Illinois Stroke System Policy Overview

Transcription

1 Illinois Stroke System Policy Overview Christopher T. Richards, MD, MS, FAEMS Department of Emergency Medicine, Northwestern Feinberg School of Medicine Associate EMS Medical Director, Region XI EMS System Presented to: Insert relevant presenter information Calibri 16pt Chair, Illinois State Stroke Advisory Sub-committee Presented on: Month day, Year November 18, 2016 Presented by: Insert relevant presenter information here

2 Conflicts None

3 Overview Evidence Base for Illinois Stroke Systems of Care Legislative Process for the Illinois Stroke System Implications for EMS Systems and Stroke Systems of Care

4 Incidence and Etiology of Stroke 800,000 people experience a stroke each year 1 every 40 seconds! Important cause of death and disability $33 billion direct and indirect costs of stroke Causes: 13% 87% Mozaffarian et al. Circulation. 2016

5 Incidence and Etiology of Stroke in Illinois Courtesy: R. Leidig, IDPH

6 Treatment: IV tpa Since 1995, mainstay of treatment has been intravenous tissue plasminogen activator (IV tpa)

7 Treatment: IV tpa Treatment: IV tpa But: Only 18% of acute stroke patients receive IV tpa Not everyone is eligible 6.4% risk of bleeding after IV tpa administration Limited time window 4.5 hours maximum for onset of symptoms Messe et al. Neurology. 2016

8 Endovascular Reperfusion Therapy Endovascular Reperfusion Therapy (ERT) is an alternative/complement to IV tpa Originally seen as an option for: Contraindications to IV tpa Posterior circulation strokes Severe stroke syndromes with persistent occlusions seen on imaging after IV tpa Initial trials did not support ERT as a therapeutic option

9 New ERT Studies 2015, 5 clinical trials that dramatically changed therapeutic options with ERT for acute stroke ERT in addition to IV tpa 26.5% 46.0% Goyal et al. Lancet. 2016

10 Key Differences of New ERT Studies Patient Selection Large Vessel Occlusions Perfusion Imaging Prabhakaran et al. JAMA. 2015

11 Key Differences of New ERT Studies Time to therapy Older Studies New Studies Prabhakaran et al. JAMA. 2015

12 Key Differences of New ERT Studies Time to therapy Fransen et al. JAMA Neurol. 2015

13 Acute Stroke Care: Time Matters Benefit of treatment is time dependent!

14 Stroke Chain of Survival: Every Link Matters Detection Dispatch Delivery Door Data Decision Drug Dispo

15 Timely Care Starts with Layperson Recognition Messaging by several professional societies that recognition of stroke symptoms is critical FAST is endorsed by AHA/ASA as a good screen by laypersons

16 9-1-1 Dispatch Call Taking Information Gathering Caller Contacts Call-taker Determines Type of Emergency Pre- Arrival Instructions Ambulance Dispatched

17 EMS Detection of Acute Stroke When EMS providers detect stroke, patients benefit: Shorter on-scene time Direct transport to stroke centers Pre-arrival notification of stroke centers Quicker door to needle More patients receiving tpa

18 Direct Transport = More Patients Treated with tpa Sustained increase in percentage of patients treated with tpa after a system-wide implementation of PSC system of care Prabhakaran et al. JAMA Neurol. 2013

19 Delayed Recognition = Less Chance of ERT Odds of ERT decrease 2.5% for every minute of transfer time between hospitals Prabhakaran et al. Stroke. 2011

20 Illinois Stroke System of Care Recognizes: Stroke care is time-dependent Recognition of stroke signs is critical to timely stroke care Stroke center designation is important to ensuring consistent stroke care Acute Stroke Ready Hospitals Critical access to stroke care Primary Stroke Centers Advanced stroke care and after care Comprehensive Stroke Centers Includes consistent ERT Data collection is important to evaluating system performance

