Welcome to the 2014 Quality Achievement Awards at International Stroke Conference! 3/5/ , American Heart Association 2
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2 Welcome to the 2014 Quality Achievement Awards at International Stroke Conference! 3/5/ , American Heart Association 2
3 Mariell Jessup, MD President, American Heart Association/ American Stroke Association 3/5/ , American Heart Association 3
4 Presented By: Lee H. Schwamm, MD, FAHA Executive Vice Chairman, Department of Neurology C. Miller Fisher Endowed Chair and Director, of Stroke Services, Massachusetts General Hospital Professor of Neurology, Harvard Medical School 3/5/ , American Heart Association 4
5 Eric Jordan Eric Jordan is a bass singer with the Metropolitan Opera in new York City widely known as the Opera Cowboy. Eric suffered a stroke in 2012 that initially rendered him speechless. Please join me in welcoming Eric Jordan. Accompanying Eric tonight is Alexander A. Khalessi, MD MS Dr. Alexander Khalessi serves the Division of Neurosurgery as Director of Endovascular Neurosurgery and Surgical Director of Neurocritical Care at UC San Diego Health System 3/5/ , American Heart Association 5
6 Eric E. Smith, MD, MPH, FRCPC, FAHA Medical Director of the Cognitive Neurosciences Clinic Assistant Professor, Dept of Clinical Neurosciences Joint Assistant Professor, Dept of Radiology Member, Hotchkiss Brain Institute University of Calgary Stroke Neurologist, Calgary 3/5/2014 Stroke Program 2013, American Heart Association 6
7 Mat Reeves, B.V.Sc., Ph.D Associate Professor of Epidemiology and Biostatistics Chair Department Admissions Committee Department of Epidemiology, Michigan State University 3/5/ , American Heart Association 7
8 Gregg C. Fonarow, MD, FAHA, FACC Professor of Medicine Director, Ahmanson-UCLA Cardiomyopathy Center Co-Director, UCLA Preventative Cardiology Program Associate Chief, UCLA Division of Cardiology The Eliot Corday Chair in Cardiovascular Medicine and 3/5/2014 Science 2013, American Heart Association 8
9 Celebrating Get With The Guidelines Stroke Gold Plus, Gold, Silver Plus and Silver Target: Stroke Honor Roll Primary Stroke Certified Hospitals Comprehensive Stroke Centers 3/5/ , American Heart Association 9
10 Get With The Guidelines Works! Hospitals Participating in Get With The Guidelines Provide Higher Quality Care with Better Clinical Outcomes than Other Hospitals 3/5/ , American Heart Association 10
11 3/5/ , American Heart Association 11
12 Years through 2013 Total Pubs by Program : *GWTG HF: 52 *GWTG Stroke: 49 *GWTG CAD: 46 *GWTG Resuscitation: 63 *Action-Registry GWTG: 48 *Mission: Lifeline: 6 *TGA: new program Note: Due to the transition over to ACTION Registry-GWTG, GWTG - CAD closed effective December 31, 2009 with final data entry completed on March 31, 2010 *Pubs for more than module are counted in both module *Pubs counted in year they went online or print Quality Research Programs 263 Research Publications Program Wide GWTG Heart Failure GWTG Stroke GWTG CAD GWTG Resuscitation ACTION-GWTG Mission: Lifeline 2 4 The Guideline Advantage Average 27% increase per year 2008 to
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14 Patient Records January 2003 to January ,865,59 stroke or TIA admissions at 1,691 GWTG-Stroke Participating Hospitals 3,000,000 2,856,599 2,500,000 2,376,574 2,000,000 1,942,304 1,500,000 1,525,457 1,000, ,427 1,150, , , , , , , , ,067 63, , , ,485 3,149 20, ,589 3,149 17,649 42,558 89,930 0 JAN 03 JAN 04 JAN 05 JAN 06 JAN 07 JAN 08 JAN 09 JAN 10 JAN 11 JAN 12 JAN 13 JAN 14 New Patients 3,149 17,649 42,558 89, , , , , , , , ,025 Cumulative 3,149 20,798 63, , , , ,427 1,150,66 1,525,45 1,942,30 2,376,57 2,856,59 Data source Microsoft Dynamics as of 02/04/14
