Current through Register Vol. 49, No. 18, September 16, 2024
(1) All ground and air ambulances shall use
the following state transport protocol for suspected stroke patients except in
those circumstances listed in sections (3), (4), and (5) of this rule:
(A) Step 1-Assess for life threatening
conditions (serious airway or respiratory compromise or immediate life
threatening conditions that cannot be managed in the field).
1. If there are life threatening conditions,
transport the patient to the nearest appropriate facility for stabilization
prior to transport to a stroke center. Consider air/ground/facility options for
timely and medically appropriate care (particularly in non-urban
areas).
2. If there are no life
threatening conditions, go to step 2 below in subsection (1)(B); and
(B) Step 2-Assess the duration of
onset of symptoms (time last known well).
1.
Group 1-If the patient is within the lytic/therapeutic window then transport to
a level I, II, or III stroke center according to local and regional process.
Consider the time for transport, the patient's condition, air/ground/hospital
options for timely and medically appropriate care (particularly in non-urban
areas), and the treatment windows. Continue to reassess the patient. If the
patient's condition changes, then start back with subsection (1)(A) and follow
the state stroke protocol outlined in section (1) starting from subsection
(1)(A) and on according to the patient's condition. Consider out-of-state
transport based on local and regional process for bi-state regions.
2. Group 2-If the patient is within the
potential therapeutic window then transport to a level I stroke center or
transport to a level I, II, or III stroke center according to local and
regional process. Consider the time for transport, the patient's condition,
air/ground/hospital options for timely and medically appropriate care
(particularly in non-urban areas), and the treatment windows. Continue to
reassess the patient. If the patient's condition changes then start back with
subsection (1)(A) and follow the state stroke protocol outlined in section (1)
starting from subsection (1)(A) and on according to the patient's condition.
Consider out-of-state transport based on local and regional process for
bi-state regions.
3. Group 3-If the
patient is out of the lytic/therapeutic and potential therapeutic windows, then
transport to a level I, II, III, or IV stroke center according to local and
regional process. Consider the time for transport, the patient's condition,
air/ground/hospital options for timely and medically appropriate care
(particularly in non-urban areas), and the treatment windows. Continue to
reassess the patient. If the patient's condition changes, then start back with
subsection (1)(A) and follow the state stroke protocol outlined in section (1)
starting from subsection (1)(A) and on according to the patient's condition.
Consider out-of-state transport based on local and regional process for
bi-state regions.
(2) All ground and air ambulances shall use
the following state transport protocol for suspected STEMI patients except in
those circumstances listed in sections (3), (4), and (5) of this rule:
(A) Step 1-Assess for life threatening
conditions (serious airway or respiratory compromise or immediate life
threatening conditions that cannot be managed in the field).
1. If there are life threatening conditions,
then transport the patient to the nearest appropriate facility for
stabilization prior to transport to a STEMI center. Consider
air/ground/facility options for timely and medically appropriate care
(particularly in non-urban areas).
2. If there are no life threatening
conditions, then go on to step 2 below in subsection (2)(B) and assess vital
signs and perform an electrocardiogram (ECG) if the ground or air ambulance has
that capability. An electrocardiogram and electrocardiogram equipment are
recommended;
(B) Step
2-Determine if the patient's vital signs and the electrocardiogram identifies
the following:
1. ST-elevation in two (2)
contiguous leads or new or presumed new left bundle branch block; and
2. The patient has two (2) of the following
three (3) signs of cardiogenic shock:
A.
