implementing pathway for neuro- intervention in hyper acute stroke for clinical and research dr....
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Implementing pathway for Neuro-intervention in
Hyper acute Stroke for Clinical and Research
Dr. Indira NatarajanConsultant Stroke Physician
Clinical Lead for Acute Stroke TIA ServicesUniversity Hospital of North StaffordshireClinical Lead for Stroke – Heart and Stroke
NetworkShrosphire and Staffordshire
UK National Stroke Strategy
There may be a role for interventional neuroradiology in the management of basilar thrombosis. Patients should have access to a stroke service with neuro-interventional capacity.
A network approach may be required to develop an agreed protocol, so that each stroke unit is linked to a regional neurosciences centre for emergency review of local brain imaging- for example by electronic link- and emergency transport (and then repatriation) of appropriate patients.
Strategic Health Authorities, through specialised commissioning arrangements, to support the co-ordination of the availability of specialist neuro-intensivist care including interventional neuroradiology and neurosurgery expertise….
DH National Stroke Strategy 2007, page 32.
BASP CS views
There is a need for RCTs of endovascular treatments and UK stroke services should recruit patients to such trials once they are open.
Endovascular treatments should not be offered routinely until evidence from RCTs is available
Until such evidence is available treatment should be on a case by case basis guided by agreed treatment and referral pathways
EVT should only be given in centres with agreed pathways and protocols including A&E, the stroke service, neuro-interventionalist, ITU and speciality nurses
Participation in national register/ International registers
Centres participating in RCTs will have to have experience in the procedure before enrolling patients.
UHNS Acute Stroke Unit (ASU) 2001 to 2010 Outcome/Results
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
Death
Ongoing Care
Home
Integrated working 32 Beds
39 Beds24 Beds
Where are we?
Regional Thrombolysis rota for 24/ 7 cover across the region
( Feb 2011)
Telemedicine ( April 2012)
Until 2010 No clear Neuro- interventional pathway
December 2009 75 year old gentleman Recent cervical spine surgery 4 months ago Admitted with collapse and found unconscious GCS 4/15 Intubated and ventilated No reversible pathology Atrial fibrillation CT brain Normal study
First encounter……..
Cervical Halo
Discussion with Orthopaedic Surgeon/ Neuro-radiologist
Agreed for Intravenous and intra-arterial Anaesthetist arranged Whole episode was chaotic Since no clear pathway - theatre team difficult to co-
ordinate ODA had to be pulled off from Neuro-surgical theatre Significant amount of time lost from arrival of patient
to A and E and before procedure commenced
Basilar occlusion on CTA
Time is Brain……
Pathway for ischaemic stroke treated with r t-PA?
999
Triaged in A and E
Within 3 - 4.5 Hrs
Neuro-interventional pathway
999
Time is Brain
The Team
1 Radigrapher1 Nurse
Anaesthetist / ODA
Stroke Physician
Interventional Neurorradiologist
Age<75 Previously fit and well Working hours (out of hours if interventional
neuroradiologist available)
Agreed patient group…
Radiology / Neuroradiology Anaesthetics/ ITU Neurosurgery Emergency Medicine
Teams that we engaged
Yellow sheet for Stroke patients CT brain and CT angiogram as agreed
protocol
Radiology protocol
CT head scan
Order a non-contrast CT head immediately after arrival (urgent e.g. within 1 hour) for all strokes.
[label form ACUTE STROKE call 4042 (daytime) or on call radiologist (nights, weekends and holidays)].
Thrombolysis candidates and patients on warfarin must be scanned immediately (within 15 min)
Order a CT angiogram (arch to Circle of Willis) if <75 y and no
contraindications to contrast and within < 8 h of onset and no haemorrhage and no signs of established
infarction on the CT head scan.
Neuro-radiologist / Stroke Physician alerted when
CT angiogram findings which suggests need for IA intervention
Carotid T occlusion (intracranial carotid bifurcation occlusion with involvement of A1 and M1 segments)
M1 (trunk of the MCA) or M2 (MCA branch in Sylvian fissure) occlusion
Vertebro- basilar thrombosis
Emergency theatres prioritisation codes
E1 Immediate transfer to theatre E2 Within 6 hours E3 Within 12 hours E4 Urgent, but timing not critical
To get a Standard Operation Pathway
agreed for Stroke as E 1
Potential indications for EVT
Primary intra-arterial thrombolysis Severe disabling neurological deficit and Contraindications to iv thrombolysis (e.g. recent surgery), 3-6 h from symptom onset
Intravenous/ Intra-arterial /EVTSevere disabling neurological deficit and Large vessel occlusion in MCA
Brain stem strokeTreatment can be delivered within 9 h of symptom onset and Occlusion of basilar artery documented on 4-vessel angiography Eligible even if consciousness impaired and or patient ventilated
Consent Sheets form 1 / form 4 Patient information sheet Theatre check list IA log Nursing pathway for Intervention
Key paperworks……
Time CT angio
IV alteplase given Y / N
Time of IV alteplase bolus
Consent/assent signed Y / N
Time of last micturition(offer bottle & conveen)
Arrival time in cathlab
Anaesthesia GA / LA
Start time of GA/LA
Time of femoral puncture = start of procedure
Start time catheter angio
Catheter used for angio
IA lysis done Y / N
Catheter used for IA lysis
Time of IA catheter at clot
Time first dose of IA tPA
Time last dose of IA tPA
Total dose of IA tPA
Total dose of IV & IA tPA
Mechanical Thrombectomy Y / N
Device used for MT
Stat time of MT
No of attempts of MT
Time of clot capture
Time of final catheter angio = end of procedure
Time of post procedure CT (after final angio)
Time out of cathlab
Arrival time in stroke unit
Potential patient for IAT/MT identified Fit for GA/ thrombectomy Previously independent NIHSS>=10 or basilar artery thrombus No bleed or sub acute infarct on CT head CTA shows large vessel occlusion (ICA/M1/M2/
VA/BA/ PCA)
Suitable patient
Start iv lysis while waiting for theatre. Give 0.6 mg /kg alteplase (bolus and infusion) iv unless iv lysis is contraindicated (recent surgery, post-partum). Leave 0.3mg/kg (max 30 mg) for i.a. lysis.
