Coordination and Regionalization of Acute Care: What about stroke?

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1 Coordination and Regionalization of Acute Care: What about stroke? Tim Lukovits, M.D. Medical Director Cerebrovascular Disease and Stroke Program at DHMC

2 Barriers to more organized acute care unique to stroke Accuracy of diagnosis in pre-hospital and ED phase is limited and often dependent on tests not widely available or easy to interpret Severe shortage of subspecialists (e.g., NH has 1 neuro-interventionalist, 1 stroke neurologist, 1 neurovascular surgeon) and limited access to subspecialty care Ambivalence among physicians is very high

3 Forces driving more organized regionalized stroke care Recognition that care is fragmented Governmental/regulatory, public pressure Limited time windows for therapies demands more efficient and coordinated care New expectations that TIA and symptomatic carotid stenosis require more rapid attention Technological advances Improved imaging allows more rapid diagnosis, identification of vascular lesions, and penumbral tissue Interventional therapies offer more options Telemedicine technology Expanded use of aeromedical transport

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5 INcreasing Stroke Treatment through Interactive behavioral Change Tactics

6 24-hospital, randomized, controlled trial testing a multi-level, systems-based educational intervention Intervention based on adult education and behavior change theory Tailored to local needs

7 The INSTINCT Intervention Stroke Champion development Site-specific Barrier Assessment Access to stroke evaluation/treatment tools Tailored CME addressing local barriers On-site visits and mock stroke codes for EMS and EDs Telephone stroke specialist access Critical incident defusing Targeted messaging and feedback

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10 Excluded pts with prior hx of both prior stroke and DM, age > 80 yrs, and severe deficits

11 It s not just about tpa ICH Correction of coagulopathy, BP control, cerebellar hematoma evacuation SAH Carotid stenosis

12 Early expansion of infarction EPITHET website

13 Salvaging penumbral tissue SM Davis 2005

14 November 2006 (DEFUSE study) Open-labeled study of 80 pts given IV t-pa at 3-6 hrs 2/3 of this group had favorable outcome 6.7% symptomatic hemorrhage

15 Trials using acute MRI imaging

16 CASE 2 A 75 yo F. June AM collapsed at home, brought to local ED. Not normal, decreased spontaneous speech but unclear what deficits were. Head CT 9:46, returned from Radiology for unclear reasons at 10:55, now aphasic and with R hemiplegia. MD not comfortable using t-pa so transfer requested. 13:02 Arrival DHMC ED (+6 hours).

17 Concentric Retriever device: FDA approved 2005

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19 Telestroke : potential benefits Improved clinical and radiographic dx Facilitating t-pa administration Triaging for transportation Identifying patients for clinical trials Improve networking Education

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24 Audebert, H. J. et al. Stroke 2005;36:

25 TEMPiS results Feb 2003-May 2006 > 9000 teleconsultations performed 454 received IV t-pa Only 5% transferred to stroke centers Hospitals in network had better outcomes

26 Alan J. Hirshberg, MD, MPH, FACEP, (former Emergency Department Director Martha's Vineyard Hospital) September 2, 2004 Although the vast majority of the patients did not require thrombolysis, many patients with acute stroke and other neurological problems were successfully treated and assessed where previously this level of assessment would have been unable to have been done. A number of patient s were able to be successfully treated on the island without transfer off- Island increasing patient satisfaction and saving limited health care resources. Patients and patient s family feedback was overwhelming positive and it was hoped that the program could be expanded to include other areas of medicine as well.

27 A majority of patients being transported by DHART for management of acute stroke continue to undergo urgent, specialized diagnostic or neurosurgical interventions, thereby supporting the role of inter-hospital helicopter transport in extending access to care in rural communities. In our region, this transport mode continues to be used primarily for hemorrhagic stroke and is underutilized for ischemic stroke. More recently, significantly more patients transferred had aneurysm coiling and less patients were subsequently transferred elsewhere for coiling of aneursyms. We expect the use of helicopter transport for stroke will increase with expanding treatment options, increased availability of cerebrovascular subspecialty services at our center, and more regional organization.

28 New London-DHMC Bypass

29 Some general principles of inter-hospital stroke protocols Goals: improve care provided locally, improve access to subspecialty care and acute therapies when indicated and feasible, and facilitate efficient and appropriate interfacility transfers All the players need to be involved (EMS, DHART, Patient Placement, ED, Critical Care, Radiology, etc). Protocols used at different facilities may vary according to the particulars of that facility but the care provided should be consistent Even if limited, local care must be efficient and of high quality (e.g., rapid triage, BP control, FFP prior to cerebellar hemorrhage evacuation) House-staff at DHMC shouldn t be bypassed Lessons from other programs (trauma, ACS care) should be learned

30 My top recommendations for improving acute stroke care in our region We all need to look at how we can improve stroke care locally and regionally We need to integrate stroke care with other areas of acute care We need to be able to share radiology studies Develop more efficient transfer protocols and better intake/rapid evaluation process at DHMC Make better use of telephone telemedicine Case review with teleconferencing Explore repatriation when appropriate