Code Stroke Optimizing Stroke Care in the Field: The Alberta Experience

Transcription

1 Code Stroke Optimizing Stroke Care in the Field: The Alberta Experience June 1st, 2018 Thomas Jeerakathil BSc, MD, MSc, FRCP(C) Professor Division of Neurology University of Alberta Northern Stroke Lead CV/S SCN, AHS Co-PI Stroke Ambulance Project

2 Disclosures Bayer 2 honoraria for 2 advisory board meetings on anticoagulants Grant funding from CIHR, HSFC, AHS, Alberta Health, SCN, University of Alberta Hospital Foundation

3 Mitigating Potential Bias The topic is unrelated to disclosures

4 Objectives Identify key components of the University of Alberta (and province of Alberta) Door to Needle Time Quality Improvement Process related to activation of Code Stroke Recognize the potential application of a Stroke Ambulance in Northwestern Ontario to improve access to care Describe the impact of implementing Code Stroke at Thunder Bay Regional Health Sciences in reducing door to needle time

5 Patient year old female accountant Acute onset right hemiparesis, aphasia, sensory loss and hemianopsia Presented (walk-in) to the Grey Nun s Stroke Centre in Edmonton Stat-stroke protocol initiated after 20 minutes in the waiting room after there was further progression Door to needle time of 80 minutes received IV tpa CTA not performed with the CT scan; performed AFTER tpa and eventually showed large vessel occlusion (LVO) Transferred to UAH arrival to transfer time 2.5 hours

6 Patient year old female University Professor Acute onset left hemiparesis, neglect, sensory loss and hemianopsia Presented (walk-in) to the Grey Nun s Stroke Centre in Edmonton Stat-stroke protocol initiated Door to needle time of 17 minutes Stat transfer to the University of Alberta Hospital for possible endovascular care Arrival to transfer time of 60 minutes

7 Patient 2 Clot visible blocking the middle cerebral artery (inside artery) Thrombus resolved after IV tpa M.L. s brain CT scan CT at UAH demonstrated resolution of the hyperdense MCA sign; CTA showed no intracranial blockages; NIH dropped from 11 to 2

8 Leading cause of disability in adults Causes 10% of all deaths in the world The cost to Alberta is approximately million per year Stroke will present soon to an ED near you! The Impact of Stroke

9 Chart 3 64 Age-Adjusted Death Rates* for Stroke by Country & Sex, Ages 35 74, * Age-adjusted to European standard. Data for years indicated in parentheses.

10 n It is impossible to remove a strong attack of apoplexy and difficult to remove a weak one. Hippocrates 400 B.C.

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12 2 kinds of hemorrhagic stroke: Aneurysmal Subarachnoid Hemorrhage Intracerebral hematoma

13 Ischemic Stroke: Clot visible blocking the middle cerebral artery (inside artery) Patient 1 M.L. s brain CT scan

14 The neuron In a typical large vessel acute ischemic stroke 1.9 million neurons 14 billion synapses 12 km of myelinated fibers are destroyed each minute (Saver et al, 2006) 5 min ~ 10 million neurons, 60km of wires 10 min ~ 20 million neurons, 120km of wires 15 min ~ 30 million neurons, 180 km of wires

15 Text The evidence for tpa given < 4.5 hours from onset in ischemic stroke is compelling. The elderly benefit as much or more Pooled individual patient metaanalysis of all 9 trials of tpa; >6500 patients

16 Adjusted benefits of tpa by 90min epoch NNT is number needed to treat Lees, Lancet 2010; 375;

17 Time and outcome [Lees et al. Lancet 2010; 375: ] 17

18 Improving Access to tpa Enter Strategy - the APSS

19 Telestroke link Northern Telestroke Network

20 Technology - Telestroke

21 Timelines in tpa use ED Registration ST paged CT ST calls CT reviewed Focused history Attending physician paged Attending physician Responds Mix tpa ER doc bloodwork Stroke protocol ST bedside Family discussion Foley catheter NIHSS/PE Decision Bloodwork reviewed tpa bolus Page

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23 Shorter DTN = better outcomes Every 15 min drop in DTN associated with a 5% reduction in mortality (OR 0.95; p<0.0001) Those with DTN < 60 min have reduced risk of intracranial hemorrhage 4.7% vs 5.6%

24 In God we trust. All others bring data. There is no substitute for knowledge. W. Edwards Deming 2 4

25 60 min 50 min UAH Edmonton; DTNs after an intensive QI program

26 QUICR Project June 2017 by zone

27 Alberta Heatmap: Pre/Post AFTER QUICR Collaborative Sep 2015-Feb 2016 Oct 2016-July 2017

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30 Stretcher to CT & Swarm EMS Stretcher ED Triage (swarm) Physician, nurse, +/- lab Transfer CT

31 Accessing the acute stroke system -- four scenarios: (for patients presenting within 6 hours of onset or wakeups presenting within 6 hours of waking) 1. The patient presents to a Primary Stroke Centre (PSC) 2. The patient presents to a non-psc (walkin or inpatient) 3. The patient is with an EMS crew (ERA Project) 4. The patient presents to a clinic call 911!

