Stroke Systems of Care

Transcription

1 Stroke Systems of Care Ashutosh P. Jadhav, MD PhD Assistant Professor, Neurology and Neurological Surgery Center for Neuro-endovascular Therapy UPMC Stroke Institute Pittsburgh, PA

2 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab 1. Emergency medical services (EMS) 2. Hospital care 3. Discharge 4. Rehabilitation - Reducing stroke deaths by 2-3% per years 20,000 fewer deaths in the US alone

3 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab Public awareness campaigns: - Vulnerable populations (female, minority, low socio-economic status) - Atypical symptoms or language impairment

4 Detection to Dispatch Ann Neurol 2008;63:

5 Detection to Dispatch Ann Neurol 2008;63:

6 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab 1. Increased patient awareness 2. Direct in-field triage modified stroke scale 3. Remote assessment (telemedicine) 4. Mobile stroke unit portable CT scanner 5. Thrombolysis screen 6. Neuroprotection

7 safe feasible

8 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab Improving treatments now available for both hemorrhagic and ischemic stroke but: 1. Treatments are often ultra time sensitive 2. Need advanced medical center multi-disciplinary infrastructure

9 First medical contact to treatment Sx Onset Balance: - Inefficient transfer: long delays lead to less likelihood to receive advanced therapy or less likely to benefit ASRH PSC ECC CSC - Futile transfer: resource utilization (direct financial costs, indirect opportunity costs)

10 Overall Workflow for Telemedicine Consults in 2014 Time interval N Min (med) Onset to ED ED to CT Telemedicine to tpa (68% received) Tpa to Depart Door in to Door out Door in to Hub arrival Jadhav et al (unpublished)

11 Restructuring Workflow Current: Serial Suspected stroke patient is traiged to ED patient room After ED physician evaluation, patient is transported to CT scanner CT scan is obtained and if no blood is noted, ED physician contacts stroke specialist via operator Stroke specialist obtains history from ED physician and reviews CT head. Decision is made to initiate telemedicine consult. Telemedicine connection is established Proposed: Parallel Suspected stroke patient is triaged to CT scanner Telemedicine connection is established. Video consult: NIHSS Video consult: history/review labs Decision to administer IV tpa is made ED physician contacts stroke specialist via operator CT scan is reviewed in real time and decision is made to proceed with telemed consult. If NIHSS is disabling: pharmacy activated. If NIHSS >= 8: transport activated Video consult: history/review labs IV tpa is mixed and initiated. Transport arrives Video consult: NIHSS Decision to administer IV tpa is made Patient departs referral facility Pharmacy activated IV tpa is mixed and initiated. Decision to transfer patient is made Transport activated Transport arrives bedside Patient departs referral facility

12 Clinical Vignette #1 39 year old woman with a history of HTN, tobacco use and prior DVT developed sudden onset of right gaze preference and left side weakness. EMS arrives on scene and sends pre-hospital page while en route. What next? Clear scanner? Notify pharmacy? Activate Neuro-cath lab.

13 Clinical Vignette #1 On-call stroke attending (Jovin) activates in-house stroke team and on-call neuro-cath team based on page. In-house stroke attending (Aghaebrahim) meets patient in ED and takes patients directly to scanner. Neuro-cath lab has been activated (Ducruet). CT head reveals no hemorrhage but CTA head/neck reveals right ICA terminus occlusion. NIHSS 10. What next? IV tpa and wait for improvement? IV tpa en route to angio-suite? Skip IV tpa, straight to angio-suite?

14 Last seen well ED arrival CT head Angio suite IV tpa Access Recanalization 102 mins 1 min 33 mins 17 mins 6 mins 22 mins Process Symptom-CT: 103 minutes Picture-Puncture: 56 minutes Puncture-Treatment: 22 minutes Discharged home day 4 with NIHSS 2

15 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab Overall goal: - minimize first medical contact to final reperfusion time Requires: - Performance measurement ( Hawthorne effect) - Feedback - Quality initiatives

16 Good outcomes are time dependent IV tpa IA therapy Marler et al, Neurology 2000 Khatri et al, Neurology 2009

17 Interdisciplinary care of stroke Detection Dispatch Delivery Door Data Decision Drug Patient awareness EMS Prehospital notification ED triage Evaluation: NIHSS, labs, CT Best treatment Door to needle time < 60 min