Hypotension where systolic blood pressure is less than ninety millimeters of
mercury (90 mmHG);
B. Respiratory
distress where respirations are less than ten (10) or greater than twenty-nine
(29) per minute; or
C. Tachycardia
where the heart rate is greater than one hundred beats per minute (100
BPM);
3. If the patient
has an electrocardiogram with ST-elevation in two (2) contiguous leads or new
or presumed new left bundle branch block and two (2) of the three (3) signs of
cardiogenic shock then transport to a level I STEMI center according to local
and regional process. Consider the time for transport, the patient's condition,
and the air/ground/hospital options for timely and medically appropriate care
(particularly in non-urban areas);
4. If initial transport from the scene to a
level I STEMI center is prolonged, then consider transporting to the nearest
appropriate facility for stabilization prior to transport to a level I STEMI
center;
5. Continue to reassess the
patient. If the patient's condition changes, then start back at subsection
(2)(A) above and follow the state STEMI protocol outlined in section (2)
starting from subsection (2)(A) and on according to the patient's
condition;
6. Consider out-of-state
transport based on local and regional process for the bi-state
region;
7. Communicate
electrocardiogram findings to the hospital;
8. If the patient has a positive
electrocardiogram but is negative for signs of cardiogenic shock, then go to
step 3 in subsection (2)(C) below; and
(C) Step 3-Calculate the estimated time from
STEMI identification with the patient to expected percutaneous coronary
intervention (PCI) with the patient in order to determine whether the patient
is within the percutaneous cornary intervention window. Communicate
electrocardiogram findings to the hospital. If no ST-elevation or new or
presumed new left bundle branch block then consider a fifteen-(15-) lead
electrocardiogram, if available.
1. Group
1-If the patient is within the PCI window or the patient has had chest pain
longer than twelve (12) hours or the patient is lytic/thrombolytic ineligible
then transport to a level I or level II STEMI center according to local and
regional process. Consider the time for transport, the air/ground/hospital
options for timely and medically appropriate care (particularly in non-urban
areas), the patient's condition, and all treatment windows. Consider the
ischemic time and the potential role for lytics (within the lytic window) at an
intervening STEMI center in route to the percutaneous coronary intervention
center if approaching longer times within the percutaneous coronary
intervention window. Continue to reassess the patient. If the patient's
condition changes, then start back at subsection (2)(A) and follow the state
STEMI protocol outlined in section (2) starting from subsection (2)(A) and on
according to the patient's condition. Consider out-of-state transport based on
local and regional process for bi-state regions.
2. Group 2-If the patient is outside the
percutaneous coronary intervention window and within the lytic/therapeutic
window, or outside both windows and the patient has no other known
complications, then transport to the STEMI center (level I, II, III, or IV)
according to local and regional process. Consider the time for transport,
air/ground/hospital options for timely and medically appropriate care
(particularly in non-urban areas), the patient's condition, and all the
treatment windows. Consider the lytic window and the potential for STEMI center
lytic administration when determining the destination(s). Continue to reassess
the patient. If the patient's condition changes, then start back at subsection
(2)(A) above and follow the state STEMI protocol outlined in section (2)
starting from subsection (2)(A) and on according to the patient's condition.
Consider out-of-state transport based on local and regional process for
bi-state regions.
(3) When initial transport from the scene of
illness or injury to a STEMI or stroke center would be prolonged, the STEMI or
stroke patient may be transported to the nearest appropriate facility for
stabilization prior to transport to a STEMI or stroke center.
(4) Nothing in this rule shall restrict an
individual patient's right to refuse transport to a recommended destination.
All ground and air ambulances shall have a written process in place to address
patient competency and refusal of transport to the recommended
destination.
(5) Ground and air
ambulances are not required to use the state transport protocols in this rule
when the ambulance is using a community-based or regional plan that has been
approved by the department pursuant to section 190.200.3, RSMo, that waives the
requirements of this rule. Copies of flow charts of an algorithm depicting the
stroke and STEMI state transport protocols are available at the Health
Standards and Licensure (HSL) office, online at the department's website
www.health.mo.gov, or may be
obtained by mailing a written request to the Missouri Department of Health and
Senior Services, HSL, PO Box 570, Jefferson City, MO 65102-0570 or by calling
(573) 751-6400.
*Original authority: 190.185, RSMo 1973, amended 1989,
1993, 1995, 1998, 2002 and 190.241, RSMo 1987, amended 1998,
2008.
