Door-to-NeedleTimesPuttingAlbertaontheWorldStage

EricE.Smith,MD,MPHAssociateProfessorofNeurologyDept ofClinicalNeurosciences

HotchkissBrainInstituteUniversityofCalgary

September23,2016

DISCLOSURES• GrantfundingfromNINDS,HeartandStrokeFoundationof

Canada,CanadianStrokeNetwork,AlbertaInnovates-HealthSolutions,AlzheimerSocietyofCanada.

• Co-Investigator(nosalary)ofESCAPEtrail,co-fundedbyCovidien.DSMBforMRWitnessStudy(MassGeneralHospital).

• VolunteermemberofAmericanHeartAssociationGetWithTheGuidelinesandTarget:Stroke ExecutiveCommittees.

• Co-chairofCanadianBestPracticeRecommendationsforStroke.

Outline

• DoortoneedletimesintheUSA:updateontheAHATarget:Stroke II

• SurveyofDTNpracticesatU.S.hospitals• BestDTNpracticesatFMC:whatworked,andhowmuchtimedidwesave?

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2002 2004 2006 2008 2010 2012 2014 2016

DN

T

Year

Median Door to Needle

GWTG-Stroke SITS

AmericanHeartAssociationTarget:Stroke

•Launched2010.•Interventions:disseminatedbestpractices,decisionsupporttools,awardrecognition.

•PhaseI(2010-2013):DTN<60minutesin≥50%.

•PhaseII(2013-2015):DTNtimes≤60in≥75%andDTN≤45in≥50%)

Fonarow GC,SmithEE,SaverJL,etal.Improvingdoor-to-needletimesinacuteischemicstroke:thedesignandrationalefortheAmericanHeartAssociation/AmericanStrokeAssociation'sTarget:Strokeinitiative.

Stroke2011;42:2983-2989.

6

Time Trend in the Proportion of Patients with DTN Times within 60 Minutes Pre- and Post-Target: Stroke

(P<0.0001 for comparison of the two slopes)

Target:StrokePhase

TimePeriod(peryear)

Yearly %increase(95%CI)

P-value

<.0001

Pre-Target:Stroke0.94(0.53,1.35) <.0001

Target:StrokePhaseI 5.33(4.84,5.83) <.0001

Target:StrokePhaseII 9.43(3.87,15.00) 0.0018

FonarowGC…SmithEE,…SchwammLH.ISC2016

Circulation:Cardiovascular QualityandOutcomes,Sept2016

USAvs.Canada

57minutes 36minutes

10

Target:StrokeSurveyofBestPractices

888hospitalstreating16,901ischemicstrokepatientswithIVtPAwithin4.5hoursofsymptomonsetbetweenJune2014andApril2015

XianY,…SmithEE,..Fonarow,GC.Underreview

Characteristic Participating Hospitals n=888

(%)

No of beds, median (IQR) 308 (201 - 446)

Annual ischemic stroke volume,

median (IQR)

174 (116 - 258)

Annual tPA volume, median (IQR) 14 (9 - 24)

Teaching hospital 432 (51.7)

Primary stroke center 360 (40.5)

Comprehensive stroke center 65 (7.3)

FrequencyofBestPractices

Strategy Hospital Use of Strategy Unadjusted

Differences in DTN Times (95% CI)

Adjusted

Differences in DTN Times (95% CI)

P values for

Adjusted Differences

Strategy (0-100% of the time) % of the time Per 20% increase

Median (IQR) Mean (SD)

EMS prehospital stroke screening tool 95 (75-100) 80 (29) -1.0 (-1.6, -0.3) -0.9 (-1.5, -0.2) 0.008

EMS triage to primary or comprehensive stroke

center

100 (85-100) 83 (30) -0.3 (-1.0, 0.4) -0.3 (-1.0, 0.4) 0.38

Advanced hospital notification by EMS 95 (75-100) 83 (25) -0.7 (-1.4, 0.1) -0.5 (-1.3, 0.3) 0.30

Rapid triage protocol and stroke team

notification

100 (90-100) 91 (17) -2.6 (-4.0, -1.3) -2.5 (-3.9, -1.2) <0.001

Single-call activation system 100 (100-100) 91 (26) -1.1 (-1.9, -0.3) -1.1 (-1.9, -0.3) 0.006

A timer or clock attached to a chart, clip

board, or patient’s bed to track time

0 (0-5) 20 (37) -0.6 (-1.1, 0.0) -0.6 (-1.2, -0.0) 0.04

Transport of patients by EMS directly to the

CT/MRI scanner

40 (0-95) 46 (43) -0.8 (-1.2, -0.3) -0.7 (-1.1, -0.2) 0.005

SurveyResponsesandDoortoNeedleTimes

Strategy Hospital Use of Strategy Unadjusted

Differences in DTN Times (95% CI)

Adjusted

Differences in DTN Times (95% CI)

P values for

Adjusted Differences

Written informed consent is not

required prior to tPA administration100 (25-100) 72 (42) -0.8 (-1.3, -0.3) -0.8 (-1.3, -0.3) 0.001

INR and platelet results are not

required prior to tPA administration80 (10-100) 60 (40) -1.2 (-1.7, -0.8) -1.2 (-1.6, -0.7) <0.001

