Update on Stroke in South Carolina: REACHing to Treat More Patients using Telestroke

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1 Update on Stroke in South Carolina: REACHing to Treat More Patients using Telestroke 1 Robert J Adams MS MD Professor of Neuroscience University Eminent Scholar Director South Carolina Center of Economic Excellence Director MUSC Stroke Center Medical University of South Carolina Charleston, SC 29425

2 MUSC Stroke Team Robert J Adams MS MD Director August 07 Marc Chimowitz MD Center Co Director Mar 08 Tanya Turan MD Stroke Neurologist Mar 08 Quill Turk MD Interventional Neuroradiology Sept 07 Ray Turner MD Interventional Neurosurgery Jul 08 Paul Ellegalla MD Vascular Neurosurgery Jul 08 Julio Chelela MD Neuro Critical Care July 05 Angela Hays MD Neuro Critical Care Jul 07 Christatos Lazarides MD Neuro Critical Care Jul 08 Nick Papamitsakis MD In Patient Stroke Director Nov 06 Ellen Debenham RN Reach Clinical Project Manager Mar 08 Ed Jauch MD, Emergency Physician Stroke Jul 08 Elizabeth Grannell RN JCAHO PSC Stroke Manager Jan 09 Imron Chaudary MD Interventional Radiology Jul 09 Christine Holmstedt DO Fellow/Instructor Oct 09 2

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4 Disclosure Speaker for pharmaceutical companies Boehringer-Ingelheim (also on Ad Board) Sanofi-Aventis, Bristol-Myers Squibb (on Ad Boards) Novartis, Genentech No stock or ownership in pharmaceuticals except as might be retirement plans etc that I am unaware of Inventor/Stockholder in ReachCall Inc, a for-profit Georgia corporation marketing a web based system to provide urgent stroke and other medical consultation

5 Stroke Care Organization organization the act of being organized or of organizing innovation the introduction of something new The Past No specific treatments for stroke No special hospital protocols No special in house destinations No specially trained teams No monitoring of measurements, processes or outcomes Great geographic variation in stroke expertise

6 Stroke Care Organization The present and future Treatments for some strokes Protocols for EMS stroke management Protocols for ED Protocols for inpatient care and follow up (GWTG) Certification of Acute Stroke destinations as Primary Stroke Centers Leveraging of Stroke Experts via telemedicine Provider training programs (NCQU)

7 Stroke Care Organization There are still gaps: What happens in the field after 911 call (or not) is often not captured When patients leave the hospital they fall off the grid We don t have treatments for many strokes and for chronic phases of brain injury The promise of managed care has largely gone unrealized as MCO s may not make the long term investment in stroke prevention

8 Stroke South Carolina has one of the highest stroke rates in the US High rates among minorities Compared to national data the probability of being < 65 with stroke is 40% higher is SC!!!! Great human and financial burden on South Carolina

9 Acute Stroke Treatment 1) Proven and Approved: IV alteplase minutes from onset 2) Proven but not (yet) Approved: IV alteplase minutes from onset 3) Somewhat proven and sort of Approved: Intra-arterial clot removal 4) Unproven but still hoped for: neuroprotection 9

10 AHA/ASA Guidelines Recommend Rapid Treatment With tpa for Eligible Patients Intravenous tpa is the only FDA-approved drug for the treatment of patients with acute ischemic stroke Treatment with tpa is associated with symptomatic intracranial hemorrhage (ICH) NINDS trials: risk of symptomatic ICH = 6.4% Given the narrow therapeutic window for treatment, the guidelines provide many recommendations for optimizing efficiency of stroke assessment and care Adams at al. Stroke. 2007;38(5): ; Graham. Stroke. 2003;34: ; Wahlgren et al. Lancet. 2007;369(9558):

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14 Stroke in South Carolina tpa usage rates in SC are very low~ 1.5% (based on 2006 data) (should be 15-20%) Increase use by increasing JCAHO certified Primary Stroke Centers we have 5 we need at least 10 web enabling many other ED s using REACH ---we have 6 REACH sites now and need at least 24 strategically dispersed around the state 14

15 Improving Access to Urgent Stroke Care in South Carolina Increase number of JCAHO certified Primary Stroke Centers web enable many other sites using REACH system 15

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17 Stroke in South Carolina What is REACH? Web based system whereby remote (based at HUB ) stroke or other specialist can Interview family and patient See and examine the patient View the brain imaging Provide formal consult to ED regarding urgent care that is documented immediately and is part of record 17

18 Telemedicine for Stroke

19 Viewing CT Scan

20 Initial Screen at Spoke Site

21 Viewing CT Scan

22 REACH Improvements in Care In the 12 months prior to implementing REACH, only 27 patients were treated with tpa at our six spoke sites Within 12 months of implementation patients will have been treated with tpa The treatment rate will be increased by a factor of ~ 2.4 REACH MUSC response time: average of 11 minutes from call to MUSC to consultant log into REACH website

23 As for the problems, I have not had a problem with the system. I have been really happy with the system so far. The neurologists have been so easy and great to work with. I feel patients are getting a more thorough evaluation with the help of the neurologist that is basically 'at the bedside,' and TPA is being giving in a timely manner when appropriate. I'm really excited to be a part of this new program and hope it will continue indefinitely. Heather Justice, MD Emergency Medicine Georgetown Memorial Hospital Thanks Heather Justice, MD

24 Site Start Date Consults as of 2/2/10 tpa Indicated tpa Given Transport to MUSC Treated with tpa Transfer to MUSC Georgetown 5/1/ % 57% Waccamaw 5/6/ % 47% McLeod 5/7/ % 14% Grand Strand 9/1/ % 79% Marion 9/18/ % 54% Williamsburg 12/23/ % 73% Coastal Carolina 1/20/ % 100% Kershaw 2/22/10 Pending Piedmont 3/22/10 Pending Totals

25 Deciding if IA should be attempted Brain Attack CT Package Non contrast CT for IV tpa decision (< 4.5 hours) CT angiography---is there a large artery clot? CT perfusion---is there a clot producing a reduction in blood flow to a significant part of the brain? CT Blood Volume---is the area viable? CT not as well studied as MR techniques CT approaches not fully proven for prime time

26 Rescue Therapy 1) Intra-arterial clot removal---window 6-8 hours or beyond depending on CT perfusion/volume 2) Hemicraniectomy shown to improve survival 3) Research protocols VAST (new thrombolytic) SENTIS (partial aorta obstruction with catheter to augment collateral flow) IMS III NINDS study of IA following IV tpa

27 Rescue Therapy-potentially salvageable case

28 Rescue Therapy probably not salvageable

29 Rescue Therapy

30 Penumbra Device

31 Kingstree, South Carolina Birthplace of Joseph L Goldstein, winner of 1985 Nobel Prize in Medicine (with Michael Brown) on LDL and cholesterol metabolism 31

32 Recent Case from Kingstree Case JB, from last night at Kingstree SC (pop 3496) 52 year old with onset partial aphasia and right hemiparesis, unclear onset but probably 10 am REACH MUSC consult at 6:30 pm NIHSS of 12, CT no change, sent to MUSC CT Perfusion showed mismatch and angio showed M1 occlusion at 9:30 pm M1 cleared with IA tpa; deficit partially resolved

33 Stroke Care Organization Programs such as GWTG are changing the way stroke care is delivered for the better Center certification provides stamp of approval to sites State wide planning is going on Destinations Delivery systems How to link them most effectively? Legislative study committee to report December 2010 Outpatient programs needed to track patients to help keep them in optimal treatment

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36 Next course July 15-19,