4th Annual New York Stroke Conference Maximizing Stroke Quality of Care: Key Ingredients

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1 4th Annual New York Stroke Conference Maximizing Stroke Quality of Care: Key Ingredients Thomas Kwiatkowski, MD Medical Director : Center for Emergency Medical Services NSLIJ No relevant financial relationships exist.

3 1. 3% % 3. Less than 1% 23% 29% 48% 1 2 3

4 1. Basilar artery occlusion 8 hours post onset 75% 2. Ischemic stroke 6 hours post onset with a significant clinical to infarct mismatch 3. Ischemic stroke with an INR of All of the Above 11% 8% 7%

5 minutes minutes minutes minutes 33% 48% 13% 7%

6 Introduction A two-tier tier system for management of acute strokes includes the Primary Stroke Center (PSC) and the Comprehensive Stroke Center (CSC). (CSC). The purpose of the CSC is to provide acute ischemic stroke (AIS) patients with advanced diagnostic and treatment procedures that are not available at a PSC, such as catheter based therapy (CBT). CBT consists of: local intra-arterial thrombolysis, mechanical thrombectomy and embolectomy Indications for transfer to a CSC for CBT include ischemic stroke patients with a major neurological deficit (NIH Stroke Scale 8) and: Who are not a candidate for IV tpa or who have not rapidly improved after IV tpa. Who are still within 6 hours of stroke symptoms onset and have a significant clinical to infarct mismatch. Who have basilar artery occlusion and a salvageable Brainstem. 6.00% 5.00% 4.00% 3.00% 2.00% I V t P A C B T 1.00% 0.00% C B T

The purpose of the CSC is to provide acute ischemic stroke (AIS) patients with advanced diagnostic and treatment procedures that are not available at a PSC, such as catheter based therapy (CBT).

8 The purpose of the Stroke Rescue Program is to improve the efficiency and safety of transportation of acute stroke patients from PSC to CSC. However, utilization of CBT remains poor: fewer than 1%of all AIS patients Inter-hospital transfer delayis a major contributor to the exclusion of otherwise eligible CBT candidates and is associated with poorer clinical outcome.

However, utilization of CBT remains poor: fewer than 1%of all AIS patients Inter-hospital

The Stroke Rescue Program would improve inter-facility transport time and result in a greater percentage of patients being eligible for CBT by: Improving EMS dispatch process and supervision

9 The Stroke Rescue Program would improve inter-facility transport time and result in a greater percentage of patients being eligible for CBT by: Improving EMS dispatch process and supervision Educational outreach to all personnel involved in patient referral and transport Organizing and dividing the transfer process into measurable time elements Reducing the time interval that EMS spends in the sending hospital

Educational outreach to all personnel involved in patient referral and transport Organizing and

The Stroke Rescue Programwas established in a large metropolitan health system to facilitate rapid transfer of AIS patients from regional (both health system (n=8) and non-system (n=4)) primary

The North Shore-LIJ Health System Center for Emergency Medical Services command and dispatch center Critical transport time elements were defined: 1) Transport 1 (Tr-1): PSC contact with CSC to EMS

10 The Stroke Rescue Programwas established in a large metropolitan health system to facilitate rapid transfer of AIS patients from regional (both health system (n=8) and non-system (n=4)) primary stroke centers (PSC) to the network s CSC, constituting the concept of a "stroke rescue". Figure 2. The North Shore-LIJ Health System Center for Emergency Medical Services command and dispatch center Critical transport time elements were defined: 1) Transport 1 (Tr-1): PSC contact with CSC to EMS arrival at PSC 2) ED Time: EMS PSC arrival to PSC departure 3) Transport 2 (Tr-2): EMS PSC departure to CSC arrival. Total transport time targetfrom hotline call received to patient arrival in the CSC emergency department was set at <60 min. Specific interventions implemented included: 1) A centralized transfer center and EMS dispatch center, with computer-aided dispatch system, MARVLIS 2) A dedicated stroke rescue hotline 3) An educational outreach program offered across disciplines, to instill "time is brain concept and to overcome referral barriers 4) 100% High Performance EMS training 5) Initiative to reduce time spent by EMS at the PSC 6) Live monitoring of transfers by EMS supervisors Patient Selection: All patients who underwent Stroke Rescue between January and June were included. Statistical Analysis: Variables such as transport time and distance were summarized as medians Categorical variables, such as number transported within total time of 60 minutes, were expressed as percentages. Comparison is made between transport times in Q (baseline quarter, n=21) and Q (the most recent quarter, n=31) Non-parametric Mann-Whitney U-Test was used to test for significance, with the significance level set at 0.05.

11 A total of 128 patients underwent a Stroke Rescue during the study period. Ischemic stroke was confirmed in 116 (91%) patients and 65 (51%) patients were drip and ship transports. Median PSC to CSC distancewas 14.4 miles (range 3.0 to 32.1 miles) and median total transport time for the entire cohort was 48 minutes.

drip and ship transports. Median PSC to CSC distancewas 14.4 miles (range 3.

