St. Jude Medical Center. Objectives. The Numbers of Stroke. Secrets of Surviving a Stroke. Stroke is a leading cause of death and disability worldwide

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Geraldine Booth
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1 St. Jude Medical Center Secrets of Surviving a Stroke Stephen Waldman, M.D.,Ph.D. Neurologist,Co-Stroke Director Sara Williams, R.N., C Director of Care Transitions Objectives Overview of Stroke Discuss treatment with rt-pa (tissue plasminogen activator) Discuss Time is Brain (tissue lost) Understand the importance of leadership support Define expertise for the ED, nursing staff, physician staff with support in lab, transportation and radiology Discuss ongoing efforts to maintain and improve outcomes The Numbers of Stroke Stroke is a leading cause of death and disability worldwide In the U.S. there are annually estimated 731,000 first-ever or recurrent strokes and 4 million stroke survivors. Financial burden estimated direct & indirect costs total $40 billion annually

2 Types of Stroke Hemorrhagic stroke (17%) Intracerebral hemorrhage (59%) Ischemic stroke (83%) Lacunar small vessel disease (25%) Atherothrombotic disease (20%) Embolism (20%) Subarachnoid hemorrhage (41%) Cryptogenic (30%) The Stroke Belt Stroke death rates, , adults aged 35 years or older, by county. Data Source: US Census Bureau Postcensal Population Estimates and National Center for Health Statistics National Vital Statistics System (ICD9 Codes ). ED Assessment of the Suspected Stroke Patient: Goals Rapid activation of stroke team Differential diagnosis Rule out conditions mimicking stroke Ischemic vs hemorrhagic stroke Assess eligibility for thrombolysis or other acute interventions Determine location and etiology of stroke Prevent and treat acute medical and neurologic complications

3 AHA/ASA Guideline Recommendations Intravenous rt-pa is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A). rt-pa should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). Adams HP Jr, et al. Stroke. 2007;38: rt-pa Should Be Used With Caution in Certain Patients Patients with severe neurologic deficit (eg, NIHSS >22) at presentation Patients with major and early infarct signs on a cranial CT scan (eg, substantial edema, mass effect, or midline shift) Patients of advanced age (eg, >75 years) Due to the increased risk of misdiagnosis of acute ischemic stroke, special diligence is required in making this diagnosis in patients whose blood glucose values are <50 mg/dl or >400 mg/dl Patients with minor strokes or rapidly resolving symptoms IV rt-pa for Acute Ischemic Stroke: NINDS Trial Primary end point: Favorable outcome at 3 months Defined as normal or near normal neurological function using a global scale that incorporated 4 commonly used scales Odds ratio: 1.7 (95% CI, ) favoring rt-pa over placebo Includes an increased incidence of symptomatic ICH (6.4% vs 0.6%) 0 to 1 2 to 3 4 to 5 Death mrs score (3 months) Placebo Rt-PA Percentage of patients ICH = intracerebral hemorrhage. Reprinted with permission from The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. N Engl J Med. 1995;333:

4 Meta-Analysis Odds Ratio of 6 Randomized, of Very Favorable Placebo- Outcome Controlled Trials by Treatment Time at Day 90 N = 2,776 Lancet 2004; 363: rt-pa Use 3 to 4.5 Hours After Stroke Currently supported by only 1 large randomized trial (ECASS III) 1 Supported by 1 large pooled analysis 2 Not supported by FDA label 3 Now supported by a new AHA/ASA science advisory 4 Class I, Level of Evidence: B recommendation European guidelines being modified Key point is to treat as soon as possible within either 3 hours or 4.5 hours 1. Hacke W, et al. N Engl J Med. 2008;359(13): Lansberg MG, et al. Stroke. 2009;40(7): Activase (alteplase) full prescribing information. 4. Del Zoppo GJ, et al. Stroke. 2009;40(8): Treatment Delays Despite its effectiveness in improving neurological outcomes, many patients with ischemic stroke are not treated with rt-pa, because they arrive late or because of delays in assessment/administration of IV rt-pa Increased Treatment Opportunities (reduce the door to needle time for IV rt-pa) Goal-Achieve a Door to Needle (DTN) Time within 60 minutes in at least 50% of ischemic stroke patients treated with IV rt-pa. The sooner that rt-pa is given to stroke patients, the greater the benefit, especially if started within 90 minutes of symptom onset