32 Stroke CFM Notes: If this is a HEADS UP call, ensure the caller has the pt ULI, LSN (if known) Call to RAAPID Age? >18 HEADS UP? More blue areas meaning maximize No LSN? time to EVT >6hrs Page EDM XXXX CAL XXXX HEADS UP follow-up <18 GEN PEDS CFM Yes Collect ULI, LSN, LAMS Start a CRIS chart The critical care line (or 911) is usually the first place to call for acute stroke. Examine why <6hr & in wake-up next slide LAMS? Yellow becomes grey <4 meaning MS ground better Page EDM XXXX CAL XXXX Examine why in next 2 slides Provide ULI, referring site and MD name if known >4 Red Referral The LAMS can help identify motor symptoms that predict LVO Call-back to RAAPID post-ct Page EDM XXXX CAL XXXX RAAPID joins audio-bridge (if required)

33 The NIHSS is A 42 point scale to grade stroke severity. A score of >6-10 could predict LVO. Prehospital scales do NOT replace the NIHSS. More blue areas meaning maximize time to EVT Examine why in next slide Yellow becomes grey meaning MS ground better Examine why in next 2 slides

34 Timelines in tpa use PSCvOct4/17 Do, but not always pre-lytic ED Registration RAAPID Heads UP to Telestroke Telestroke Calls RAAPID back CT reviewed Focused history Telestroke Connects with ED Doc Telestroke Videoconf Mix tpa bloodwork CT Stroke protocol ER doc Sees (10 min) NIHSS/PE Foley +/- EKG +/- Family discussion Decision Bloodwork reviewed tpa bolus Page

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36 Tips on Door in Door Out (DIDO) Door in door out time (DIDO) Keep the incoming EMS crew on site if possible to avoid delays in transfer of care In return, nonpscs and PSCs should have a fast turnaround The expectation of physician assessment within minutes (like an MI) for a STATstroke (or Code stroke) PSCs - Speed up your CTA process to <5-10 min so that you can do the CTA right after the plain CT Goal DIDO 25 min for nonpsc; 45 min for PSC

37 Patient presents to non-psc walk-in Fast physician assessment (within min like an MI); Call RAAPID immediately Determine the LAMS score (RAAPID will be able to assist) If LAMS >= 4 then conference in the telestroke physician, STARS, Provincial Flight, CCC (EMS Dispatch) A decision may be made for diversion from local PSC to Comprehensive Stroke Centre (CSC) instead for faster EVT If LAMS <4 then contact the closest PSC activating STATStroke Protocol (not just arranging a CT with DI) Fast DIDO time (ideally less than 25 minutes rarely achieved)

38 Patient presents to a non PSC with tpa capability Fast physician assessment (within 10 min like an MI); Then call the stroke system immediately (usually via a critical care line) Arrange stat transfer consult with stroke physician Stat CT (within minutes); and fast CTA (within 10min of plain CT being done); can be done while waiting for transport; A decision may be made for stat transfer to tertiary: post tpa or FOR tpa or EVT Transport priority RED (or local term) (v important if being transferred for EVT or tpa) Ideal DIDO (door in door out or recognition to transfer time) of 45 minutes (although not always realistic);

39 Example of a Non-PSC Walk in stroke protocol

40 tpa treatment window 4.5 hours Door-to-needle times of minutes Northern and Central Alberta dead zones Very difficult to achieve timely thrombolysis

41 Non-PSC Northern Alberta Stroke Ambulance If within a 250 km range around Edmonton and during the weekday hours of 8-4 call RAAPID with any acute stroke regardless of LAMS The patient may be a candidate for a Stroke Ambulance dispatch which might allow the fastest thrombolysis as well as transport to Edmonton for EVT We have activated phase 2 (response to in- Zone Edmonton Hospitals) Transport doc should involve telestroke in the field call in this radius during operational hours Phase 4 is being considered co-dispatch

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44 ACHIEVE STUDY Patient comes to the local hospital with stroke symptoms Physician on duty attends and contacts stroke expert at UAH through Rapid North. Obtains consent communication Stroke physician at UAH, collects the information and advises on recruitment and dispatches CT mobile unit Patient transferred to UAH by ambulance Blood work done at local hospital and report sent over to UAH The CT mobile meets ambulance at predetermined location CCT completed in the field ICH ruled out, meets inc/exc criteria, NIHSS, mrs rt-pa therapy initiated in the ambulance Patient arrives at UAH for continued care CCT, NIHSS, mrs, Data collected and processed CCT equipped mobile unit with stroke fellow dispatched towards the local hospital Telestroke UAH Repeat assessment after 24 hr (CCT, NIHSS, mrs, Barthell Index) Follow up after 7, 30 and 90 days (Follow up on phone if patient is discharged)

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46 Northwestern Ontario

47 Take Home Points Stroke remains a highly morbid disease Have a systematic approach to acute stroke and seek consultation immediately IV tpa is a highly effective treatment for ischemic stroke and time limited EMS and nonpscs still play a critical role in brain survival

48 Thank-you