Stroke Systems of Care Sharon Webb, MD, FAANS, FACS, FAHA
Disclosures No Disclosures
Objectives Describe Systems of Care Describe stroke levels of care Discuss SC stroke council state Initiatives
What is the systems of care? When it comes to stroke and heart disease, the systems of care incorporates the coordination of care along the following continuum: 1. Primary prevention 2. Notification and response of emergency medical services (911 and EMS) 3. Acute treatment 4. Sub-acute care and secondary prevention 5. Recovery and rehabilitation 6. Continuous quality improvement initiatives
Why are systems of care important? To prevent the incidence and death of stroke, it is important to address the whole system from prevention to rehabilitation. The health threats that the systems of care is designed to fight against are some of the leading causes of death in America. For example, stroke, heart attack, trauma. If every state implemented a strong systems of care, we could help reduce heart disease and stroke deaths among Americans by 20 percent by the year 2020.
What specific improvements can be made to the systems of care? States can officially recognize the best medical centers to treat stroke to ensure that the best care is delivered promptly States can develop a registry to track the response and outcome of each incident in order to discover and implement future improvements in the systems of care States can mandate the utilization of EMS transport protocols to ensure that all patients having signs or symptoms of stroke be transported to the nearest appropriate certified stroke center. Positive patient outcomes are reliant on specialized care and quick treatment that can be found in certified stroke hospitals
Stroke Systems of Care Study Committee Report (S*26) (November 30, 2010) Recommendation summary (Primary Recommendations are listed in bold) 1. Support evidenced-based policy and systems changes which promote stroke prevention such as increasing the number of hypertension specialists in SC. Support campaigns to enhance public education and awareness of stroke. Provide resources to implement strategies to reduce stroke treatment disparities. 2. Establish hospital designation based on level of stroke care through designation by DHEC so that EMS can transport patients to the most appropriate, facility. Fund a full-time position, to be managed through DHEC's EMS Division, to establish and monitor regulations relating to hospital designation. 3. Ensure tele-health coverage through both public and private Insurance providers. 4. Ensure adequate coverage by private and public payers (including Medicaid) to provide stroke rehabilitation in free-standing interdisciplinary rehabilitation hospitals and home health based on need. 5. Offer tax credits, or limited state income tax, for stroke rehabilitation professionals in underserved areas including physiatrists, physical therapists, occupational therapists, and speech therapists. 6. Establish a statewide stroke registry, which will capture and link data on pre-hospital, hospital, and rehabilitation services. 7. Establish a statewide stroke steering committee to evaluate Implementation, adherence, and continuous improvement of the recommended changes. 8. Establish a full-time position, to be managed through DHEC's Heart Disease and Stroke Prevention Division, to implement the state stroke plan.
Stroke Systems of Care Act of 2011 Establish hospital designation Establish a statewide stroke registry EMS triage tool EMS transport protocols Establish a statewide stroke steering committee
Establish a Statewide Stroke Steering Committee
Stroke Advisory Council Responsible for advising the department through the Bureau of EMS on all things related to stroke systems of care within the State. Like the EMS advisory Council, the members of the Stroke Advisory Council have the power to bring issues before the Council, make motions, and vote on matters that they see appropriate. Advisory Councils within the State have tremendous power and influence on system development and improvement.
Establish Hospital Designation
Stroke Levels of Care Acute Stroke Ready Hospital Primary Stroke Center Comprehensive Stroke Center
Stroke Hospital Certification CSC PSC ASRH Stabilize All Stroke Types Stabilize/Transfer All Stroke Types Role Treat All Stroke Types Treat Most Ischemic Strokes IV tpa for Ischemic Strokes Available 24/7 Available 24/7 Available 24/7 Actue Stroke Team Bedside within 15 min Bedside within 15 min Bedside within 15 min Neuro-ICU Stroke Unit Stroke beds (not ICU) none required with 24/7 neuro-intensivist Routine Imaging CT/MRI (24/7) CT/MRI (24/7) CT/MRI (24/7) 24/7 CTA, MRA, angiogram, not required Advanced Imaging CTP, TC doppler, carotid doppler, not required (except 1 cardiac imaging) TTE & TEE Neurologist Neurosurgery 24/7 in person, able to handle multiple complex pts Available 24/7, able to handle aneurysm clipping, AVM resection, carotid endartectomy 24/7 in person or telemedicine 24/7 in person or telemedicine Access within 2 hours (at center or transfer) Access within 3 hours (at center or transfer) Neurosurgery OR Available 24/7 Available 24/7 only if NSGY at center not required Endovascular Available 24/7 not required not required IV tpa, open neurosurgery, Minimum Treatment endovascular treatments IV tpa IV tpa protocol for transfer to CSC for Transfer Protocols accepts from PSC/ASRH neurosurgery/endovascular protocol for transfer to CSC/PSC Minimum Yearly Volume Education Research 20-25 SAH 10-15 aneurysm treatments 25 IV tpa (50/2 years carotid treatment variable Prehospital personnel education Public stroke education (2/yr) Internal educational courses (2/yr) IRB approved patient-centered research none required Prehospital personnel education Public stroke education (2/yr) none required none required Prehospital personnel education none required
Accreditation Organizations
Primary Stroke Center Mostly urban and suburban Typically 300+ stroke patient admissions per year Same level of care 24/7/365 All attributes of acute stroke ready, plus.
