier (less than six persons per square mile) and a total population estimated at 755,393. Purpose: To identify barriers experienced by EMS professionals in North Dakota when responding to, assessing, providing care, and transporting potential stroke patients. Methods: EMS providers were recruited to participate in in-person focus groups. Four focus groups were performed (n=24) using a semi-structured interview guide. Sessions were digitally recorded and field notes with abridged transcripts were analyzed for recurrent themes using content analysis. Results: Participants were 37.5% male, 91.7% non-Hispanic White and included unpaid EMS volunteers (29.0%). Several common themes were identified, including: 1) importance of public awareness for timely recognition of stroke symptoms and the importance of calling 9-1-1 at early onset of symptoms; 2) frequent receipt of inaccurate/insufficient information from Dispatch; 3) difficulties notifying accepting hospitals due to loss of cell service in rural areas; 4) perceptions that accepting hospital staff due not trust EMS clinical assessments; 5) technical barriers and time restraints experienced when providing written and verbal patient reports to hospitals; and 6) lack of formal feedback from hospitals to EMS agencies regarding stroke patients transported by EMS agencies. Conclusions: EMS providers in North Dakota experience several challenges inhibiting their ability to provide timely pre-hospital care to stroke patients. Although several barriers were identified, most are modifiable and can be remedied with enhanced education and training focused on improving effectiveness and efficiency of EMS communications with dispatch and hospitals.
Introduction: The American Heart Association (AHA) Mission: Lifeline Stroke program is a 3-year statewide initiative in North Dakota which aims to improve consistency of guideline-based care of stroke patients thereby improving outcomes. In year one a public awareness assessment of stroke awareness was completed. Purpose: The intent of this survey was to establish a baseline of symptom awareness related to the F.A.S.T acronym, actions and behaviors when stroke is suspected, and media preferences in ND. Methods: The AHA commissioned Marketing & Advertising Business Unlimited, Inc., to conduct a telephone survey. Four hundred phone interviews were completed with ND residents by random selection from a list of 24,000 residential landlines and 8,000 mobile phones. Numbers were stratified into five distinct regions to ensure a proper urban/rural balance. Data was also weighted by gender, age, and region to conform to the latest statewide census projects. The telephone survey had a 4.9% margin of error and a 95% confidence interval. Results: Forty seven percent of respondents stated that they had learned the signs of stroke, however only 17% classified themselves as very familiar. The most common signs identified were “Speech/Slurred Words” and “Face/Drooping Face” at 39% and 30%, respectively. In terms of F.A.S.T. awareness, 46% of survey respondents correctly identified “Face” while only 15% identified “Time.” “Arm” and “Speech” were identified 32% and 23%, respectively. Respondents indicated they would call 9-1-1 64% of the time. When asked why it may be better to be transported by personal vehicle, 74% responded you may be able to get to the hospital faster. Men and those over 65 were far less likely to correctly identify the components of F.A.S.T. Media preferences expressed were: 1) F.A.S.T. acronym over other longer options, 2) visual examples with real humans versus icons, 3) the tagline “Care Starts When You Call”, and 4) television and Facebook were the preferred mediums. Conclusions: Overall, the survey data is encouraging and may provide guidance for future rural programs. A significant portion of the respondents were deficient in stroke symptom awareness, however most survey respondents expressed interested in learning these symptoms.
Background: North Dakota has substantially rural demographics with unique logistics, challenges, and other socio-economic complexities affecting timely intervention in stroke patients. The North Dakota Stroke System of Care (NDSSoC) Taskforce was legislatively created in 2009 and implemented, with authority to recommend system changes for state health officer implementation. The NDSSoC Task Force is composed of 11 appointed multidisciplinary members collaborating to provide recommendations in the development of a Stroke System of Care in North Dakota. Hypothesis: Implementation of the NDSSoC will result in improved timely interventions and increased quality of care. Methods: Quality of care was measured based on data input into the State Stroke Registry (SSR). The SSR utilizes the American Heart Association’s Get with the Guidelines®-Stroke (GWTG-S), an in hospital quality improvement program. The 2010 and 2013 data was compared. Results: The percent of acute ischemic stroke patients who arrived at the hospital within 2 hours of time last known well and for whom IV t-PA was initiated within 3 hours increased from 30.9% in 2010 to 80.9% in 2013. Cases receiving a brain CT scan within 25 minutes of arrival to the hospital increased from 16% of patients in 2010 to 25% in 2013. The structure has led to tertiary and state resource investment to support NDSSoC strategies, with a state annual investment of funding equivalent to 59 cents per capita and a state funded FTE coordinator. Conclusions: A collaborative statewide effort led by a multidisciplinary team can improve timely intervention and quality of care in stroke. The statewide task force with implementation authority can be successfully applied to areas with a rural demographic.
Introduction: Telemedicine (TM) is a promising solution for providing timely and efficient care for patients experiencing a stroke in rural and underserved areas . Although TM services are available in many Critical Access Hospitals (CAHs), wide adoption has been limited by a multitude of barriers. Purpose: To describe current utilization practices and identify barriers to utilization of TM services in assessment and treatment of stroke patients in North Dakota CAHs. Methods: Directors of Nursing (DONs) at Acute Stroke Ready CAHs in North Dakota were recruited to participate in data collection efforts using a mixed methods approach including a survey and in-person focus groups. An online survey was disseminated via email to DONs (response rate=74%) and a semi-structured interview guide was used to conduct three focus groups (n=16). Sessions were digitally recorded and field notes with abridged transcripts were analyzed for recurrent themes using content analysis. Results: Most participants (91.3%) indicated CAH staff have access to TM services that include consultation with emergency medicine physicians, but only 17.4% indicated their services include consultation with a neurologist. Despite wide availability, participants reported staff forget to use existing TM services or are unaware of specific services available. Most frequently used TM services include assistance with patient documentation, medication dosage checks, and assistance with patient transport. Least frequently used TM services include ePharmacist consults and physician assistance with stroke assessments. Identified barriers to utilization of TM services include high confidence level of attending providers in performing independent assessments, staff concerns that decisions will be questioned, and preference of attending providers to directly contact physicians at accepting Primary Stroke Centers. Conclusions: While general TM services are widely available in North Dakota CAHs, services are underutilized. Access to specialized neurology services via TM is also limited. Targeted efforts to enhance understanding and utilization of existing TM services, particularly for stroke patients, will be beneficial to improving stroke systems of care in North Dakota.
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