Mark J. Alberts, MD. Turning the Wheels of Stroke Care

Transcription

1 Mark J. Alberts, MD Vice-Chair, Clinical Affairs Professor of Neurology Department of Neurology and Neurotherapeutics University of Texas Southwestern Medical Center Dallas, Texas Turning the Wheels of Stroke Care 1

2 Mark J. Alberts, MD Presenter Disclosure Information FINANCIAL DISCLOSURE: Speaker s Bureau: Genentech, Inc. Unpaid Consultant: The Joint Commission, HFAP UNLABELED/UNAPPROVED USES DISCLOSURE: None 2

3 Outline Review the overall impact of Stroke and Stroke Centers Discuss how Stroke Systems of Care are designed to function Present options for EMS triage and diversion Consider options for continued growth and evolution of Stroke Systems 3

4 Impact of Stroke Centers 4

5 EMS Plays a Key Role in a Stroke System They are typically the first medical professionals with direct patient contact But in some cases, 50% of patients come in via private car Their initial assessments, actions, treatments, and decisions will have significant consequences in the patients treatment and recovery But in some cases an accurate Dx is made in only 50-60% of cases Their role in initial patient triage, diversion, and routing cannot be overestimated 5

6 Medical Impact of Stroke Recent study of 91,134 patients admitted to 625 hospitals with acute stroke (all Medicare patients) Average age = 79 years 58% female 82% Caucasian Overall, 62% of these patients were dead or re-admitted after just 1 year Fonarow et al., Stroke,

7 Characteristics of Different Stroke Centers Comprehensive Stroke Center Academic Medical Center Tertiary Care facility Primary Stroke Center Wide range of hospitals; standard stroke care; stroke unit; use TPA Acute Stroke Ready Hospital Rural hospitals; basic care; drip and ship; use tele-technologies 7

8 Numbers of Various Types of Stroke Centers >5000 total acute care hospitals in the U.S. Comprehensive Stroke Center 70 now; final = total Primary Stroke Center > 1000 now; final = Acute Stroke Ready Hospital Unknown; could be ? 8

9 Impact of Stroke Centers on Patient Care Stroke is the 4 th leading of death in the US and the 2 nd leading cause of death globally Stroke Centers (PSCs, and CSCs) are associated with 2% to 3% reduction in deaths This translates into 16,000 to 24,000 fewer deaths each year in the US Globally this means 320,000 to 480,000 fewer stroke deaths each year There are very few medical interventions that reduce deaths Trauma centers DO Coronary stenting vs angioplasty DOES NOT CEA vs medical therapy DOES NOT Meretoja A, et al, Stroke, 2012; Kim et al., J of Stroke, 2013; Xian et al., JAMA,

10 Impact of Stroke Centers on Patient Care Another Perspective The average PSC has an annual stroke population of patients Assuming 1000 PSCs, this means that between 350,000 and 450,000 patients with stroke are cared for at a PSC each year (may not count readmissions) Therefore, about 50% of the almost 800,000 patients with stroke in the U.S. annually are cared for at a PSC (may be an over-estimate) Considering the improved care processes and outcomes at PSCs, this translates into a significant public health benefit for patients across the spectrum of stroke care 10

11 Hospital NIR Staffing About 800 NIRs live within 50 miles of a large metro area 4% to 14% of AIS patients may be eligible for IA therapy 2 major caveats: * This was before IMS3 and other results * Having 1 or more NIR does not = a CSC Zaidat et al, Neurology, vol 79, S 35-41, 2012

12 Acute Stroke Ready Hospitals Typically small facilities Located remotely away from a PSC or CSC Typically serve small cities or rural populations Stroke population small; likely 1 patient a week (or less) on average Limited staffing and bed availability Concept: EMS would take patient to nearest ASRH for: 1. initial diagnosis 2. acute stabilization 3. acute treatments 4. then send patient to nearest PSC or CSC Alberts et al., Stroke, October 2013

13 Element Key Elements of a ASRH Acute Stroke Team Comment At least 2 members; staffed 24/7; at bedside within 15 minutes EMS and ED Care Protocols Annual training and education Able to do rapid brain imaging and lab testing 45 minute turn around time IV TPA protocol Written transfer protocols Telemedicine link within 20 minutes 60 minute door to needle time To a CSC + PSC Procedures set up beforehand

14 Examples of Acute Care at an ASRH Acute Intervention Comment IV TPA 60 minute DTN time Reversal of coagulopathy ICH and SAH patients Treatment of increased ICP ICH, SAH patients Treatment of seizures All patients Acute blood pressure control Stabilize patient (if possible) Variable depending on clinical scenario Vital signs, respiratory status, etc.

