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

safe feasible

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

ASRH

PSC

ECC

CSC

Balance:

- Inefficient transfer: long

delays lead to less likelihood

to receive advanced therapy

or less likely to benefit

- 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Jadhav et al (unpublished)

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

Video consult: history/review labs

Video consult: NIHSS

Decision to administer IV tpa is made

Pharmacy activated

Decision to transfer patient is made

Transport activated

Transport arrives bedside

Suspected stroke patient is

triaged to CT scanner

ED physician contacts stroke

specialist via operator

CT scan is reviewed in real

time and decision is made to

proceed with telemed consult .

Video consult: history/review

labs

Telemedicine connection is

established.

Decision to administer IV tpa is

made

If NIHSS is disabling:

pharmacy activated. If NIHSS

>= 8: transport activated

Transport arrives IV tpa is mixed and initiated.

Video consult: NIHSS

IV tpa is mixed and initiated.

Patient departs referral facility

Patient departs referral facility

Restructuring Workflow Current: Serial Proposed: Parallel

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

Process

Symptom-CT: 103 minutes

Picture-Puncture: 56 minutes

Puncture-Treatment: 22 minutes

Recanalization

102 mins 1 min 33 mins 17 mins 6 mins 22 mins

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

Khatri et al, Neurology 2009 Marler et al, Neurology 2000

IV tpa IA therapy

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

- 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

Strategies to reduce DTN

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

9.5 hours 50 minutes 20 minutes 5 minutes 30 minutes

Recanalization

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

Enhancing recovery

1:1 randomization of

patients 5-10 days post

stroke (NIHSS < 20) to

20 mg fluoxetine vs

placebo

Disposition and outcomes

Stroke size and cost: each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35.

Streib et al (submitted)

Small Final Infarct Volume

Early detection

Good collaterals

- Permissive hypertension

Minimize core expansion

- neuroprotection

Patient selection

- Small core on presentation

Short time to recanalization

High quality recanalization

- TICI 2b/3

Good outcome

Opitimize Rehab

- Young age

- IRF vs. SNF

- neurostimulant

Achieving good outcomes after

ischemic stroke

Minimize post stroke complications

- Hemorrhagic transformation

- DVT

- Infection

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.