Rishi Gupta, MD Susan Zimmermann, RN, BSN, CNRN Kerrin Connelly, RN, MSN, MPH Cheri Kommor, RN, CEN, CFRN, NREMT-P

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1 Rishi Gupta, MD Susan Zimmermann, RN, BSN, CNRN Kerrin Connelly, RN, MSN, MPH Cheri Kommor, RN, CEN, CFRN, NREMT-P

2 Rishi Gupta FINANCIAL DISCLOSURE: Consultant: Stryker Neurovascular, Covidien DSMB: Rapid Medical, Reverse Medical Associate Editor Journal of Neuroimaging Susan Zimmermann Kerrin Connelly Cheri Kommor FINANCIAL DISCLOSURE: No relevant financial relationship exists

3 How an interventionist sees patients Neurologists look to the data

4 - Where must we go? (Vision) - How can we get there? (Strategy) - What is to be done next? (Tactics) - How are we doing? (Assessment) Styles and processes may differ with the type of organization and environment.

5 Vision must be clear, have laser focus and specific Strategic plan must lay out the steps to achieve the vision over 1 year, 5 years and 10 years. Metrics must be developed to ascertain success. Example: Many facilities hire faculty, nursing to fulfill needs. Important not to hire but to select team members

6 Direct Physician to Physician Contact Selective in Patient Transfer Acceptance Feedback Mechanisms Linking systems

7 EMS ER Radiology IV tpa Referring Physician Telemedicine Vascular Neurology NICU Endovascular Anesthesia

8 Time of CT Time contacting EMS Time EMS Leaves Time Imaging obtained Time Reperfusion achieved Time of Arrival to Outside ER Time of contacting INR Time EMS Arrives Time EMS Arrives at your hospital Groin Puncture The process where humans change their behavior simply because they know they are being studied Implementation of quality assurance projects aimed at measuring processes for the care of an endovascular stroke patient

9 - Assess distance - Assess EMS services available in county - Investigate helicopter options * Is there a helipad? * Where is origin of helicopter? - Traffic patterns - Weather

10 Telemedicine? Tier 1: Excellent Neurology Coverage - Telephone call, transfer Tier 1 Tier 2: Inconsistent Neurology - Image Transfer - Phone call Tier 3: Rural areas - Telemedicine Tier 2 Impact is: - Meet needs - Less intrusive - Rapid triage - Build trust Tier 3

11 Acute ischemic Stroke with NIHSS 8, Anterior circulation Likely to Benefit Age< 80 and Sx onset < 6 hrs ASPECTS > 7 or MRI DWI or CTP < 1/3 MCA core Uncertain Benefit Onset 6-8 hours with < 1/3 MCA Core by DWI, CTP or ASPECTS Or if < 6 hours and age >80 with MCA or ICA occlusion Unlikely to benefit Onset < 8 hours with >1/3 MCA involvement? Prevent hemicrani or selected reperfusion of eloquent cortex Transfer patient for IA therapy Notify INR team Decision between Vascular Neurology And INR attending, consider Clinical trial Decision between Vascular Neurology and INR attending, family discussion Repeat CT Direct to IA Patient received IV tpa or > 1 hour In transportation < 1 hour in Transport and No IV tpa given Transfer if agreement Transfer if agreement or for cerebral edema management

12 MSNC Thrombolysis Experience (431 total strokes) 2011 (632 total strokes) 2012 (824 total strokes) IV tpa (Grady) IV tpa (outside facility) Endovascular therapy Any thrombolytic therapy

13 Refine internal processes Educate key partners Consult with key partners Provide feedback

14 What does your internal process look like? Patient tracers Current transfer protocols Registration Imaging Bed placement/icu/nursing unit Education

15 Capability Define and communicate what you do Patient selection Provide guidance Contact options Be consistent and reliable Telemedicine/image transfer What do you have to offer? Engage marketing/pubic relations!

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17 Current capability What can you offer to complement it? Current process Does it include endovascular consideration? Plan for transport Is there a commitment from air and ground EMS? Plan for education How can you assist with roll out?

18 Accepts images from any CT or MRI Neutral viewing platform Immediate, secure, eliminates need for CD Improves patient selection Allows collaboration, education, fosters trust

19 Refer back to community rehabilitation and physicians Feedback and kudos Treatment, disposition and process Verbal, written, posters Internal & external trickle down effect Continually refine processes

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21 WellStar Kennestone Regional Medical Center The largest of a 5 hospital system in Marietta Georgia Reside 23 miles from our closest CSC 633 bed licensed beds with 120,000 annual ED visits - Primary Stroke Center caring for 1,200 stroke/year - CARF certified Inpatient Rehab / Outpatient Rehab on campus

22 Established acute stroke team in your facility Build professional relationships with CSC team NETWORKING Georgia Stroke Professional Alliance Association American Heart Association Support Strong desire to provide the most updated stroke care