15 ASRH CARE ELEMENTS EMS Rationale: EMS will be responsible for initial identification, assessment, treatment, and triage Details: Training, dialogue, feedback on continual basis Function: Include latest guideline; annual updates

16 ASRH Elements ACUTE STROKE TEAM Rationale: Such teams expedite care and focus resources; they are key to increase the use of IV TPA Details: Composition at least one nurse, one MD (could be PA/NP with prescribing authority Function: Target largest regional providers

17 ASRH Elements CARE PROTOCOLS Rationale: Ensure standardized care and reduce mistakes Details: Should apply to ED care and acute work-up and therapies Function: Should reflect latest guideline, SOC, community standards; update at least annually

18 ASRH Elements TESTING AND IMAGING Rationale: Important to make proper Dx of stroke and type Details: Basic lab tests, brain imaging (CT) Function: Available 24/7; turn around time = 45 min; might use main hospital lab

19 ASRH Elements NEUROSURGICAL SERVICES Rationale: Life saving interventions for patients with ICH, SAH, increased ICP Details: 3 hour time window for NSGY services could be remote Function: Identify coverage schedules; 24/7 coverage

20 TELEMEDICINE COVERAGE ASRH Elements Rationale: Provides neurologic and imaging expertise in remote areas Details: Includes real time audio-video exchange Function: Available within minutes; 24/7 coverage

21 TRANSFER AGREEMENT ASRH Elements Rationale: Most patients will require transfer to PSC or CSC if real stroke Dx Details: Pre-arranged protocols, methods, preferred transport service providers (ambulance, helocopter) and PSC/CSC destination Function: Leaves ED within 2 hours of arrival

22 ASRHs and Other Hospitals ASRHs would have some type of relationship with one or near-by more CSCs and PSCs Protocols for transfers and referrals Tele-stroke link to another facility Educational programs Transfer agreements (informal) Track transfers and outcomes

23 Should ASRHs admit Stroke/TIA Patients? Stroke Unit Care: Clearly improves outcomes Validated in many studies and meta-analyses If ASRH plans to admit patient, they should go to a Stroke Unit Consider becoming a PSC TIA Evaluation Can be done in various settings

24 Where to Locate these Hospitals?? Currently 12 PSCs in Iowa; total hospitals = PSCs cover 37% of the population 31 PSCs could cover 75% if forced location Or 54 could also cover 75% Who should direct PSC location?? Leira et al., Stroke, 2012

25 Possible Performance Metrics at an ASRH Evaluation of stroke severity Time to first brain imaging DTN time for IV TPA Time to initiation of anticoagulation reversal therapy Time to initiation of telemedicine link Time to transfer of patient to PSC or CSC Protocol violations

26 Options for EMS Triage Objective: Get the most appropriate patient to the most appropriate facility as rapidly as possible Challenge: Patients present with SYMPTOMS, not a clear diagnosis NEED: Tools that can be used in the field for Diagnosis and Triage Options: High-tech (video, portable CT).Low tech (exam skills)

27 Recent Studies Kwok et al. (Stroke, 2013) Used GCS for field triage Goal: Predict death, ICH, SAH GCS alone had PPV ; NPV patients; only 8% had a ICH or SAH Sultan-Qurraie et al., Stroke Used FAST score and time (3.5 hr; 3.5 to 6, > 6 hr) 1682 patients in Washington state 2500 patients Rx with IV TPA; 450 Rx with EVT 90% and 91% sensitivity and specificity

