Annual Certified Primary Stroke Center Luncheon

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1 Welcome to the American Heart Association/American Stroke Association & The Joint Commission s Annual Certified Primary Stroke Center Luncheon International Stroke Conference 2013 Thursday, February 7, :00AM 12:15PM Honolulu, Hawaii 2 1

2 Hosts Stephanie Chapman MJ Hampel, MPH, MBA Senior Director Quality & Systems Improvement American Heart Association SWA Advocacy & Health Quality Senior Associate Director Disease-Specific Care Certification The Joint Commission Phone: Geographic Distribution of Certified Stroke Centers As of 1/24/12 2

3 Lee H. Schwamm, MD, FAHA Professor of Neurology at Harvard Medical School Vice Chairman of Neurology Massachusetts General Hospital Boston, Massachusetts 5 Lee H. Schwamm, MD, FAHA Presenter Disclosure Information FINANCIAL DISCLOSURE: Stroke Systems Consultant, MA Department of Public Health Chair, AHA GWTG Steering Committee UNLABELED/UNAPPROVED USES DISCLOSURE: None 6 3

4 Facts about AHA/ASA & TJC s Primary Stroke Certification The American Heart Association/ American Stroke Association & The Joint Commission in collaboration launched the Primary Stroke Center Certification Program in December Certification is available only to stroke programs in Joint Commission-accredited acute care hospitals. Certification is for organizations that make exceptional efforts to foster better outcomes for stroke care. Programs that apply for advanced certification must meet the requirements for Disease-Specific Care Certification. 7 Primary Stroke Certification Requirements Certification recognizes hospitals that meet standards to support better outcomes for stroke care. To be eligible, hospitals must meet a variety of standards, including: A dedicated stroke-focused program Staffing by qualified medical professionals trained in stroke care Individualized care to meet stroke patients needs Patient involvement in their hospital care Coordination of post-discharge patient selfcare based on recommendations of the Brain Attack Coalition and guidelines published by the American Heart Association/American Stroke Association or equivalent guidelines Streamlined flow of patient information while protecting patient rights, security and privacy Collection of the hospital s stroke treatment performance data Hospital team performance data Use of data to assess and continually improve quality of care for stroke patients 8 4

5 Congratulations to Trinity Health in Minot, ND, for being the 1,000 th Certified Primary Stroke Center in the U.S.!! 9 How are you promoting achievement of certification? Downloadable art files of the TJC gold seal and AHA Heart-Check mark are available for hospitals use to promote their advanced certification on the TJC extranet site. 10 5

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9 Mark J. Alberts, MD Vice-Chair, Department of Neurology Professor of Neurology University of Texas Southwestern Medical Center Dallas, Texas 17 Mark J. Alberts, MD Presenter Disclosure Information FINANCIAL DISCLOSURE: Speakers Bureau/Consultant: Genentech, Inc. Unpaid Consultant: The Joint Commission UNLABELED/UNAPPROVED USES DISCLOSURE: None 18 9

10 Accomplishments of Primary Stroke Centers 19 What is a Stroke System of Care? A comprehensive, diverse, longitudinal system that address all aspects of stroke care in an organized and coordinated manner Spans the spectrum of stroke care from primary prevention, calling 9-1-1, acute care, secondary prevention, rehabilitation, return to the community As with any system, it is only as strong as its weakest link This talk will focus on the acute care aspects But all elements are important Will be addressed in an upcoming AHA/ASA publication 20 10

11 Pictorial Stroke System of Care Return to the community Primary Prevention/ Secondary Prevention Public Education Rehabilitation Calling 911 Secondary Prevention EMS elements Acute Care Transportation to hospital Stroke Centers 21 EMS Plays a Key Role in a Stroke System Is typically the first medical professionals with direct patient contact Their initial assessments, actions, treatments, and decisions will have significant consequences in the patient s subsequent care Their role in patient triage, diversion, and routing cannot be over-estimated 22 11