Interpretation of brain imaging is

performed immediately by stroke team members

95 (15-100) 68 (42) -1.7 (-2.2, -1.3) -1.6 (-2.0, -1.1) <0.001

Treatment decision made by

neurologist attending or trainee after in-person evaluation

75 (20-100) 61 (39) -1.5 (-1.9, -1.0) -1.2 (-1.7, -0.7) <0.001

Treatment decision made by neurologist

attending or trainee after telephone only

evaluation

25 (0-75) 38 (39) 0.4 (-0.2, 0.9) 0.3 (-0.3, 0.8) 0.31

Treatment decision made by ED physician,

without input from neurologist or trainee0 (0-10) 13 (27) 0.1 (-0.6, 0.8) 0.0 (-0.6, 0.8) 0.87

Trainees (residents, fellows) are

involved in the stroke team and perform the initial assessment

0 (0-100) 39 (45) -1.1 (-1.6, -0.6) -1.1 (-1.5, -0.6) <0.001

Pre-mix of tPA ahead of time 25 (0-90) 41 (41) -1.2 (-1.7, -0.7) -1.1 (-1.6, -0.7) <0.001

SurveyResponsesandDoortoNeedleTimes

SurveyResponsesandDoortoNeedleTimes

Strategy Hospital Use of Strategy

Unadjusted Differences in

DTN Times

(95% CI)

Adjusted Differences in

DTN Times

(95% CI)

P values for

Adjusted

Differences

Prompt patient-specific data feedback to the ED staff and stroke team

95 (70-100) 79 (30) -1.7 (-2.3, -1.0) -1.6 (-2.3, -1.0) <0.001

Prompt patient-specific data feedback to EMS providers

60 (15-95) 56 (38) -1.2 (-1.7, -0.7) -1.0 (-1.5, -0.5) <0.001

Whenall16significantDTNstrategieswereanalyzed incrementally,hospitalsadoptingagreaternumberofstrategiestendedtohaveshorterDTNtimes.Onaverage,1.3minutes(95%CI1.0-1.6)couldbesavedforeachstrategyimplemented,oratotalof20minutes(95%confidenceintervals15-25minutes)ifallstrategieswereuse

SurveyResponsesandDoortoNeedleTimes

SurveyResponsesandDoortoNeedleTimes

WhatWorkedatFMC?

• 350consecutiveeligiblepatientstreatedwithalteplase duringtheHASTEproject(June62012toJune292015).

•Meanagewas71.6(SD16.35),48.3%werewomen

•MedianNIHSSwas13.

NoreenKamal,PhDPEng1;Jessalyn K.Holodinsky,MSc2;CarolineStephenson,RN3;Devika Kashayp,BA4;AndrewMDemchuk,MDFRCPC1,3,5;MichaelDHill,MD1,3,5;ReneeL.Vilneff BNSc MNRN5,ErinBugbee,BScNRN4;CharlotteZerna,MDMSc3;NancyNewcommon,RNMNNP;3EddyLang,MD4;DarrenKnox,PT3;EricE.Smith,MDMPH1,3,6

HASTEIn(%)

June62012toJune52013

HASTEIIn(%)

June62013toJanuary242015

HASTEIIIn(%)

January252015to June292015

Locationtreatmentadministered

StrokeUnit 44(46.8) 20(9.4) 1(2.3)EDBay 44(46.8) 134(62.9) 22(51.1)CT/Imagingarea 0(0) 48(22.5) 15(34.9)Angiosuite 0(0) 2(0.9) 0(0)UTD 6(6.4) 9(4.2) 5(11.6)

StretchertoCTYes 0(0) 0(0) 24(55.8)No 94(100.0) 213(100.0) 19(44.2)

PatientRegisteredasunknown

Yes 7(7.4) 99(46.5) 25(58.1)No 84(89.4) 107(50.2) 17(39.5)UTD 3(3.2) 7(3.3) 1(2.4)

STATStrokePageYes 0(0) 110(51.6) 26(60.5)No 94(100.0) 102(47.9) 17(39.5)UTD 0(0) 1(0.5) 0(0)

HASTEInterventions

Independent

Variable N

%

Decrease

inDNT

95%

Confidence

Interval

p-valueMeanDecreasein

DNT(mins)*

HASTEPhases

HASTEI 94 Reference - -

HASTEII 213 16 6to25 0.003 9

HASTEIII 43 31 18to42 <0.001 19

LowerDoortoNeedleTimesinPhaseIIandIII

IndependentVariable

UnivariableAnalysis

MultivariableAnalysis

N MedianDNT(min)

p-value%

DecreaseinDNT

95%ConfidenceInterval

p-value

MeanDecreaseinDNT(mins)*

LocationtreatmentAdministered

StrokeUnit 65 62 -30 -47to-15 <0.001 -18EDBay 200 47 0.0001 Reference - - -CT/Imagingarea 63 29 32 23to39 <0.001 19

StretchertoCT Yes 24 28 <0.0001 30 16to42 <0.001 18No 325 48

PatientRegisteredasunknown

Yes 132 40 <0.0001 12 3to20 0.013 7No 208 53

STATStrokepage

Yes 136 40 <0.0001 11 1to20 0.032 6No 213 51

EstimatedEffectofIndividualHASTEInterventions

ThankYouEDErinBugbeeSudhir PandyaErinHendersonSharonHolowachukGordonSzolEddyLangKathyDorringtonDevika Kashyap

EMSReneeVilneffDanaDalgarno

DIMelissaKearnsRoyPool

AdmittingLenoreDemeterJaniceCarnevaleErinSymcox

Unit112representationErinSymcoxShantelHunterShellyBohn

StrokeTeam/QUICREricSmithMichaelHillAndrewDemchukCharlotteZernaNancyNewcommonCarolineStephensonNoreenKamal