15 ISC Recognition Event Attendance Year Attendance Location New Orleans Orlando San Francisco New Orleans San Diego San Antonio Los Angeles New Orleans Honolulu San Diego 3/5/ , American Heart Association 15
16 Improvement Over Time in GWTG-Stroke in the Use of IV rt-pa in Eligible Patients 100% Baseline YR1 YR2 YR3 YR4 YR5 80% 65.00% 69.10% 72.65% 72.84% 60% 53.46% 40% 42.09% 20% 0% IV rt-pa 2 Hour 3/5/ , American Heart Association 16
17 DTN Times Within 60 Minutes, % Temporal Trends in the Proportion of Patients with DTN Times 60 Minutes % 80% 60% 40% 26.3% 24.1% 26.6% 27.0% 29.1% 20% 0% Fonarow GC et al. Circulation. 2011;123: GWTG-Stroke Hospitals
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19 Target: Stroke Target: Stroke is a national quality improvement campaign of the American Heart Association/American Stroke Association designed to improve outcomes for ischemic stroke patients by helping hospitals achieve door-to-needle (DTN) times of 60 minutes or less. By participating in Target: Stroke, hospital teams can work towards eliminating delays in treating stroke patients, with the ultimate goal of improving clinical outcomes. 3/5/ , American Heart Association 19
20 The Importance of Time in t-pa Treament Hacke, W., G. Donnan, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-pa stroke trials. Lancet 2004;363:
21 Number of Patients Who Benefit and Are Harmed per 100 Patients tpa Treated in Each Time Window Lansberg et al, Stroke 2009 Benefit Harm 3/5/ , American Heart Association 21
22 Association of DTN Time 60 Minutes with in-hospital Clinical Outcomes in GWTG-Stroke 25,504 acute ischemic stroke patients treated with tpa within 3 hrs of symptom onset at 1082 hospital sites. After adjustment, DTN times 60 minutes was associated with 22% lower odds of in-hospital mortality, adjusted OR, 0.78; 95% CI, 0.69 to 0.90; P= Lower rates of sich and any tpa complications * Variables included in multivariable GEE models were age, sex, race, prior medical history of AF, stroke/tia, CHD/MI, carotid stenosis, diabetes, PVD, hypertension, dyslipidemia, smoking, NIHSS (continuous), arrival mode (EMS vs other), arrival time on hours, hospital characteristics of geographic region, academic, PSC, bed size, annual number of strokes, annual number of tpa patients. Fonarow GC et al. Circulation. 2011;123:
23 % of Sites Few Hospitals had >50% of their Ischemic Stroke Patients with DTN Times 60 Minutes ~6% % Patients with DTN Times within 60 Minutes Fonarow GC et al. Circulation. 2011;123: Among hospitals with at least 10 tpa patients (N=641) 3/5/ , American Heart Association 23
24 Target: Stroke Door-to-IV t-pa within 60 minutes for > 50% of patients 100% 80% 60% 50.0% 40% 29.1% 20% 0% DTN within 60 min 2009 Goal Fonarow GC et al Stroke. 2011;42:
25 3/5/ , American Heart Association 25
26 Target: Stroke Primary Goal Achieve a Door to Needle (DTN) Time within 60 minutes in at least 50% of ischemic stroke patients treated with IV tpa Fonarow GC et al Stroke. 2011;42:
27 Target: Stroke All The Necessary Components For timely, but safe and effective, acute ischemic stroke care, the following components are necessary: early identification of a candidate for thrombolysis activation of a stroke team evidence-based, readily assessable, effective protocols rapid ordering, acquisition, and interpretation of brain imaging accurate and rapid physician orders reliable intravenous tpa treatment administration coordinated patient monitoring ongoing assessment accurate time logs for tracking and timely data feedback Fonarow GC et al Stroke. 2011;42:
