The impact of pre-alert on stroke thrombolysis door to needle time

Transcription

1 The impact of pre-alert on stroke thrombolysis door to needle time John Reid - Stroke Neurologist Alexander Bown - GPST1 Andrew Barrett - 4 th year Medical student Aberdeen Royal Infirmary

2 "Top-speed Bradford hospital staff saved my life in 22 minutes" THANKS: Nurse Stacey Wheeler, Keith s wife Rita Robertshaw, Dr Alastair Jones and Dr Hawraman Ramadan at Keith s bedside in BRI after the drama a clot-busting wonder drug just 22 minutes after he got through A&E s doors halving the national average of time It was like a military operation,.. it went like clockwork. They performed a miracle. Dad had gone, he was just a shell of himself but they brought him back to us. Onset to treatment time 61 min

3 Dr Ramadam said: There are three key parts to this story. 1. Mrs Robertshaw s swift thinking 2. The ambulance getting to him quickly and warning us he was coming in to A&E 3. The A&E and stroke team working together and acting very fast.

4 Strategic drivers for thrombolysis 1995 NINDS trial 1996 FDA approved - tpa licensed in USA 0-3 hours 1999 approved in Canada 2002 approved in Europe 2008 ECASS3 confirms efficacy of tpa up to 4.5 hours NICE/RCP/SIGN clinical guideline 2012 IST3 confirming benefit in patients aged>80

5 Timing of thrombolysis 1996 post NINDS trial Door to CT 25 min Door to needle 60 min Quality Improvement Scotland standard 80% treated within 60 min of admission Safe Implementation of thrombolysis New campaign to recruit centres to improve door to needle times to 40 min

6 Time is Brain The typical patient loses 1.9 million neurons each minute in which stroke is untreated Odds Ratio (corrected; 95% CI) favourable Outcome Upper 95% CI Mean Lower 95% CI NNT: NNT: NNT: NNT: 3.5* 7* 9* 11* (11)** (13)** (>30)** Symptom-to-needle time in minutes * NNT at absolute point of time ** NNT for each 90 min interval Slide by Prof G Ford, presented at UKCRN based on Saver, Stroke 2006

7 a reduction of start of treatment times by 8 min (compared with the present time) would confer a population benefit as large as that conferred by extension of the time window from 3 0 h to 4 5 h Pitt M, et al. Will delays in treatment jeopardize the population benefit from extending the time window for stroke thrombolysis? Stroke 2012; 43:

8 Systematic review of barriers to delivery of thrombolysis for acute stroke 1 TIME 1. Kwan et al Age and Ageing 2004; 33:

9 Barriers to thrombolysis 2) GP called not EHS 3) Triaged as non-urgent by paramedics/erps 4) Delays to CT TIME Telemedicine link Local hospital 6) Difficulties obtaining consent 7) Physicians uncertainty about administering tpa 1) Lack of symptom recognition 5) Inefficient process of emergency stroke care

10 Key recommendations Continuous public awareness campaigns Education of emergency medical service personnel the use of standardised, validated scales for recognition of stroke symptoms triaging to the appropriate institution advance notification to the receiving hospital Use of telemedicine technologies for interaction between the emergency site and hospital Fassbender et al, Lancet Neurology June 2013

11 Pre-hospital notification Fassbender et al, Lancet Neurology June 2013

12 Effect of pre-notification 1 Onset to Door Door to CT/MRI Door to TPA TPA treatment rates 2 min (-40 to +60) 26 min ( 7-85) 30 min ( -2-60) 14% 23% vs. 9% 1. Fassbender et al, Lancet Neurology June 2013

13 AHA and ESO guidelines Emergency services should pre-notify the receiving hospital Benefits Activation of Hospital stroke team including radiology Could even allow preliminary informed consent for later treatment Pitt M, et al. Stroke 2012; 43:

14 SSCAS report 2011 Scottish average 27%

15 SSCAS 2012 Scottish average 29%

16 Across Scotland, only 29% of patients are treated within one hour of arrival...little improvement from No hospital is achieving the standard of 80% treated within one hour of admission. This is an area which will require attention nationally.

17 SIGN (108), revised recommendations for the acute management of stroke, Patients admitted <4.5 hours of definite symptoms, who are considered suitable, should be given thrombolysis. 2. Onset to treatment time should be minimised. 3. Systems should be optimised to allow the earliest possible delivery of thrombolysis within the defined time window.

18 Grampian stroke thrombolysis Elgin Aberdeen Dundee

19 Stroke physician and radiologist on-call from home Pre-ECC AE majors 200 metres from lifts One floor up 40 metres Post-ECC ED dept CT scanner 20 metres from acute assessment bay

20 Thrombolysis timing audit 12 months of data ± ECC (opened 01/12/12) May-Nov 2012 vs. Dec 2012-May 2013?out of hours, Pre-notified to ED Door to CT, door to treatment times Demographics Age, gender, NIHSS, mrs Excluded 10 pts with missing data, in-hospital stroke

21 Door to CT=14 min Door to needle=39 min Onset to treatment=105 min

22 58 yr old male Left TACS Symptom onset NIHSS= hour NIHSS=4

23 Effect of ECC Pre ECC Post ECC P value N Mean door to CT (min) % Door to CT 25 min 15% 35% 0.04 Mean door to Needle time (min) Door to Needle 60 min 69% 63% 0.70 Door to Needle 40 min 44% 26% 0.09

24 Effect of pre-hospital notification Pre-notified? Yes No P value N 39 (46%) 46 Mean door to CT (min) Mean Door to Stroke Doc (min) 9.6 (18.1) 30.8 (18.7) % Door to CT 25 min 44% 13% 0.04 Mean Door to Needle Door to Needle 60 min 82% 56% 0.01 Door to Needle 40 min 44% 26% 0.09

25 Who gets pre-notified? Pre-notified? Yes No P value N Mean Age % Female 41% 43% 0.85 Mean NIHSS 12.6 (5.7) 13.5 (7.1) 0.39 Pre-stroke median mrs 1 (0-2) 1 (0-2) mrs > 2 1/34 5/ mrs > 1 11/34 15/ Out of hours 85% 67% 0.12

26 Conclusion Nearer sited CT scan feels like an improvement but Despite improved door to CT times No difference in door to needle time Pre-notification 1. Achieve DTN times with 80% <60 min 2. Improves door to CT + door to Stroke Doc times

27 5.2 Thrombolysis pre-alerts There is variation in how pre alert of FAST positive stroke patients is communicated to Accident & Emergency departments. Following consultation with NHS24 and the Scottish Ambulance Service it was felt that a Scotland wide policy would not be particularly helpful The preferred option would be for stroke MCNs to develop a local pathway meeting local needs accounting for rurality and the local thrombolysis service.

28 Effect of out of hours? OOH? Yes No P value N Door to Doctor (min) Door to CT (min) Door to Needle