12 Median ED Time was 23 minutes before the study intervention versus 14 minutes after the intervention (U = 171, p <.01, r =.40). See Figure 3. Median Total Transport Time was 56 minutes before and 44 minutes after initiation of the Stroke Rescue Program transport initiative. (U = 199 p <.05, r =.33). See Figure 4. Percent Transported Within 60 min increased from 57% in Q to 81% in Q See Figure 5. Figure 3. Comparing Median ED Time between Q and Q shows a statistically significant decrease in the time EMS spends in the referring ED. Figure 4. Comparing Median Total Transport Time in Q and Q2 2011, there was a statistically significant decrease. Figure 5. Comparison between Q and Q showing increased percentage of patients transported to CSC within the goal of 60 minutes (not statistically significant).

Percent Transported Within 60 min increased from 57% in Q1 2010 to 81% in Q2 2011. See Figure 5. Figure 3.

13 The intervention yielded an increase in the percentage of patients being transferred within the 60 minute transport goal to 80%. Unnecessarily prolonged paramedic stay in the transferring facility ED directly contributes to transfer delay. Reducing time spent by EMS retrieving clinical information, increasing physician to physician phone-based transfer of relevant patient information, and discontinuing unnecessary intravenous medications all reduce EMS time in the PSC emergency department. Post-intervention there was a statistically significant decrease in the median time spent by EMS in the referring ED that translated into a statistically significant decrease in the median total transport time for AIS patients from a PSC to a CSC.

Reducing time spent by EMS retrieving clinical information, increasing physician to physician phone-based transfer of relevant patient information, and discontinuing unnecessary

14 Other aspects of the intervention that may have contributed to overall improved time include development of a centralized and specialized EMS dispatching system, a stroke hotline number and transfer center, outreach to referring PSC personnel, and high performance EMS training Previous studies on inter-facility transfer delay have been limited to: a) direct transfer of patients from the field to a CSC, and b) avoidance of imaging studies at the PSC. Limitations of our study include a) small sample size and need for a larger, multi-center study and b) inability to specifically identify which recommendations within our intervention had the greatest impact on the study findings Further investigation is needed to determine whether improved stroke network efficiency translates into a higher frequency of CBT and better clinical outcomes. The Stroke Rescue Program is a simple, innovative and effective solution to minimize transfer delay and total transport time by reducing ED time and effectively increasing the percent transported within a transfer time goal of less than 60 minutes.

a CSC, and b) avoidance of imaging studies at the PSC.

15 Adeoye O, et al. Recombinant Tissue Type Plasminogen Activator Use for Ischemic Stroke in the United States: A Doubling of Treatment Rates Over the Course of 5 Years. Stroke. 2011; 42: Alberts M, et al. Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition. Stroke. 2005;36: de la Ossa P, et al. Influence of direct admission to Comprehensive Stroke Centers on the outcome of acute stroke patients treated with intravenous thrombolysis. J Neurol. 2009; 256: Demaerschalk, B. Seamless Integrated Stroke Telemedicine Systems of Care A Potential Solution for Acute Stroke Care Delivery Delays and Inefficiencies. Stroke. 2011; 42: Evenson K, et al. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. International Journal of Stroke. 2009, 4: Gladstone D, et al. A Citywide Prehospital Protocol Increases Access to Stroke Thrombolysis in Toronto. Stroke. 2009;40: Khatri P, et al. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 2009;73: Kleindorfer D. National US Estimates of Recombinant Tissue Plasminogen Activator Use ICD-9 Codes Substantially Underestimate. Stroke. 2008;39: Leifer D, et al. Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations. Stroke. 2011;42: Nedeltchev K et al. Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis. Stroke. 2003;34: Pfefferkorn T, et al. Drip, Ship, and Retrieve: Cooperative Recanalization Therapy in Acute Basilar Artery Occlusion. Stroke. 2010;41: Prabhakaran S, et al. Transfer Delay Is a Major Factor Limiting the Use of Intra-Arterial Treatment in Acute Ischemic Stroke. Stroke. 2011; 42: Rymer M, et al. Expanded Modes of Tissue Plasminogen Activator Delivery in a Comprehensive Stroke Center Increases Regional Acute Stroke Interventions. Stroke. 2003;34:e58-e60. Saler M,et al. Use of Telemedicine and Helicopter Transport to Improve Stroke Care in Remote Locations. Current Treatment Options in Cardiovascular Medicine. 2011; 13: Saver J. Time Is Brain Quantified. Stroke. 2006;37: Schwamm L et al. Recommendations for the Establishment of Stroke Systems of Care. Recommendations From the American Stroke Association s Task Force on the Development of Stroke Systems. Circulation. 2005;111:

Influence of direct admission to Comprehensive Stroke Centers on the outcome of acute stroke patients treated with intravenous thrombolysis. J Neurol. 2009; 256:1270 1276. Demaerschalk, B.

Stroke Systems of Care

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 Stroke chain of survival