28 Target: Stroke 10 Key Best Practice Strategies 1. Hospital pre-notification by Emergency Medical Services 2. Rapid triage protocol and stroke team notification 3. Single call/paging activation system for entire stroke team 4. Use of a stroke toolkit containing clinical decision support, strokespecific order sets, guidelines, hospital-specific algorithms, critical pathways, NIH Stroke Scale and other stroke tools 5. Rapid acquisition and interpretation of brain imaging 6. Rapid Laboratory Testing (including point-of-care testing) if indicated 7. Pre-mixing tpa medication ahead of time for high likelihood candidates 8. Rapid access to intravenous tpa in the ED/brain imaging area 9. Team-based approach 10. Rapid data feedback to stroke team on each patient s DTN time and other performance data Fonarow GC et al Stroke. 2011;42:
29 Target: Stroke Honor Roll Criteria To be eligible for the Target: Stroke Honor Roll Award a hospital must: Be registered in Target: Stroke Be participating in GWTG-Stoke Currently hold Gold, Silver or Bronze Performance Achievement status in GWTG-Stroke Have DTN times within 60 minutes for at least 50% of applicable patients (minimum of 6 patients) for at least one calendar quarter
30 % Subjects It s a Home Run!!!!!!!! 60 DTN Times 60 Minutes after Implementation of Target: Stroke among GWTG-Stroke Hospitals Months /5/ , American Heart Association 30
31 If you re from a Target: Stroke Honor Roll Hospital Throw your hats up in the air! 3/5/ , American Heart Association 31
32 Get With The Guidelines 2013 Highlights More than 65 CSCs certified in the US GWTG-Afib launched and growing Acute Stroke Ready Hospital certification on the horizon Clinical Trials in GWTG: Coming Soon 3/5/ , American Heart Association 32
33 Please attend the Late Breaking Science Presentation: Date: Friday, February 14, 2014, 11:00 AM - 1:00 PM (12:47 PM) Location: Hall E Plenary Session 3 Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative Gregg C. Fonarow MD, Xin Zhao MS, Eric E. Smith MD, MPH, Jeffrey L. Saver MD, Mathew J. Reeves PhD, Deepak L. Bhatt MD, MPH, Ying Xian MD, PhD, Adrian F. Hernandez MD, MHS, Eric D. Peterson MD, MPH, Lee H. Schwamm, MD
34 Target:Stroke 2.0 ** T2: Thrombolysis Day ** Coming soon to an ED near you 3/5/ , American Heart Association 34
35 Target: Stroke Phase 2 New National Goals: Achieve DTN times within 60 minutes for 75% of eligible patients Achieve DTN times within 45 minutes for 50% of eligible patients Additional Hospital Recognition (Coming Soon) Target: Stroke Honor Roll: existing criteria Target: Stroke Honor Roll Elite: DTN 60 minutes in 75% of eligible patients Target: Stroke Honor Roll Elite-Plus: DTN 60 minutes in 75% of eligible patients and DTN 45 minutes in 50% of patients Additional Target: Stroke Resources Updated time tracker and new tools Additional strategies and evidence New educational resources
36 Congratulations to Target: Stroke / GWTG-Stroke Hospitals and Hospital Teams on your tremendous success in achieving the Target: Stroke Phase I goals! The Better Your Times, The Better Your Patient s Chances of a Full Recovery
37 Target: Stroke Status Update 1497 Unique Hospitals Registered in Program 392 Target: Stroke Honor Roll Hospitals As of January 31, 201 3/5/ , American Heart Association 37
38 Comprehensive Stroke Center Certification Launched in July 2012 in collaboration with The Joint Commission Recognizes hospitals that have specific abilities to receive and treat the most complex stroke cases. Programs that apply for advanced certification must meet the requirements for Disease-Specific Care Certification in addition to the Primary Stroke Centers certification requirements. To date, there are: 66 Advanced Comprehensive Stroke Center certified hospitals
39 Stroke Certifications Stroke Certifications Current Status February 2014* Primary Stroke Certification (PSC) (Launched December 2003) 1022 hospitals Comprehensive Stroke Certification (CSC) (Launched July 2012) 66 hospitals Total 1,088 Accreditations/ Certifications
