3 ways community paramedics can assist with after

By working on prescription compliance, smoking cessation and other risk factors, community medics can make a difference in the lives of stroke patients

Learn stroke assessment, recognition and timely decision-making as to where to transport a patient for intervention in EMS1's on-demand webinar, "Time is Brain: Stroke assessment and treatment guidelines".

By Mark E. Milliron, MS, MPA, MHS, EMT, CCHW

Stroke is the fourth leading cause of death (not including COVID-19) in the United States. Nearly 800,000 people will suffer a stroke each year; and for Black Americans, the risk of a first stroke is nearly twice as high, with the highest death rate.

Strokes are also the leading cause of long-term disability usage; in 2017, $53 billion was spent between related medical expenses and lost workdays [1].

A study of 2,706 patients discharged between 2007-2009 found that 6.4% were readmitted to the hospital within 30 days. Of those, 29% were found to be readmitted after inadequate outpatient care coordination and 4% readmitted after being discharged with inadequate discharge instructions [2]. Another study from the 2013 Nationwide Readmission Database of 319,317 patients with acute ischemic stroke – which accounts for 87% of strokes – found 12.1% of patients were readmitted. Factors for readmission included patients who were older, had Medicare coverage, and a lower household income [3].

Most providers are familiar with the acronym FAST – Face, Arm, Speech, Time – to identify a stroke. Recurring strokes have similar warning signs [4]:

Community paramedicine follow-up and care after hospital discharge can help alleviate the impact of factors such as poverty and access to medical care, improve patient and family education, and help prevent the negative economic impact following a stroke.

There are several ways community paramedics can play a key role in helping patients avoid a second stroke, mostly centered around discharge instruction compliance [5].

1. Smoking cessation. Community paramedics should ensure patients have access to an effective program to help them stop smoking, due to the high risk of stroke it presents. However, nicotine can be very addictive, and relapse is not uncommon – nonjudgmental support from family and friends is important. Some obstacles to quitting include:

Look for a support system that works for the patient. Start with the Quitline at 800-QUIT-NOW (800-784-8669). The CDC also offers several smoking cessation resources on its How to Quit Smoking site, including tips from former smokers, a step-by-step guide to quitting cigarettes and access to the quitSTART app for customized goals and motivational tips [12].

2. Prescription compliance. Following a stroke, many patients are sent home on prescriptions that are vital to preventing a secondary stroke or more complex medical conditions, including:

To prevent another stroke, patients should maintain a heart-healthy diet, maintain a healthy weight, exercise daily, avoid smoking, limit alcohol and manage stress [10].

Despite the medical need, many stroke patients do not adhere to their prescribed medications for a variety of reasons, including [8]:

Prescribed medications can be prohibitively expensive for patients who do not have prescription insurance coverage. The discharging hospital or a community medical clinic may be able to support patients in accessing prescription medication programs through pharmaceutical manufacturer's medication assistance programs. There are also websites that can search for assistance programs, such as the Medicine Assistance Tool, and local medicine assistance teams may develop their own list of pharmaceutical assistance programs.

3. Risk screenings. Dysphagia, or difficulty swallowing is a common condition following both ischemic and hemorrhagic strokes. A study found that nearly 40% of all stroke patients had dysphagia [11]. The Dysphagia Outcome Severity Scale (DOSS) can be used to assess stroke patients through several questions:

Generally, a stroke can affect speech, movement and memory, which in turn affect the patient's daily living activities. Ongoing reassessment can help the patient understand their current needs, as well as inform family members, caregivers, and medical providers about possible complications and adjustments. Various organizations have developed checklists to assess a patient's status [13-15]. Key indicators that patients, family members and caregivers should watch for include:

All of this information can be shared with the patient, family members, and caregivers who may be coming into the patient's home.

Following a stroke, it's important for connected family and loved ones to understand the patient's short- and long-term physical and occupational therapy goals, speech and language pathology goals, as well as the operation and maintenance of adaptive equipment.

Make sure that everyone knows and understands the BE-FAST mnemonic to recognize a stroke – balance, eyes, face, arm, speech, and time – as well as the differences between an ischemic and hemorrhagic stroke [16]. Time is of the essence when a stroke occurs, and EMS should be notified immediately.

Ensure family members are aware of what medications have been prescribed and how they are administered and stress the importance of follow-up appointments with providers. Help them to understand the individual patient's risk factors, both the uncontrollable, such as age, race and prior stroke and those that can be controlled, such as blood pressure, cholesterol levels, diabetes, atrial fibrillation, smoking and tobacco use, alcohol and other drug use, and weight.

Ultimately, community paramedics want to give the patient, family and other caregivers the tools they need to prevent another stroke in the future.

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Mark Milliron is currently with the UPMC Center for Clinical Education and Development in Harrisburg, Pennsylvania. He has been an EMS provider since 1982, an administrator with several community health and human services organizations and a public health administrator with the Pennsylvania Department of Health. He is an EMT instructor and a certified community health worker, and has taught for Penn State University, Purdue University Global and York College of Pennsylvania.