28 Recent Studies Allen et al. Stroke 2014 Used 3ISS and LAMS scores to triage patients in the field to PSC or CSC Resulted in 12 patients per month going to CSC instead of PSC OR for intervention = 3.84 at CSC Solenski et al. Stroke 2013 Impact of State Task Force (Virginia) 2007 compared to 2011 Number of PSCs increased from 7 to 34 (1 for every 230,000 people) Telestroke facilities increased from 1 to 18 Rx at a PSC increased from 28% to 70% LOS fell by 1 day

29 Getting the Right Patient to the Right Hospital Rapidly: Limitations of Field Triage Inaccurate Diagnosis Stroke type Stroke size Stroke severity Cannot predict deterioration or complications Patient preference Location of their prior care

30 Potential Solutions More accurate EMS Field Triage Cameras in ambulance Field brain imaging capabilities Field assessment tools for stroke severity Early ED assessment of the patient Rapid evaluation Patient goes back into the ambulance ASAP if they need CSC level care Do not waste time with an admission for a few hours this is highly inefficient

31 Reasons to Contemplate or Require Transfer Patient requires higher level of care upon admission NICU Surgery Specialized intervention Patient deteriorates after admission Increased ICP Bleeding complications Medical complications

32 Patients and Inter-Hospital Transfers West Virginia study 24 hospitals 4 hospitals accounted for 49% of transfers Neurologic and critical care conditions = 54% of requests Stroke and suspected-stroke were most common transfer Dx or reason Nair, Gibbs; W V Med J, 2013

33 Inefficiencies with PSC to CSC Transfer Initially taken to PSC, then to CSC Taken to CSC Initially 1) Ambulance dispatch to scene 1) Ambulance dispatch to scene 2) Scene to hospital 2) Scene to hospital 3) PSC back to base 3) CSC back to base 4) Base back to PSC 5) PSC to CSC 6) CSC back to base

34 Wasted Time and Effort Assume each transfer leg = 30 to 40 minutes 3 extra trips = 90 to 120 minutes May delay needed care for 2-3 hours, if not more Risk of miscommunication Need to repeat some or all testing Increases stress on family members

35 Characteristics of Transferred Patients Almost 41,000 patients, of which 1874 were inter-hospital transfers 49% of transfers were VERY SICK vs 35% of direct admits Ratio of in-hospital deaths = 1.99 (transfers vs direct admits) Overall increase in mortality and increased LOS (after adjustment for illness and other factors) for transferred patients Gordon and Rosenthel, Med Care, 1996

36 Do Transfers Have Worse Outcomes? Definitive proof would require a prospective trial (these data do not exist) Current data could be biased by several factors Confounding issues Delayed care could have led to worse outcomes Mistakes in care at outside institution Higher severity of illness (not fully accounted for in various models) for transferred patients

37 How do They All Fit Together? Stroke System of Care Spans the continuum; prevention through rehabilitation and all steps in between Will vary in different settings, but key elements should stay fairly constant 2 broad approaches to implementation: IMPOSE IT GROW IT

38 How To Implement a Stroke System ISSUES IMPOSE GROW/EVOLVE Advantages Achieve goal rapidly Get buy-in over time Overall coordination Perhaps less squabbling Disadvantages Resentment Further delays Passive-aggressive reaction May be inefficient overall

39 GETAC Recommendations Transport the patient to the highest level of Stroke Center CAVEATS: 1. can get there within minutes of added transportation time 2. patient is stable from an ABC perspective 3. hospital is accepting patients CHALLENGE Local RACs and EMS may not follow these protocols May make diversion a suggestion, not required

40 Implications Stroke Systems need for form and function soon to improve patient care Many different aspects of the Stroke System will be a challenge to coordinate Need some overall guiding principles Need for enforcement mechanism Need to track ALL patients, processes, and outcomes Need for positive feedback and rewards Need for flexibility as new care paradigms are developed 40

41 Conclusions 1. Texas has many of the building blocks for an excellent Stroke System of Care 2. Some coordination is needed to ensure these resources are used most efficiently 3. Despite the diversity of our state, some consistency of stroke care must be enforced 4. There should be one standard of care for the entire state 41