Statewide Acute Stroke Triage The Washington Story David Tirschwell, MD, MSc Medical Director of Comprehensive Stroke Care Professor, Department of Neurology UW Medicine Comprehensive Stroke Center at Harborview UW School of Medicine
Outline The problem Stroke Facts from 2000s The process The recommendations The LAW The rollout (then the pull back!) The update
Stroke Facts 15 million/yr worldwide strokes 5 million die 5 million permanently disabled Incidence decreasing in developed countries, but absolute numbers continue to increase Better BP treatment, less smoking Aging populations Washington State Stroke 2005 3 rd leading cause of death, 3,167 deaths > 13,000 hospitalizations $321,000,000 in hospital costs (equal amt. in nursing home costs) http://www.who.int/entity/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf http://www.doh.wa.gov/cfh/heart_stroke/publications/ecs-report.pdf
The Process CDC funding to WA DOH included emphasis on emergency care for stroke Emergency Cardiac and Stroke Workgroup Technical Advisory Committee (ECS-TAC) Work began in 2006 Report with Recommendations approved in 2008
http://www.doh.wa.gov/cfh/heart_stroke/publications/ecs-report.pdf
Prevention Recommendations Education: healthy life style, risk factors, signs and symptoms Early recognition and treatment Education: know the signs and symptoms, call 911 Data collection and quality improvement Prehospital care, triage Hospital care level, self identification
The Law signed March 2010
SSHB 2396 Key Points It is the intent of the legislature to support efforts to improve emergency cardiac and stroke care in Washington through an evidence-based coordinated system of care By January 1, 2011, the department shall endeavor to enhance and support through: Encouraging hospitals to voluntarily self-identify cardiac and stroke capabilities/levels Adopting cardiac and stroke prehospital patient care protocols, patient care procedures, and triage tools, consistent with the recommendations of the ECS-TAC
SSHB 2396 Key Points A hospital that voluntarily participates Shall participate in internal/regional QI Shall participate in a data collection system that includes consensus measures for stroke May advertise participation in the system Report to legislature by 12/1/12 Protects from disclosure emergency cardiac and stroke care QI activities at the regional level
WA State Stroke Facility Self-Identification Level 1 (Comprehensive) Stroke Centers personnel, infrastructure, and expertise to Dx/Rx stroke patients who require intensive medical and surgical care, specialized tests, or interventional therapies Large ischemic strokes or hemorrhagic strokes Endovascular therapies Neurosurgery always available 2005 Brain Attack Coalition (BAC) paper on comprehensive stroke centers Level 2 (Primary) Stroke Centers Staffing and infrastructure to stabilize and treat most acute stroke patients consistent with the Joint Commission criteria for PSC certification in 2007 Level 3 Acute Stroke Capable capability to care for acute stroke, including administration of IV t-pa Most patients would be transferred to a Level 1 or 2 stroke center Encouraged to partner with higher level stroke centers http://www.doh.wa.gov/forpublichealthandhealthcareproviders/emergencymed icalservicesemssystems/emergencycardiacandstrokesystem
Case Presentation 75 yo woman with new right sided weakness and trouble speaking Husband calls 911 EMS initial evaluation reveals: BP 190/110, HR 85 regular, no dyspnea PMH of HTN, diabetes Symptoms came on acutely, 1 hour ago What s next?
First Approved Stroke Triage Tool
Any chance this is a stroke?
Sensitive screening test
Level 1,2,3????
Nearest vs. Highest level
FAST+, <3.5 hrs to destination Intent is to maximize chances of patient getting IV tpa as quickly as possible Best evidence based treatment for acute ischemic stroke More likely to help the earlier it s given Gives hospital 60 min from door until treatment window closes (at 4.5 hrs) Nearest vs. highest may vary depending on local conditions and resources
Alternative Case History Symptoms instead identified upon awakening at 8am; but a 4am was awake, went to bathroom, and was fine Where to now?
Intra-arterial therapies (IA) Lower level of evidence at time Circulation. 2009;119:2235-2249
Additional Case History Symptoms instead identified upon awakening at 8am; went to bed at 11pm and did not wake up at all overnight Where to now?
Closest participating hospital If Level 3, many patients would be transferred to higher level Initial evaluations begun Patient stabilized Level 2 vs. 1, mode of transfer, can be decided based on Patient factors (e.g. stroke type, severity, etc.) Regional factors (e.g. distance to Level 2 vs. 1, referral patterns)
Why Level 2 or 1? Greater resources dedicated to providing high quality stroke care Stroke Units Dedicated physical ward with collaborative multidisciplinary care and specialized training 14% decreased odds of death recorded at final (median one year) follow up 18% decreased odds of death or institutionalised care 18 % decreased odds of death or dependency Cochrane Systematic Reviews, 2007, Issue 4.