40 What s Next With Get With The Guidelines? 3/5/ , American Heart Association 40
41 A TREAT FOR THE ELITE!
42 New Randomized Controlled Trials Task Force Observational registry data is the future of designing research trials efficiently and inexpensively. Randomized controlled trials (RCTs) are the gold standard of study designs. AHA has brought together a task force to guide the future of clinical trials within the Quality registries. 3/5/ , American Heart Association 42
43 Stroke Studies Launching NOW MaRISS ARAMIS PROSPER Expect exciting news this Spring as AHA begins study enrollment for these and others! 3/5/ , American Heart Association 43
44 Introducing: The MaRISS PROJECT Mild and Rapidly Improving Stroke Study 3/5/ , American Heart Association 44
45 MaRISS Background 795,000 annual strokes of which 85% are ischemic Mild & rapidly improving strokes (MaRISS) account for 31% to 46% of patients brought to hospital by EMS Only 10% of MaRISS patients are treated with reperfusion Rx, but MaRISS patients often don t have good outcomes In GWTG: 28.5% not independent at discharge 3 month outcomes for MaRISS patients have not been well studied The temporal profile of MaRISS is not well understood, and there is likely high variability in how these patients are classified 3/5/ , American Heart Association 45
46 MaRISS Specific Aims Overall goals: Elucidate long term outcomes of patients with Mild and Rapidly Improving Stroke Determine 90-day outcomes in MaRISS Evaluate reliability of automated patient reported outcomes (PRO) Define the predictors of poor outcome Compare safety and efficacy outcomes in those treated with IV rtpa vs. non-treated patients. 3/5/ , American Heart Association 46
47 MaRISS Interventions and Outcomes 2650 patients across 100 representative GWTG-S hospitals Primary outcome: % with a Modified Rankin Scale 0-1 at 90 days Secondary Outcomes: Barthel Index, Stroke Impact Scale and Euro-QOL at 90 days Outcomes assessed by telephone interview Subgroup will complete a web-based Patient Reported Outcome tool Site/coordinator responsibilities: Consent patient after tpa treatment decision Complete 2 extra NIHSS during hospitalization and record stroke etiology using TOAST criteria 30-day check-in telephone call 90-day telephone outcome 3/5/ , American Heart Association 47
48 MaRISS Timeline Hospital recruitment will begin mid 2014 Patient enrollment will begin late /5/ , American Heart Association 48
49 Can my Hospital can Participate in MaRISS? Study Site Requirements for Participation > 300 stroke discharges per year Ability to enroll patients over a 2 year study period High baseline completion rates of initial NIHSS in GWTG 3/5/ , American Heart Association 49
50 How to Get More Information or Enroll Please Sara Camp RN MSN ACNP CCRN Director Quality Marketing and Research American Heart Association National Center 3/5/ , American Heart Association 50
51 Congratulations to Julie Blakie From the Southwest Affiliate Winner of Lee H. Schwamm Award of Excellence 3/5/ , American Heart Association 51
52 Congratulations to Get With The Guidelines - Stroke Quality Achievement Award Hospitals! 3/5/ , American Heart Association 52
53 AMERICAN STROKE ASSOCIATION UPDATE
54 Together to End Stroke, a national initiative to educate Americans that stroke is largely preventable, treatable and beatable.
55 May, American Stroke Month 119+M Impressions
56 Fall Campaign 86+M Impressions Awarded 2 nd Place by the World Stroke Organization for our Campaign efforts
57 Spot a Stroke F.A.S.T. Campaign Received $25.1M donated media 20,800+ downloads of F.A.S.T. Mobile App
58 Legislative Gains Senate Finance Bill passed! Will permanently repeal Medicare therapy caps (begins Jan 1, 2015)
59 Let s Continue This Momentum.. Together, we can end stroke! Help us during American Stroke Month (May) and World Stroke Day, October 29! Stroke Resource Center StrokeAssociation.org/resources
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61 Special Thanks to the Dedicated Affiliate Staff and any Volunteers who made this evening possible! See you next year in Nashville, TN! 3/5/ , American Heart Association 61
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