18 Strategies to reduce DTN - advance hospital notification by EMS - rapid triage protocol and stroke team notification - single-call activation system - access to stroke expertise rapid acquisition and interpretation of brain imaging - rapid laboratory testing (including point-of-care testing if indicated) - tpa administration protocols - mix tpa medication ahead of time - rapid access to intravenous tpa - team-based approach - prompt data feedback

19 Strategies to reduce DTN - rapid triage protocol with stroke team notification 8.1 minutes - single-call activation system all the time 4.3 minutes - tpa being stored in ED 3.5 minutes minutes could be saved for each strategy implemented

20 Additional strategies - Direct transfer from transport to scanner - Minimize additional labs (INR, platelets may be deferred in many patients) - Real time interpretation of CT scan - Consent (can be deferred if patient not competent or LAR not reachable)

21 Door to CT time

22 Direct transfer to angiosuite - Jan 2013 to July 2015: review of 379 patients undergoing endovascular therapy - 8.9% were triage directly from helipad to the angio-suite - Mean door to puncture time: 21.1 minutes Kenmuir et al (submitted)

23 Stroke Emergency Room? - Fast track suspected stroke patients to a specialized ED with direct access to: specialized neuro nursing, CT scanner, IV tpa and neuro-cath lab

24 Quality of Performance Metrics

25 In-house stroke patients with community-onset stroke vs 973 in-house strokes ( ) 1. in-hospital stroke had more stroke risk factors and comorbid illness, greater severity of their stroke, and poorer outcomes, particularly in terms of length of stay and disability 2. Symptoms onset to neuroimaging: 4.5 hours for in-hospital stroke, compared with 1.2 hours for community-onset stroke 3. median time of IV tpa delivery was longer, at 2 vs 1.2 hours from door or symptom recognition

26 Clinical Vignette #2 59 year old man who presented with NSTEMI and heart failure in the setting of RCA occlusion requiring CABG and valve repair. After extubation: NIHSS 16 (1 LOCC, 2 VF, 2 gaze, 4 LLE, 4 LUE, 1 sensation, 2 neglect). What next? Tpa? Additional imaging? Thrombectomy?

27 Clinical Vignette #2 CT head obtained on angio table: No hemorrhage DSA reveals right M1 occlusion and favorable collaterals.

28 Clinical Vignette #2 Last seen well Symptoms Angio suite CT head Access Recanalization 9.5 hours 50 minutes 20 minutes 5 minutes 30 minutes Dual energy CT Process Symptom-CT: 70 minutes Picture-Puncture: 5 minutes Puncture-Treatment: 30 minutes

29 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab 1. Establish guidelines 2. Address treatment gap: Local and national stroke quality improvement program to address this treatment gap. Risk factors of mortality and morbidity - Non-modifiable (stroke severity, age, pre-morbid status) - Modifiable

30 Stroke size and complications Streib et al (submitted)

31 Complications after stroke Kumar et al (Lancet Neurology, 2010)

32 Schwamm et al (Stroke, 2009)

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34 Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab Enhancing recovery? Rehab versus SNF

35 1:1 randomization of patients 5-10 days post stroke (NIHSS < 20) to 20 mg fluoxetine vs placebo Enhancing recovery

36 Disposition and outcomes

37 Stroke size and cost: each additional 1cc of infarcted brain tissue increased hospitalization cost by $ Streib et al (submitted)

38 Achieving good outcomes after ischemic stroke Early detection Good collaterals - Permissive hypertension Minimize core expansion - neuroprotection Patient selection - Small core on presentation Short time to recanalization Minimize post stroke complications - Hemorrhagic transformation - DVT - Infection Small Final Infarct Volume Opitimize Rehab - Young age - IRF vs. SNF - neurostimulant High quality recanalization - TICI 2b/3 Good outcome

39 Summary 1. Multiple steps are necessary to optimize good outcomes 2. Failure at any particular step can impact eventual outcome 3. Emergency services are increasingly adopting cardiac and trauma model 4. In-hospital process should tailored for various types of presentation - Direct front door admission - Transfer - In-house stroke 5. Tracking outcomes and quality metrics with feedback and quality initiatives is necessary to improve current process 6. Minimizing post stroke complications and maximizing early rehabilitation are critical steps.