The Rollback Big influential hospital Level 2 Stroke Center No endovascular - Uproar - WSHA got involved - Lesser evidence for endovascular noted - Modification demanded, made Patient Acute Stroke Called 911 3.5-6 hours Smaller hospital Level 1 Stroke Center
No time criteria 2012 present
Prehospital Stroke Triage (the update) WA State MPD Meeting June 6, 2016 Presented by David Tirschwell, MD on behalf of the Emergency Cardiac and Stroke TAC
Outline Why change? Evidence for thrombectomy What to change? Destination for select patients How to change? Choice of prehospital severity scale Time frame for diversion Questions, Arguments New triage destination procedures
Case Prenotification, HMC stroke team waiting for patient 3.5h from onset NIHSS = 11 right hemiparesis right facial droop diminished sensation Dysarthria mild anomia and mildmoderate word-finding difficulties M4 L ASPECTS = 10 2 = 8
Door to puncture 38 minutes Door to intervention 41 minutes NIHSS down to 3-4 including an immediate reduction after procedure Discharged home
Why change? Evidence for Thrombectomy 5+ RCTs have consistently shown benefit NNTs vary from 3-7 patients for 1 additional excellent outcome Varying inclusion criteria Most consistent features included in new AHA Guideline Minimizing time to Rx still paramount Stroke. 2015;46(10):3020-35.
Thrombectomy Candidates Patients who should get thrombectomy with a stent retriever (Class I; Level of Evidence A): Prestroke mrs score 0-1 Acute ischemic stroke w/ IV tpa within 4.5h Occlusion of the ICA or proximal MCA (M1) (LVO) Age 18 years NIHSS score of 6 ASPECTS of 6 Groin puncture possible within 6h of LKW Stroke. 2015;46(10):3020-35.
Destination What to change? Destination for select patients Limited # of hospitals perform thrombectomy WA Hospital Stroke Levels Level 1 - ~Comprehensive, do it all, including thrombectomy 24/7 Level 2 - ~Primary, some can perform thrombectomy 24/7 Level 3 - ~Acute Stroke Ready, ED care including IV tpa, most patients transferred, NO thrombectomy Diversion to thrombectomy hospitals
What to change? Destination for select patients Select patients Those that present early Last known well < 6 hours subset of possible strokes Those that appear to have severe stroke Increases probability of large vessel occlusion A number of scales have been evaluated to identify A further subset overall small % diverted
How to change? Choice of prehospital severity scale 3 Item Stroke Scale 3ISS, Stroke. 2005;36:773-776 Los Angeles Motor Score LAMS, Stroke. 2008;39:2264-2267 Rapid Arterial occlusion Evaluation RACE, Stroke. 2014;45:87-91 Cincinnati Prehospital Stroke Severity Scale CPSSS, Stroke. 2015;46(6):1508-12
Clinical Items Level of consciousness Gaze Motor Fxn Aphasia (left) Agnosia (right) 3ISS LAMS RACE CPSSS X X Gaze + head X Hemiparesis X Face,arm,grip X Gaze + head X Face,arm,leg X X X X Gaze X Arm Simple Overlaps with FAST Reasonable performance
How to change? Time Frame for Diversion Key concepts and components of a modern stroke system of care in the United States These elements will vary in different parts of the country The general approach and principles should be useful to many healthcare professionals Stroke. 2013;44:2961-2984
How to change? Time Frame for Diversion Stroke. 2013;44:2961-2984
Stroke. 2016;47:1965-1967
LVO Triage to Closest PSC? YES Go to closest PSC Only a small % will qualify for thrombectomy We cannot accurately diagnose LVO in the prehospital setting Prevents IV tpa delay Keeps patient in their local community NO Bypass to CSC IV tpa less effective for LVO Avoid time delays of between hospital transfer Up to 2 hours increase in DTP Improve outcomes via more timely thrombectomy CSC may give IV tpa faster (lower DTN times) Stroke. 2016;47:1965-1967
New
LAMS (Los Angeles Motor Scale)
2016 WA Stroke Triage Final vote September 21, 2016 Initial and conservative test of diversion Only a short time differential allowed Only effects small areas surrounding Level 1 and Level 2 with endovascular center Most of WA unaffected by change Does demand follow up QI follow up mandatory for diverted patients 24/7 endovascular services must be clear and consistent (verification system) Part of larger system mandated since 2010 Funding needed for verification, CQI
STROKE IS AN EMERGENCY! Time is Brain Call 911