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 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
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
Detection to Dispatch Ann Neurol 2008;63:466 472
Detection to Dispatch Ann Neurol 2008;63:466 472
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
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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
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)
Overall Workflow for Telemedicine Consults in 2014 Time interval N Min (med) Onset to ED 95 80 ED to CT 99 18 Telemedicine to tpa (68% received) 60 32 Tpa to Depart 22 44 Door in to Door out 31 118 Door in to Hub arrival 100 161 Jadhav et al (unpublished)
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
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.
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?
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
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
Good outcomes are time dependent IV tpa IA therapy Marler et al, Neurology 2000 Khatri et al, Neurology 2009
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
Strategies to reduce DTN - advance hospital notification by EMS - rapid triage protocol and stroke team notification - single-call activation system - access to stroke expertise 24 7 - 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
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 - 1.3 minutes could be saved for each strategy implemented
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)
Door to CT time
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)
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
Quality of Performance Metrics
In-house stroke 28 837 patients with community-onset stroke vs 973 in-house strokes (2003-2012) 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
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?
Clinical Vignette #2 CT head obtained on angio table: No hemorrhage DSA reveals right M1 occlusion and favorable collaterals.
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
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
Stroke size and complications Streib et al (submitted)
Complications after stroke Kumar et al (Lancet Neurology, 2010)
Schwamm et al (Stroke, 2009)
Stroke chain of survival Early Recognition EMS evaluation Triage Reperfusion therapy Early advanced care Aggressive rehab Enhancing recovery? Rehab versus SNF
1:1 randomization of patients 5-10 days post stroke (NIHSS < 20) to 20 mg fluoxetine vs placebo Enhancing recovery
Disposition and outcomes
Stroke size and cost: each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Streib et al (submitted)
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
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.