Stroke Systems of Care for Wyoming. David B Wheeler, MD, PhD, Director Primary Stroke Center at Wyoming Medical Center

Transcription

1 Stroke Systems of Care for Wyoming David B Wheeler, MD, PhD, Director Primary Stroke Center at Wyoming Medical Center

2 Disclosures Clinical Investigator Novartis (multiple sclerosis) UCB Biosciences (epilepsy) Medical Director Neurology, Wyoming Medical Center President Wyoming Neurologic Associates, LLC

3 The problem of stroke Fourth leading cause of death Leading cause of long-term disability Treatment is available but time is brain

4 The solution for stroke Primary prevention Acute treatment Systems of care improve both Stroke rates are decreasing Stroke survival is increasing Stroke disability is declining Improved public awareness Increased rates of thrombolysis

5 Primary Stroke Centers (PSC) Certified by The Joint Commission, HFAP, DNV Quality Assured by AHA: Get with the Guidelines State Agencies recognize and certify Wyoming passed legislation in 2013 for Stroke/AMI Many regions require EMS transport to certified facilities New category of Comprehensive Stroke Centers (CSC) Larger academic centers with large population bases

6 The Rural Conundrum >50% of Americans live >60 min from nearest PSC Rural hospitals see relatively few acute strokes How to maintain preparedness for acute stroke care?

7 Acute Stroke-Ready Hospital Brain Attack Coalition recommends new certification* ASRH certification to identify facilities capable of delivering high quality acute stroke care Will enhance regional systems of care and increase effective treatment rates Will further reduce morbidity and mortality Will reduce economic burden of stroke Will allow care delivery closer to home * Alberts, Mark J., et al. "Formation and function of acute stroke ready hospitals within a stroke system of care recommendations from the Brain Attack Coalition." Stroke (2013):

8 ASRH Care Elements Acute Stroke Team Stroke Protocols Emergency Medical Services Emergency Department Laboratory Testing Brain Imaging Emergent Therapies Stroke Unit Neurosurgical Services

9 Acute Stroke Team AST is an independent predictor of tpausage Minimum requirement is a Physician and a Nurse with Attendance of national conference on stroke care At least 4 hours/year acute stroke CME Telemedicine access to stroke expert if needed Team should be available and onsite or within 15 min from facility 24x7

10 Stroke Protocols Many studies show protocols dramatically increase treatment rates Standardized order sets that encompass all aspects of the acute stroke management process Should be developed by multidisciplinary team Reviewed and revised at least annually Covers all types of strokes

11 Emergency Medical Services EMS must recognize possible stroke Use field assessment tool e.g. Cincinnati Stroke Scale Communicate with receiving hospital Activate Acute Stroke Team Stabilize and transport to ASRH Bypass non-asrh facilities Written policies standardized across Stroke System Triage, Assessment, Treatment, Transportation

12 Emergency Department Standardized protocols and order sets Detailed instructions on use of tpa Protocol for reversal of anticoagulation Training and usage of NIH Stroke Scale Mock stroke codes for low volume facilities 4 hours/year CME in acute stroke care

13 Laboratory Testing Mandatory CBC, CMP, Coags, HCG, troponin, ESR Electrocardiogram Might be helpful Chest X-ray Tox screen, thyroid function, hypercoag panel Ability to report mandatory results within 45 minutes In most cases tpashould be given even if not resulted

14 Brain Imaging Non-contrast head CT is the gold standard Necessary to exclude hemorrhage or mass lesions In acute stroke usually negative or subtly abnormal MRI, CTA and CT perfusion helpful if available but should not delay tpa Should be interpreted and reported to treating physician within 45 minutes May be read by onsite provider, teleradiologyor telestroke Interpretation available 24x7

15 Emergent Therapies Maintain airway and stabilize vitals BP<185/110 if tpa considered IV tpastarted within 60 min of arrival Time window up to 3 hours from symptom onset 4.5 hours if <80, not diabetic, not on coumadin, no prior stroke Reverse anticoagulation in hemorrhagic strokes Reduce increased intracranial pressure Control seizures

16 Ongoing Care If tpanot given probably stays in home facility on stroke unit Telemetry, nursing care maps, protocol for establishing cause of stroke, algorithm for secondary stroke prevention If tpagiven should go to PSC/CSC Admission to ICU with neurology attending Neurosurgery available Established transfer agreements critical to Systems of Care for Stroke

17 Building an ASRH Full support of Hospital Administration is critical! Increased ED staffing Invest in Telestroke and Teleradiology Partnerships with PSC/CSC in the region Identify, support and compensate stroke team leaders Establish regular team meetings with peer review

18 Telestroke May be needed where neurologist is not regularly available Standard has been telephone consultation with on-call neurologist, but 2-way audio-video consultation improves adherence to treatment guidelines and increases tpa usage TeleConsultant should be available within 20 minutes Standards being established for quality of AV data with many different solutions available Requires established call schedules and compensation to on call consultants

19 Transfer Agreements Patient should leave ASRH within 2 hours Written transfer agreements with PSC/CSC Contact info, transportation plan, 24x7 availability Standards for care during transport Transport personnel should have stroke training Drip and ship is safe and effective for IV tpa Do not transfer if care is futile

20 Performance Metrics Brain Attack Coalition recommends >67% compliance for ASRH for: IV tpagiven to eligible patients NIHSS scoring done Time to first brain imaging Door to needle time for IV tpa Time to begin anticoag reversal Time to initiate TeleStroke link Time to initiate transfer to PSC/CSC

21 Certification Wyoming has a certification system that could recognize ASRH Expect TJC and AHA to develop guidelines

22 The ASRH in Wyoming ASRH is a critical component to our Stroke System of Care Will increase the probability that the patient gets the right care in the lest time possible Provides great opportunities to increase collaboration amongst facilities at all parts of the continuum from prevention to rehab