5 Improved Treatment Over Time GWTG-Stroke/ Use of IV rt-pa in Eligible Patients 100% Baseline YR1 YR2 YR3 YR4 YR5 80% 65.00% 69.10% 72.65% 72.84% 60% 53.46% 40% 42.09% 20% 0% IV rt-pa 2 Hour Opportunity for Improvement Timeliness of IV rt-pa in Ischemic Stroke % 80% 60% 40% 20% 24.10% 22.30% 24.70% 25.80% 27.40% 0% DTN within 60 min Target Stroke Goal Target: Stroke The Time is Now Door-to-IV rt-pa within 60 minutes 100% 80% 60% 50.0% 40% 27.4% 20% 0% 2009 Goal DTN within 60 min GWTG-Stroke Database, data on file DCRI

6 NIH-recommended ED Response Times The golden hour for evaluating and treating stroke Door-to-needle time 60 minutes Minutes: Suspected stroke patient arrives at ED Initial MD evaluation CT scan initiated CT & labs interpreted tpa given if patient is eligible Stroke team notified Bock BF. National Institute of Neurological Disorders and Stroke, National Institutes of Health; Time is Brain STARS Registry 38 community, 18 academic hospitals, 389 IV TPA pts Median door to needle time: 96 minutes CDC 4 State Pilot Acute Stroke Registry 98 hospitals, 6867 acute patients, 118 IV TPA Treatment within target 60 minutes: 14.4% = Target Stroke at St. Jude Median Door to Needle Time Minutes Minutes (STARS Registry-96 Minutes) Treatment within Target 60 Minutes % % (CDC 4 State Pilot-14.4%)

7 Program Beginnings Multidisciplinary Team Neurologists ED Physician Champion ED Nurse Manager Stroke Nurse Practitioner Ancillary Department Managers Executive Team Support Stroke Team Meetings Code Stroke Review Stroke Leadership Team Stroke Neuro Excellence Regional Stroke Meetings Best Practices Advance Hospital Notification by EMS Orange County Stroke/Neuro Receiving Centers Spoke and Hub Hospitals Quarterly Paramedic Education (Cincinnati Pre-hospital Scale) Rapid Triage Protocol and Stroke Team Notification Protocol and Order Set Development Developed by multidisciplinary team Physician education Rapid Stroke Team Activation by ED Physician Call to hospital operator Can be activated after base station contact Code Stroke Physician Checklist

8 Best Practices (contd.) Stroke Tools Guidelines Algorithms NIH Stroke Scale Stroke Specific Order Sets Code Stroke Ischemic Stroke Hemorrhagic Stroke Rapid Acquisition and Interpretation of Brain Imaging Radiologist paged for Code Stroke Clear 64-Slice CT Scanner when Code Stroke Called Radiologist communication with ED Physician Best Practices (contd.) Rapid Laboratory Testing Lab draws immediately after Code Stroke called INR CBC Creatinine Labeled as Code Stroke Rapid Access to Intravenous rt-pa Pharmacist part of Code Stroke Team Tackle box Time out with nurse Mixed at bedside- Turn around time-5 min. Best Practices (contd.) Team-Based Approach Multidisciplinary meetings Frequent meetings Ad hoc meetings Prompt Data Feedback Monthly Code Stroke Review One-on-one Education with MD/Nurse Fallouts discussed with team within one week

9 Code Stroke Review Patient Age 91 M Date Arrival Mode: OC EMS Onset: Left sided weakness, fell at home, wife called 911 Time Accrual Time Turn Around Times Goal Times Goal Met Arrival Time 1618 Code Stroke Called min Door to CT Performed min < 25 min Door to CT Results min 12 min Door to tpa min 133 min from LKW < 60 min CBC 1621/ min PT 1621/ min Creatinine 1621/ min CXR 1621/ min ECG 1621/ min Pharmacy Call Time 1652 ED Physician Pharmacy-tPA to RN 1705 ED Nurse Admission NIHSS Discharge NIHSS Discharge Date/Dx Location of Stroke 9 to a 2 after tpa 2 2/19/10 CVA right hemisphere Neuro Pharmacist Notes Outcome transferred to acute rehab then home 3/2/10 No bleed post tpa

10 Community Education Sudden numbness or weakness of the face, arm or leg especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headaches with no known cause F.A.S.T. Success Story Initial MD Evaluation - 3 minutes Stroke Team Notification - 4 minutes CT Scan Initiated - 6 minutes CT Scan Interpreted - 15 minutes Lab Results Received - 26 minutes rt-pa given - 55 minutes Outcome - NIHSS upon arrival-9, NIHSS at discharge-1, transferred to Acute Rehab and discharged home 2 weeks later.

TIME LOST IS BRAIN LOST. TARGET: STROKE CAMPAIGN MANUAL

TIME LOST IS BRAIN LOST. TARGET: STROKE CAMPAIGN MANUAL 2010, American Heart Association TARGET: STROKE CAMPAIGN MANUAL 01 INTRODUCTION Welcome to the Target: Stroke. The purpose of this manual is to provide