12 Medical Impact of Stroke Recent study of 91,134 patients admitted to 625 hospitals with acute stroke (all Medicare patients) Average age = 79 years 58% female 82% Caucasian Overall, 62% of these patients were dead or re-admitted after just 1 year Fonarow et al., Stroke, Characteristics of Different Stroke Centers Comprehensive Stroke Center Academic Medical Center Tertiary Care facility Primary Stroke Center Wide range of hospitals; standard stroke care; stroke unit; use TPA Acute Stroke Ready Hospital Rural hospitals; basic care; drip and ship; use tele-technologies 24 12

13 Numbers of Various Types of Stroke Centers Comprehensive Stroke Center total Primary Stroke Center Final count 1200 Acute Stroke Ready Hospital Perhaps >5000 total acute care hospitals in the U.S. 25 Primary Stroke Centers More than 1000 PSCs currently certified by TJC About 80 or so certified by other organizations Mostly urban, suburban Provide organized care in most states and regions Some academic, some not Typically have stroke admissions per year Some up to /yr; some less 26 13

14 Updated PSC Recommendations MRI with diffusion available for stroke patients Vascular imaging for stroke patients MRA of head/neck CTA head/neck Carotid Doppler alone not acceptable Cardiac imaging TTE, TEE, or cardiac MRI Stroke Unit monitoring protocols Multichannel telemetry Clinical monitoring plans Who to call/when to call plans Begin rehabilitation efforts ASAP Certification by an independent organization Alberts et al, Stroke, PERFECT Study-Finland Compared outcomes among patients admitted to different types of hospitals Used BAC criteria for PSC and CSC Adjusted for baseline differences CSC = 20,045 PSC = 10,749 GH = 30,891 Meretoja et al, Stroke,

15 NY State PSC Study 30,947 patients admitted with acute ischemic stroke One year follow-up 15,297 admitted to a designated stroke center (PSC) Used 39,000 and 40,000 patients with GI hemorrhage and MI as internal controls Xian et al, JAMA, NY State Study Mortality Outcomes Reduced mortality appeared early and increased Xian et al, JAMA,

16 Impact of Reduced Death Rates for Stroke Stroke is the 4 th leading of death in the US and the 2 nd leading cause of death globally 2% to 3% reduction in deaths in US means 16,000 to 24,000 fewer deaths in the US Globally this means 320,000 to 480,000 fewer stroke deaths each year There are very few medical interventions that reduce deaths Trauma centers DO Coronary stenting vs angioplasty DOES NOT CEA vs medical therapy DOES NOT 31 Use of IV TPA at PSCs Illinois State Experience Data from 193 hospitals, 52 PSCs, > 119,000 patients Prabhakaran et al, Stroke,

17 Methods We analyzed data from PSCs certified by The Joint Commission (TJC) from Rates of IV TPA use in eligible patients (ischemic strokes, presentation within 2 hr. of Sx onset/last known normal, no contraindications to TPA therapy) Analyzed number of certification cycles, hospital setting, and teaching status 33 Results 34,909 eligible patients at 842 PSCs were identified 455 teaching hospitals; 367 non-teaching 783 urban; 39 rural 1 cycle = cycles = cycles = cycles = 83 Alberts et al, presented at ISC, February 2011, New Orleans 34 17

18 TPA Use by Year Overall TPA was given to 81% of eligible patients The overall rate of TPA use increased from 79.4% in 2008 to 83.5% in 2011 (p < 0.001) 35 TPA Use by Number of Certification Cycles Overall 10% absolute increase in rate of TPA use between 1 and 4 certification cycles (p < 0.004) 36 18

19 TPA Use at Teaching vs. Non-Teaching PSCs 37 Key Elements at a PSC for IV TPA Administration Care Element Odds Ratio P Value Written care protocols CME Stroke Unit Acute stroke team Emergency dept EMS Neuroimaging Douglas et al., Neurology,