Do CT head immediately post procedure and after 24 h. Stay with patient until awake and settled on stroke unit. Ensure patients is monitored according to the IAT nurse
pathway.
Lysis Protocol
Pathway in action…. Keep next of kin on site for consent /queries or establish contact
route Clinician (stroke physician / A&E doctor) to get an anaesthetist
STAT: neuro-anaesthetist, if possible, otherwise on call: contact via switch
Clinician (Stroke physician / A&E doctor) to inform ODA Out of hours Arrange for an anaesthetist – go to online services /
rota watch / on call anaesthetist – bleep 3rd on call Radiologist to get radiographer and scrub nurse for the
procedure. Set up operating trolley and equipment immediately. Inform Stroke Unit for arranging a bed – Stroke team
(A&E staff/ stroke team/ neurointerventionalist) Discuss procedure Complete consent form Complete theatre checklist (inside the consent
form) Put patient into a theatre gown Offer bottle or catheterize Put in IA line (in A&E or theatre) Transfer to neuro-interventnional theatre
Prepare the patient
Start the intra-arterial intervention log Theatre team to move patient onto the intervention table Theatre team to cover patient with sterile sheets Anaesthetist and ODA to commence local/ general anaesthesia Neuroradiologist or scrub nurse to clean/ disinfect groin.
Prepare for intervention
Complete intra-arterial intervention log Remove catheter/ intra-arterial line Liaise with ASU to alert team about patient transferGet a bed tracked to the intervention suite to transfer patient to ASU Patients who were ventilated before the procedure may need ITU/MIU.
During / After Intervention
Devised protocols through our Heart and Stroke Network for regional DGH’s
Clear pathway for in hours and out of hours Drip and Ship with escort We have accepted patients outside our
region on occasions
Regional referral protocols….
Trust
Commissioning
Costing
Getting all the teams together
Barriers…..
Media – Not a good idea
Pioneering stroke drugs saved PatientThis is Staffordshire
FATHER-OF-FOUR owes his life to being at the right place at the right time after suffering a massive stroke
.The attack was severe enough to give him just a 20 per cent chance of surviving.
•
Tuesday, February 09, 2010
Consumables overall £ 1600 Device cost ranges roughly around £ 4000 ( prices can be negotiated depending upon trusts) Average use of devices is around 1.5 (from our
experience of 50 cases) Out of hours theatre staff cost £ 500 ---------------------------------------------------------------------------------
------------ Overall rough cost estimate is around £ 6100
Costings……
Hospital Care Basic bed day in Stroke unit: £ 170 /day With added costs : £ 350/ day Patients with mRs 4 and 5 average LoS: 90 days Cost for 90 days: £ 31,500
Social / Residential care: mRS 5 : £550 / week ( £ 28,600/ year) mRS 4: £ 400 - £ 450 /week ( £ 20,800 - £ 23,400/year) mRs 3: ( if care required) : £ 300/week ( £ 15,600/year)
Cost for Post Stroke Care
Funding
Primary Care Trust 2NHS 2Stroke Network 1Stroke Fund 1Intervention Fund 1Neuroscience Department 1Geriatric Medicine 1Under discussion 1
Percutaneous trans-luminal embolectomy / thrombectomy of artery:
L 712 HRG - QZ15 A - Major complication with co-
morbidities £ 9554 HRG – Q Z15B – Minor complications £ 5098 HRG – QZ15 C – No complications £3731 On top for Alteplase: you get another 800£
HRG Coding
24/ 7 Sustainability Reliant on key individuals Job Plan Integrated pathway agreement with other
centres Need to demonstrate quality before taking
part in Research trials
Challenges
Centres in the UK
> 1 per month 5 – 10 / 10 months
Frequency of endovascular treatments for acute ischaemic stroke in active centres in 2010
Number of centres
0 4
1-4(1 every 3 mo or less)
8
5-9(one every other month)
5
>=10 6
Capacity, organisation, and quality control ( Nationally)
23 active centres
71 interventional Neuroradiologists in the UK in 2010
46% of centres not providing EVT had no procedures for referral to centres providing such treatments.
56% of centres providing EVT entered patients into the SITS register
56% of centres providing EVT entered patients into the SINAP
Type of Approach
Thrombolysis pathway Neuro-interventional pathway
Newer interventions needs newer pathway Part of expansion of Neurosciences Units Part of the Clinical Research activity
One needs to start somewhere………………..
In Summary
http://www.stroke-in-stoke.info/
You can look at our: Pathway Patient Information leaflet Procedure log Nurse pathway Protocols Data entry file – We are happy to support data
Resources
Prof Christine Roffe Dr. Sanjeev Nayak All the Neuro-interventional team /
Anaesthetic team/ ITU team / Stroke team/ Exec Board
Acknowledgements….