KPNC Stroke EXPRESSEXpediting the PRocess of Evaluating & Stopping Stroke

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Jeffrey G. Klingman, MD

Disclosures

None

75% DTN < 6050% DTN < 45

Why should we care about DTN?: Time is brain

2 million nerve cells die per minute For every 15 minutes faster time:More go home Fewer die Fewer bleedMore are independent at discharge

Stroke.2006; 37: 263-266

JAMA. 2013;309(23):2480-2488. doi:10.1001/jama.2013.6959.

Endovascular stroke care: Time is Brain

Proven effective therapy Time sensitive Better reperfusion and outcomes with shorter door to groin

The challenge in the age of endovascular stroke treatment

Deliver IV t-PA as efficiently / quickly as possible (within 15-20 minutes)Rapidly select (and transfer) patients with large

vessel occlusion (LVO) for endovascular treatment (within 45 – 60 minutes)Rapidly retrieve clots (within 90-120 minutes)

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Why does it take so long to give IV alteplase?

Patient picked up and evaluated by

paramedics

Transport to hospital

Arrival in hospital

Nurse evaluation

EMS ring down

Roomed

ED doctor evaluation

Vitals, monitor

IV’s

Orders placed

Transport to CT Move to CT scan

Get CT scan

Read CT scan

Return to ED

ED doc calls Neurologist

“Go” for Alteplase decision

Order alteplase

Mix Alteplase

Deliver alteplase

Weigh Patient

Draw labs

Labs?

Medication double check

Recheck vitals Recheck exam

Push IV alteplase

Start drip

Blah blah blah

Blah blah blah

Blah blah blah

What’s wrong with this picture?

Which steps are value added? Which serial steps could be parallel? Where are duplications which could be removed? Where are non value added steps?

Keys to rapid IV alteplase treatment

Do as much as you can before the patient arrives Stroke neurologist involved from the beginning Direct to CT scan Order Alteplase ASAP Alteplase in CT scanner Stop doing things that don’t matter EKGMost labsRooming

Do things at the same time (parallel processing)

Labs and Alteplase

INR only for patients on warfarin PTT only for patients on heparin CBC / platelets only for patients with suspected abnormality Creatinine only for patients with known abnormality

AJNR NOVEMBER 2008 29: 1826-1830

Journal of NeurologyNovember 2007, Volume 254, Issue 11, pp 1491–1497

http://dx.doi.org/10.1161/STROKEAHA.107.482778Stroke. 2007;38:2364-2366

Improving DTN in a system:Kaiser Permanente Northern California (KPNC)

3.8 million members 21 Medical Centers 17,000 square miles > 8000 physicians 75 neurologists Thousands of ED MD’s + RN’s

KPNC Acute Stroke Care: prior to 1/2016

• Every KPNC hospital is primary stroke certified

• Each hospital with its own stroke alert process

• DTN variable among hospitals but across all medical centers 60% in 60 minutes

• Endovascular times vary by location and treating MD’s

The Neurologist challenge

Key component = early involvement of stroke neurologist Problem: small volumes cannot justify in house stroke

neurologist

Solution: video consultation + redesigned process

Teleneurology “Hub”

Small core group of stroke specialist neurologists who are involved in all stroke alerts Remote exam by teleneurologists with RN / ED MD

assistance Active 7am – midnight 7 days a week (rate very low in “off”

hours) Neurologist orders the t-PA and “runs” the stroke “code”

Serial vs. parallel processes

Patient arrival

RN evaluation

Stroke alert called

ED doctor evaluation

CT ordered

Lab drawn

Transport to CT

Roomed in ED

CT done

Transport back to ED

CT read and called to ED

doc

Call to Neuro Alteplase ordered

Alteplase prepared

Lab Resulted

Alteplasepushed

Back to CT for CTA

CTA done

CTA resulted

Ambulance called

Ambulance arrival

Transport

Stroke alert called

Patient arrival

Team evaluation in ambulance

bay: ED, RN, Stroke

Neurology

Alteplase, CT, CT, CTA< ambulance

ordered

Transport to CT

Alteplase prepared

CT read and called to

teleneurologyAlteplase given (in CT)

CTA doneAmbulance arrival

Transport

OLD: Serial NEW: Parallel

Stroke Neurologist involvement

Neurologist involvement

April 2015 – Sept 2016 ED DTN Results

16

% Door-to-Needle TPA < 45 mins

All sites live! % D

oor-to-Needle TPA <

45 min

# of

Stro

ke C

ases

that

rece

ived

TPA

Results: All Facilities Median DTN

First quarter 2015

Median = 54 minutes, 3% < 30 minutes

38 cases per month

First quarter 2016

Median = 32 minutes,45% < 30 minutes

80 cases per month

Results: All Facilities

Identification and transfer for large vessel occlusion

Order CCT ambulance BEFORE even getting initial CT in selected patients CTA on nearly all patients - without leaving CT scan Adds about 4-5 minutes With two IV lines we can do CTA while alteplase is infusing Immediate reading by neuroradiology Teleneurologist contacts endovascular treatment center

Rapid transfer

Early order of CCT rig vs 911 ambulance with nurse ride along Prep patient before leavingGownGroin prep Foley

Sign out on phone as rig is coming Grease the wheels with accepting centerRapid door to groinOne call referral Ideally able to review images

2016 arrival at outside hospital to groin at RWC

SWIFT PRIME OH Arrivals

SWIFT PRIME CSC Arrivals

SWIFT PRIME

Current KP OH arrival to CSC average

Complications?

2014 symptomatic bleed rate : 4.5% 2016 symptomatic bleed rate: 4.3%

Field based diversion vs rapid treatment and transfer

18% of acute strokes need endovascular treatment 82% DO NOT

5% of patients identified with acute strokes by paramedics need endovascular treatment 95% DO NOT

Field based diversion advantages the few to the detriment of the many

Endovascular treatment – first give IV t-pa

82% of acute ischemic strokes arriving in time window DO NOT have a large vessel occlusion Patients with large vessel occlusion benefit from IV t-pa Large strokes with vessel occlusion (NIHSS>10) substantially benefit

from t-pa with 35% vs 17% having good outcome (NNT = 7)

Stroke 2013 Nov 44(11):3109-13

Conclusions

World class DTN times can be achieved in a network of community hospitals Rapid IV t-PA treatment > identification of LVO > transfer >

endovascular treatment is possible across a large geographic network of community hospitals Successful field based diversion is unlikely to be practical

and would likely be inferior to rapid treatment and transfer

Thank You

KP EXPRESS (EXpedited PRocess for Evaluating and Stopping Strokes)

KPNC Stroke FORCE (Fast Operating Remote Cerebrovascular Experts)

Building County Wide Program

Population engagement and education DTN improvement efforts Expedited transfer protocols Facilitated imaging, contact, information exchange Expedited door to groin Results sharing