20 Changes in ED Performance at a PSC > 15,000 patients pre-psc > 11,000 patients post-psc 55 min reduced ED time for patients with ICH 11 min reduced time for head CT 197 min reduced time for MRI 88% increase in use of MRIs Ballard et al., AJEM, Phoenix Operation Stroke Targeted Phoenix metropolitan area Included PSC support Public education EMS and triage to stroke centers Total costs = $3.5 million over 8 years GOAL: Increase use of IV TPA Demaerschalk et al., Stroke,

21 Phoenix Operation Stroke 41 Effects of PSC Care for ICH and SAH National study 31,272 patients with ICH 6197 with SAH All Medicare 315 PSCs Unknown number of non-pscs Primary outcomes were: 30 day all cause mortality 30 day all cause re-admission Lichtman et al., Stroke,

22 Primary Outcomes Lichtman et al., Stroke, Risk Adjusted Outcomes Lichtman et al., Stroke,

23 PSCs Achieve High Rates of Compliance with other Care Paradigms Alberts et al, ISC 2011 * = statistically significant 45 Where to Locate PSCs?? Currently 12 PSCs in Iowa; total hospitals = PSCs cover 37% of the population 31 PSCs could cover 75% if forced location Or 54 could also cover 75% Who should direct PSC location?? Need for dialogue and coordination Leira et al., Stroke,

24 AHA/ASA Quality Consumer Map Locate Your PSC 47 Barriers to the Development of PSCs and Related Stroke Systems Studied 4 states: Florida, Massachusetts, New Mexico, New York Identified several areas: PSC Standards Lack of coordination with EMD, ED, dispatch Lack of Neurologists Telemedicine issues (state to state) Complexity of hospital care delivery systems Complexity of governmental agencies O Toole et al., AJPH,

25 Stroke Systems: Population and Patient Perspective CSC PSC ASRH 49 By-passing Hospitals in a Stroke System of Care With multiple hospitals of various capabilities in a geographic area (or Stroke System), how can we properly triage and divert patients to the most appropriate facility? Guiding Principles # 1 If all are close, go to the highest level Stroke Center initially WHY? We do not know the type of stroke Patients can deteriorate Unclear what tests and treatments will be needed

26 By-passing Hospitals Guiding Principle # 2 Time is more important than distance, because time is brain Factors to consider include: Weather Traffic Local geography Mode of transportation 51 By-passing Hospitals Guiding Principle # 3 To make the best decision, personnel must know the actual capabilities of their local hospitals as well as the EMS system Not every hospital that claims to be a PSC or CSC will have those capabilities EMS triage and routing skills may vary by city and region All politics are local!!! 52 26

27 Key Members of the PSC Movement PSCs would not be successful without the hard work of the many nurses, physicians, therapists, staff, and many other healthcare professions who work 24/7 to care for patients in all care settings!!! We thank you all for your hard work and dedication day in and day out!!! 53 Conclusions Many elements of a PSC contribute to improved care processes and outcomes There is now a 60 minute national standard for DTN times for IV TPA PSCs improve care and outcomes for ALL types of stroke patients Looking to the future, the key challenges relate more to EMS triage and diversion The location of PSCs is emerging as another key issue PSCs offer an ideal venue to test and validate new diagnostic and treatment modalities for stroke patients 54 27

28 55 We appreciate you joining us today! On behalf of the American Heart Association/American Stroke Association and The Joint Commission, we thank you for your dedication to improving stroke care. Your continued efforts are making the lives of your patients better

29 Join Us in Learning More About Comprehensive Stroke Certification: What: When: Presentation: Presenter: Location: 27-Comprehensive Stroke Center Certification: Current Update Thursday, Feb 07, 2013, 12:30 PM - 2:00 PM Becoming a Comprehensive Stroke Center: A Guide to Certification Lori Massaro, Pittsbugh, PA Kalakaua Ballroom A 57 29

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