Stroke Systems of Care Update

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1 Stroke Systems of Care Update Edward C. Jauch, MD MS FAHA FACEP Professor and Director, Division of Emergency Medicine Professor, Department of Neurosciences Associate Vice Chair, Research, Department of Medicine Medical University of South Carolina COMPREHENSIVE STROKE CENTER Professor, Department of Bioengineering Clemson University

2 Disclosures Research support National Institutes of Health (NINDS) funding Novo Nordisk (drug in kind) STOP-IT Study Genentech PRISMS Study Cleveland Clinic (lab in kind) BASES Study Remedy Pharmaceuticals GAMES-RP Study Stryker, Covidiene, Penumbra POSITIVE Study National Organizations (my comments today are mine) AHA/ASA leadership and guidelines member JC CSC and PSC Technical Advisory Panels NQF Ambulatory Care Committees

3 Lecture Goals String together 3 important concepts in acute stroke into one passion best stroke care: The growing global burden of stroke is also local Increasingly we have the technology and knowledge Stroke systems of care development is needed to maximize our technology for maximize clinical outcomes Coming together is a beginning; Keeping together is progress; Working together is success. - Henry Ford

4 Trends in US Stroke Organization Continuation of the regionalization of stroke systems of care State-based / regional plans continue to expand Departments of Health critical to affecting change Often must start modest to avoid offending major stakeholders Regionalization extends beyond EMS and triage, timely transfers for some patients who require higher level of care

5 Team Based Approach to Establish National Best Practice

6 (Schwamm, Circulation 2005;111: ) (Higashida, Stroke 2013;44)

7 Hospital Capabilities in Stroke (Higashida, Stroke 2013;44)

8 Stroke Systems of Care Nonstroke Center Primary Stroke Center Primary Stroke Center Acute Stroke Ready Hospital Comprehensive Stroke Center Acute Stroke Ready Hospital

9 Recombinant tissue-type plasminogen activator (rt-pa) use rates by quarter, pre, and post primary stroke center (PSC) certification, compared with non stroke center hospitals during the same timeframe (ranging from FY 2001 to 2010). Kleindorfer D et al. Stroke 2013;44:S129-S131 Copyright American Heart Association

10 Figure I (Continued). Kleindorfer D et al. Stroke 2009;40: Copyright American Heart Association

11 Current SC PSC

12

13 Impact of Telemedicine in SC MUSC Network Total (5 years) 3529 consults 627 IV tpa 886 transfers 2013 (6 months) 502 consults 103 IV tpa 119 transfers

14 Delivery: Prompt Transport & Pre-arrival Notification

15 Door to Needle Times

16 Partner with Others STEMI & post-cardiac arrest share similar issues Time is Brain Have similar resource needs QI registries key to measure Goals: Identify stakeholders Develop best practices for state Build integrated systems of care in all regions of the state

17

18 Why Go to All This Trouble? Triage to most appropriate hospital PSC more likely to have a plan and administer tpa EMS prehospital activation Decreases Door to MD, CT, and Needle times Decreasing Onset to Needle Time 30 decrease increases relative favorable outcome 10% Decreasing Onset to Reperfusion Time 30 decrease increases absolute favorable outcome 10%

19 Next Steps Increase public awareness of stroke risk factors and warning signs Utilize ORS and NEMSIS databases for 911/EMS utilization rates Standardized prehospital stroke assessment and management Standardize EMS prehospital tool use Create new tool appropriate for state Utilize NEMSIS III database Prehospital notification for all identified strokes in the field Utilize GTWG database Do radio systems allow for this, especially longer transports out of normal communication systems

20 Next Steps Ensure optimal triage based on regional resources Utilize NEMSIS III database Define best practice and implement regionally Interfacility transport Pre and Post tpa / Availability, education, etc Optimize hospital care Optimize rtpa utilization Decrease Door to Needle time Utilize GTWG database Post tpa care Utilize GTWG database Optimize disposition Stroke survey tools

21

22 Stroke System Development: Learn From and Partner With Others Provide public education Identify center capabilities Develop regionally specific systems of care Integrate prehospital care Develop strong collaboration with specialists within region Measure quality and performance Provide feedback to all

23 SC-CoAST South Carolina Collaborative Alliance for Stroke Trials Medical University of South Carolina, University of South Carolina, Greenville Health System New national NIH stroke network for performing clinical stroke trials Primary prevention Acute therapies Secondary prevention Rehabilitation Imaging biomarkers Univ. Cincinnati National Coordinating Center 25 RCC hubs, many with background networks

24 Pay Attention to the Transfer Plan ahead! Know who, how and when Train on post-tpa protocol Blood pressure & bleeding precautions Angioedema Follow the neuro exam Ensure communication en route Know where to go when you get there Like prehospital EMS, provide feedback to all

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