KPNC Stroke EXPRESS EXpediting the PRocess of Evaluating & Stopping Stroke

Transcription

1 KPNC Stroke EXPRESS EXpediting the PRocess of Evaluating & Stopping Stroke Jeffrey G. Klingman, MD 1

2 Disclosures None

3 75% DTN < 60 50% DTN < 45

4 Why should we care about DTN?: Time is brain 2 million nerve cells die per minute For every 15 minutes faster time: More go home Fewer die Fewer bleed More are independent at discharge Stroke.2006; 37: JAMA. 2013;309(23): doi: /jama

5 Endovascular stroke care: Time is Brain Proven effective therapy Time sensitive Better reperfusion and outcomes with shorter door to groin

6 The challenge in the age of endovascular stroke treatment Deliver IV t-pa as efficiently / quickly as possible (within minutes) Rapidly select (and transfer) patients with large vessel occlusion (LVO) for endovascular treatment (within minutes) Rapidly retrieve clots (within minutes) 6

7 Why does it take so long to give IV alteplase? Patient picked up and evaluated by paramedics EMS ring down Transport to hospital Arrival in hospital Roomed Blah blah Nurse evaluation blah Vitals, monitor IV s Draw labs Weigh Patient Blah blah ED doctor blah evaluation Orders placed Transport to CT Recheck vitals Medication double check Labs? Deliver alteplase Mix Alteplase Order alteplase Go for Alteplase decision Blah blah ED doc calls blah Neurologist Return to ED Read CT scan Get CT scan Move to CT scan Recheck exam Push IV alteplase Start drip

8 What s wrong with this picture? Which steps are value added? Which serial steps could be parallel? Where are duplications which could be removed? Where are non value added steps?

9 Keys to rapid IV alteplase treatment Do as much as you can before the patient arrives Stroke neurologist involved from the beginning Direct to CT scan Order Alteplase ASAP Alteplase in CT scanner Stop doing things that don t matter EKG Most labs Rooming Do things at the same time (parallel processing)

10 Labs and Alteplase INR only for patients on warfarin PTT only for patients on heparin CBC / platelets only for patients with suspected abnormality Creatinine only for patients with known abnormality AJNR NOVEMBER : Journal of Neurology November 2007, Volume 254, Issue 11, pp ; 38:

11 Improving DTN in a system: Kaiser Permanente Northern California (KPNC) 3.8 million members 21 Medical Centers 17,000 square miles > 8000 physicians 75 neurologists Thousands of ED MD s + RN s

12 KPNC Acute Stroke Care: prior to 1/2016 Every KPNC hospital is primary stroke certified Each hospital with its own stroke alert process DTN variable among hospitals but across all medical centers 60% in 60 minutes Endovascular times vary by location and treating MD s

13 The Neurologist challenge Key component = early involvement of stroke neurologist Problem: small volumes cannot justify in house stroke neurologist Solution: video consultation + redesigned process

14 Teleneurology Hub Small core group of stroke specialist neurologists who are involved in all stroke alerts Remote exam by teleneurologists with RN / ED MD assistance Active 7am midnight 7 days a week (rate very low in off hours) Neurologist orders the t-pa and runs the stroke code

15 Serial vs. parallel processes Patient arrival Roomed in ED OLD: Serial Transport NEW: Parallel Stroke alert called Patient arrival RN evaluation ED doctor evaluation Stroke alert called CT ordered Lab drawn Transport to CT CT done Transport back to ED Neurologist involvement CT read and called to ED doc Ambulance arrival Ambulance called CTA resulted CTA done Back to CT for CTA Alteplase pushed Lab Resulted Alteplase prepared Stroke Neurologist involvement Transport Ambulance arrival Team evaluation in ambulance bay: ED, RN, Stroke Neurology Alteplase, CT, CT, CTA< ambulance ordered Transport to CT Alteplase given (in CT) CTA done Alteplase prepared CT read and called to teleneurology Call to Neuro Alteplase ordered

16 April 2015 Sept 2016 ED DTN Results # of Stroke Cases that received TPA % Door-to-Needle TPA < 45 mins All sites live! % Door-to-Needle TPA < 45 min 16

17 Results: All Facilities Median DTN

18 Results: All Facilities First quarter 2015 Median = 54 minutes, 3% < 30 minutes 38 cases per month First quarter 2016 Median = 32 minutes, 45% < 30 minutes 80 cases per month

19 Identification and transfer for large vessel occlusion Order CCT ambulance BEFORE even getting initial CT in selected patients CTA on nearly all patients - without leaving CT scan Adds about 4-5 minutes With two IV lines we can do CTA while alteplase is infusing Immediate reading by neuroradiology Teleneurologist contacts endovascular treatment center

20 Rapid transfer Early order of CCT rig vs 911 ambulance with nurse ride along Prep patient before leaving Gown Groin prep Foley Sign out on phone as rig is coming Grease the wheels with accepting center Rapid door to groin One call referral Ideally able to review images

21 2016 arrival at outside hospital to groin at RWC SWIFT PRIME OH Arrivals SWIFT PRIME CSC Arrivals

22 SWIFT PRIME Current KP OH arrival to CSC average

23 Complications? 2014 symptomatic bleed rate : 4.5% 2016 symptomatic bleed rate: 4.3%

24 Field based diversion vs rapid treatment and transfer 18% of acute strokes need endovascular treatment 82% DO NOT 5% of patients identified with acute strokes by paramedics need endovascular treatment 95% DO NOT Field based diversion advantages the few to the detriment of the many

25 Endovascular treatment first give IV t-pa 82% of acute ischemic strokes arriving in time window DO NOT have a large vessel occlusion Patients with large vessel occlusion benefit from IV t-pa Large strokes with vessel occlusion (NIHSS>10) substantially benefit from t-pa with 35% vs 17% having good outcome (NNT = 7) Stroke 2013 Nov 44(11):

26 Conclusions World class DTN times can be achieved in a network of community hospitals Rapid IV t-pa treatment > identification of LVO > transfer > endovascular treatment is possible across a large geographic network of community hospitals Successful field based diversion is unlikely to be practical and would likely be inferior to rapid treatment and transfer

27 Thank You KP EXPRESS (EXpedited PRocess for Evaluating and Stopping Strokes) KPNC Stroke FORCE (Fast Operating Remote Cerebrovascular Experts)

28 Building County Wide Program Population engagement and education DTN improvement efforts Expedited transfer protocols Facilitated imaging, contact, information exchange Expedited door to groin Results sharing