23 Identification of the acute stroke patient and a clear last known well - Hemiplegia - Gaze preference - Language deficit - Profound aphasia Last Known Well < 8 Hours T-PA patient s who do not show improvement

24 ED Champion - Physician and Nursing Neurology Champion - Decision makers consulting the CSC Strong Stroke Coordinator - Protocols, support, dedicated to the team, keep good records Transparent with Senior Administration

25 In-services provided by CSC Interventionalist - Helped build rapport with Neurologist and ED Staff at PSC - Criteria for patient identification was provided - Phone numbers were made accessible - Open communication was a clear focus - Incorporated regional PACS system - Mock transfer runs with Air Life Georgia

26 Daily communication between the Outreach Manager of the CSC and the Stroke Program Leader of the PSC Communication between Care Coordination at the CSC and the PSC to determine eligibility for IRU Open communication to Air Life GA discussing any issues with transfer or safety Quarterly rounds between Interventionalist at the CSC and our Neurology and Emergency Physician Team. Transfer of the right patient Discussion of treatment Outcomes

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28 Speed! Critical care team of flight nurse and flight paramedic (and the pilot too) Higher level of care than average ground EMS transport (because of flight RN on board) Advanced training and capabilities to include: RSI/intubation Management of multiple drips (i.e., tpa, antihypertensives, pressors, sedation, etc.) Management of invasive lines Ventilator management and much more...

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30 Collaborative effort between Air Methods Air Life Georgia (ALG) and Marcus Stroke Center (MSC) at Grady Hospital Plan developed through strong working relationships between ALG staff and neuro interventionalists from MSC Relationships established as a result of the following efforts: MSC reaching out to provide info related to capabilities/services of the comprehensive stroke center ALG working to understand the types of patients best suited for the specialty services provided by MSC

31 Reduce the length of time from MD acceptance to patient arrival Reduce the need for additional imaging Increase opportunities for pt to receive interventions needed to improve morbidity and mortality Average transport time prior to development of rapid stroke transport plan = 90 minutes

32 Identify the appropriate patient Meetings to discuss key components/ways to reduce time Intercept the pt closer to the helipad Develop a checklist to follow Rapid assessment and pt report Rapid transfer of tpa to flight crew IV pump Hot load Coordinate with sending hospital staff (CT, ED, security), ALG flight crews, ALG dispatch, MSC staff

33 STROKE TRANSFER REPORT AND CHECKLIST Item Needed for Flight Transfer Please or Fill In Blank 1.Time of Last Known Normal Date 8/1/12 Time Last Blood Glucose Time: 1442 Result: 106 mg/dl Tx: None required 3. Significant medical history (if any) CAD/ Prior MI AFib/ Flutter IDDM HF Previous Stroke HTN Hx Head Bleed Other 4. Does the patient take blood thinners at home? Yes No 5. Patient weight (in kg) Weight 100 kg 6. Patient allergies (list or indicate none ) NKDA 7. tpa bolus amount given (list bolus, time given, or none ) See t-pa protocol Woorksheet 8. tpa infusion (total amount to be infused or none ) See t-pa protocol Worksheet 9. List any other drugs given while in the ED (list drug, amount, and time given) Drug Amount Time Given ASA 81 mg At home 10. Oxygen provided NC Facemask 11. Any other patient related concerns while in ED (markedly abnormal VS, seizure activity, dysrhythmias, abnormal labs, etc or indicate none.) None 12. Last set of vital signs (list the last set of vital signs) (See tpa protocol worksheet) 13. EMTALA transfer form completed Check to acknowledge complete 14. Patient s Chart can be faxed to Marcus Stroke Center post transfer X Check to acknowledge complete Grady Neuro ICU 15. Face sheet Check to acknowledge complete 16. EMS consent form Check to acknowledge complete

34 Training: Sending hospital staff Plan components Helipad safety Flight crews Plan components tpa drip transfer Communication Hot loading Receiving hospital staff Transfer papers to be faxed Electronic transmission of CT films Communication of ETA by flight crew and response to helipad Dry runs (timed) at various times of day, weekends Establishing a Go Live date Ensuring everyone is trained

35 Review each transfer Tweak the plan as needed Identify areas for improvement Identify areas for additional training Evaluate effectiveness Average transfer time after development of rapid transport plan = 59 minutes (down from 90) Reduced the number of patients requiring repeat CT = 50% (down from 71%) Improved morbidity and mortality

36 year old male LKN 0950 patient witnessed to be driving erratically, involved in a minor MVC EMS assessment revealed right sided weakness and aphasia 1034 Arrival to Kennestone via ground EMS, initial NIHSS of 17

37 1039 CT revealed left MCA thrombus 1047 Grady neurointerventionalist paged IV tpa administered 1120 patient transported to helipad by ED team to meet Air Life Georgia crew for rapid transport

38 1130 patient arrived at Grady 1148 CT at Grady 1215 groin puncture at Grady Door at Kennestone to door at Grady = 56 min. Patient discharged to home two days later

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