21 History of Illinois Stroke Systems of Care 2003: Creation of the Illinois State Stroke Task Force : legislative allies and supporters identified 2009: Introduction and passage of HB : P.A , signed and effective January 1, 2010 Courtesy: J. Mirostaw

22 PA : Illinois Stroke Law Establishes a statewide stroke system of care IDPH designation of PSCs and Emergent Stroke Ready Hospitals State Stroke Advisory Subcommittee comprised of a variety of experts and stakeholders, tasked with advising IDPH on stroke-related issues Regional Stroke Advisory Committees Advises regional EMS medical directors on stroke policy and facilitating the creation of new regional stroke protocols, protocols are approved by the EMS director and the IDPH Courtesy: J. Mirostaw

23 Updates for Advanced Stroke Care: HB : Introduction of HB 5742, update to 2009 legislation This legislation is based off of recommendations from the State Stroke Advisory Subcommittee 2014: HB 5742 passes and is signed by Gov. Quinn, becoming P.A , effective 01/01/15 11/06/2015 draft rules posted for public comment by JCAR, public comment ends 12/21/15 04/2016 rules unanimously pass JCAR 06/2016 rules officially published becoming law Courtesy: J. Mirostaw

24 New Stroke Legislation: PA Stroke Center Designations: Adds Comprehensive Stroke Centers Changes Emergent Stroke Ready Hospital to the more nationally accepted Acute Stroke Ready Hospital Acute Stroke Ready Hospitals can receive IDPH designation Creates the Stroke Data Collection Fund Fees from designation applications are allocated to a statewide stroke registry, with additional funds going towards a stroke coordinator or other stroke-care initiatives under the IDPH Courtesy: J. Mirostaw

25 IDPH Stroke Advisory Subcommittee

26 Certifying Agency Recommendations

27 Long but Fruitful Process 2003 Creation of the Illinois State Stroke Task Force, promoting dialogue about systems policy 2010 P.A signed & in effect 01/01/ Rules Formation of State published Stroke Advisory Subcommittee August 2014 HB 5742 is signed & became P.A , effective 1/1/15 April 2016 Rules pass JCAR unanimously June 2016 Rules are officially published in the Illinois Register Today Introduction and passage of the House Bill 2244, PSC legislation w/in EMS Act Introduction & passage of HB 5742, updates to 2009 legislation 2014 Rules posted for 45 day public comment period November Legislative allies and supporters identified Joint Commission on Administrative Rules process for implementation of Public Act Courtesy: J. Mirostaw

28 Illinois is a Leader in Systems of Stroke Care Courtesy: J. Mirostaw

29 Illinois is a Leader in Systems of Stroke Care Courtesy: J. Mirostaw

30 Impact on Designation 73 acute stroke ready hospitals 58 primary stroke centers 10 comprehensive stroke centers Courtesy: R. Leidig, IDPH

31 Impact on Patients and Stroke Care Door-to-Needle <60 minutes Courtesy: J. Mirostaw

32 Impact on Patients and Stroke Care Prenotification for Stroke Courtesy: J. Mirostaw

33 Future Steps Operationalization of IDPH Stroke Registry Data elements Software host Funding sustainability Evaluate state-wide data metrics EMS systems to incorporate ASRH, PSC, and CSC into regional stroke protocols National quality metrics for stroke: EMS Compass Project

34 Thank you! Questions? Contact:

35 References Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet Messe SR, Khatri P, Reeves MJ, et al. Why are acute ischemic stroke patients not receiving IV tpa? Results from a national registry. Neurology 2016;87: Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016;133:e Prabhakaran S, Ruff I, Bernstein RA. Acute stroke intervention: a systematic review. JAMA 2015;313: Prabhakaran S, O'Neill K, Stein-Spencer L, Walter J, Alberts MJ. Prehospital triage to primary stroke centers and rate of stroke thrombolysis. JAMA neurology 2013;70: Prabhakaran S, Ward E, John S, et al. Transfer delay is a major factor limiting the use of intra-arterial treatment in acute ischemic stroke. Stroke 2011;42: