The 8 D's of Stroke Care
According to the National Stroke Association, strokes are the fourth leading cause of death in the United States. Even if an individual survives a stroke, it can lead to permanent impairment. Depending on the extent of damage to the brain, a stroke may leave a person with deficits such as vision loss, memory problems and/or paralysis or weakness on one side of the body.
Fast recognition and treatment can not only make the difference between life and death, but it can also decrease long-term disabilities. To develop a streamlined response to potential stroke patients, the American Heart Association developed the Stroke Chain of Survival. The chain involves eight links or steps to be taken by patients, family members, prehospital and emergency room personnel in caring for stroke patients.
This streamlined approach to stroke is an effective way to ensure that appropriate care is delivered as quickly as possible, optimizing the possibility of full recovery. Each of the 8 D’s in the chain of survival are critical steps which increase the likelihood of prompt diagnosis and treatment of stroke.
Detection: Detection involves recognizing the signs and symptoms of an acute stroke. Early signs of a stroke include weakness on one side of the body, slurred speech and facial drooping. Early detection and recognition of stroke symptoms speeds the implementation of appropriate medical interventions and improves patient outcomes.
Dispatch: The second step in the chain of survival is ‘dispatch’, which involves activating emergency medical services. In most cases, this involves calling 911. Medical dispatch should be thoroughly trained to identify a possible stroke patient so that the appropriate level of EMS services can be dispatched to the patient. Simply stated, the faster EMS can be dispatched, the quicker lifesaving treatment can be delivered.
Delivery: Delivery is the prompt transport of the patient to a hospital, preferably a stroke center. Emergency medical personnel should be trained in performing a rapid assessment of the patient’s condition. If a stroke is suspected, the patient should be transported to an appropriate receiving hospital as soon as possible. A medical history and baseline mental status should be documented. The time since onset of symptoms should also be noted and is referred to as ‘time zero’, or the last time the patient was seen to be normal. Emergency medical workers need to provide pre-arrival information to the receiving facility so that the ED can prepare for the arrival of a potential stroke patient.
Door: The fourth step in the chain of survival is ‘door’, which refers to the arrival of the patient at the emergency room (ED). Ideally, the stroke team should be in place at the receiving facility prior to the patient’s arrival to ensure prompt assessment and diagnosis. According to recommendations from the National Institute of Neurological Disorders and Stroke, an assessment should be completed by an ER physician within ten minutes of arriving in the ED.
Data: Data collection is a vital component of the chain of survival. Data collection includes results from laboratory tests and both a physical and a neurological exam. A 12-lead electrocardiogram is recommended to rule out cardiac arrhythmias. In addition, a CT scan is an essential piece of the puzzle and is needed for an accurate diagnosis. A CT scan should ideally be performed within 25 minutes of arrival in the emergency room. Data collected is also needed to rule out conditions which may mimic a stroke, such as a brain tumor, drug overdose or hypoglycemia.
Decision: A ‘decision’ regarding the type of treatment needed is the next step in caring for a patient with a stroke. Information, such as the type of stroke which has occurred and the time from onset of symptoms, is considered before a treatment decision is made. The severity of the stroke may also play a role in deciding what the most appropriate treatment will be. The patient and family members should also be informed of the risks and benefits of treatment options.
Drug/Device: Drug administration, if appropriate, is the next link in the chain of survival. If the patient is a candidate for fibrinolytic therapy, the window of opportunity for administration is narrow. According to the American Heart Association guidelines, fibrinolytic therapy should be administered within three hours of the onset of symptoms. If the patient is not a candidate for drug therapy they may qualify for Endovascular therapy to remove the clot mechanically rather than with fibrinolytics.
Disposition: Disposition is the last link in the chain of survival. This step in stroke care focuses on the continuing care of the stroke patient. It is recommended that patients be admitted to an intensive care unit or stroke unit within three hours of arrival in the ED. Continued monitoring of a stroke patient includes frequent assessment of neurological status and monitoring of glucose levels and vitals, as well as prevention of complications. Determining the cause of the stroke is also part of disposition.
Juach, E. Cucchiara, B. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010. http://circ.ahajournals.org/content/122/18_suppl_3/S818.full Accessed August 2014.
National Institute of Neurological Disorders and Stroke. Stroke Proceedings; Acute Care. http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/recs-acute.htm Accessed August 2014.
The Stroke Foundation. http://www.thestrokefoundation.com/index.php/about-stroke/62-the-seven-d-s-of-stroke-survival Accessed August 2014.
American Heart Association Advanced Cardiac Life Support Provider Manual (2016)