Primary Stroke Center Collaboration with EMS providers. Access to stroke treatment & destination protocols. Provide support to remote area hospitals. Transfer protocols to primary or comprehensive stroke center, when needed.
Primary Stroke Center Neuroimaging 24/7 basis: Able to obtain brain image within 25 minutes and interpretation within 20 minutes of completion. Advanced imaging: MRI with diffusion Vascular imaging (MRA, CTA, carotid doppler) Cardiac imaging (TTE, TEE, or cardiac MRI)
Primary Stroke Center Laboratory Services: Stroke labs within 45 minutes from order on 24/7 basis. ECG and chest x-ray within 45 minutes from order, when clinically indicated. Outcome and quality improvement activities. Community educational programs.
Primary Stroke Center Neurosurgeon available within 2 hours of need identified. Or written transfer plan to facility with this capability. Operating room capability 24/7.
Primary Stroke Center Stroke Units Does not require specific enclosed unit, but must be a unit where majority of patients are admitted where staff have annual education & specialized experience in caring for the stroke patient.
Primary Stroke Center Rehabilitation Services: Speech Language Therapy Physical Therapy Occupational Therapy Assessment and early initiation of a plan.
Primary Stroke Center, Metrics Stroke Core Measures Volume of Ischemic, TIA, ICH & SAH admits Acute Stroke workup times: Door to CT Door to lab results Door to EKG & CXR IV tpa volume, door to needle times
Must show that you deliver care based on these published guidelines.
Comprehensive Stroke Center Everything we ve discussed so far, plus Health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology. Advanced neuroimaging capabilities, such as MRI and various types of cerebral angiography, 24/7/365, most within 30 minutes of clinical need. Surgical and endovascular techniques, including clipping and coiling of intracranial aneurysm, carotid endarterectomy and stenting, and endovascular treatments for ischemic stroke. Infrastructure and programmatic elements such as a dedicated neuro intensive care unit staffed with neurointensivists. Post hospital care coordination. Extensive data collection and peer review process. Participation in stroke research.
Comprehensive Stroke Center Increased data collection requirements. Examples: Ischemic stroke % of patients who received IV tpa in 60 minutes from arrival % who arrive in less than 6 hours of onset who were considered for endovascular tx 90 day modified Rankin scores Hemorrhagic stroke Initial severity scores documented (ICH & SAH) Procoagulant reversal times for ICH Median time from admit to surgical or endovascular tx for aneurysm % of patients who receive nimodipine within 24 hours of admit Serious complication and mortality rates for CEA, aneurysm coiling & clipping, carotid stents, thrombectomies, decompressive cranis, ventriculostomies, EVD s & transduced lines, cerebral angiograms. Follow-up calls on complex stroke patients within 7 days of discharge.
Comprehensive Stroke Center Enhances the ability to analyze and optimize how patients move through the system (EMS on through back into community). It allows for more team thinking of how we all work together to provide an efficient & optimal patient experience, rather than just thinking in silos about what occurs in and would work best for my own department. Regular communication among stakeholders through an organized committee/advisory group structure helps to reinforce the team concept, helps to identify common goals, sets clear priorities, and builds positive working relationships.
GHS Stroke Team CORE STROKE TEAM Mahmoud Rayes, MD Neuroscience Associates & Southeastern Neurosurgical & Spine System Stroke Medical Director CSC Medical Stroke Director Clinical Lead: Stroke, Research Sharon Webb, MD Southeastern Neurosurgical & Spine Director Cerebrovascular, Endovascular, Neurocritical care CSC Surgical Stroke Director Clinical Lead: Endovascular, NICU Angel Rochester, MD GHS Emergency Medicine Division Chief of Adult Emergency Medicine Clinical Lead: Emergency Department Shannon Sternberg, RN Greenville Memorial Hospital GHS Stroke Program Manager Core Stroke team represents Nursing, Neurology, Neurosurgery, Endovascular, Neurocritical Care & Emergency Medicine STROKE ADVISORY TEAM Physician: Neurology, Neurosurgery, Emergency, Radiology, Physiatry, Hospitalist Nursing: ED, IP, NeuroRadiology Laboratory Pharmacy Radiology Rehab Therapy Nutrition Hospital Case Management Quality Management Referral Center EMS
Future of Hospital Certification JCAHO: Thrombectomy-Capable Stroke Center 4 th designation + thrombectomy and ICU care - neurosurgery/endovascular capabilities for other stroke types 12 thrombectomies/year, 2 operators SNIS: Neuro-Endovascular Ready Add on State designation (like Trauma) + thrombectomy capable 36 thrombectomies/year, 2 operators, proper training
EMS Triage Tool
EMS Transport Protocols
GC EMS CVA Protocol
Establish a Statewide Stroke Registry
Statewide Stroke Registry Will use the GWTG data but will eventually also include prehospital data from EMS and post hospital stay data from rehab facilities ALL certified hospitals will be required to participate in the state stroke registry and submit data quarterly
Power of Data Stroke Core Measures STK-1 VTE Prophylaxis initiated by hospital day 2 STK-2 Discharged on Antithrombotics STK-3 STK-4 Anticoagulation for Afib % who arrive in ED w/in 120 minutes of onset who received tpa w/in 3 hours of onset STK-5 Antithrombotics started by hospital day 2 STK-6 LDL> 100 discharged on a statin STK-8 Patient/family stroke education provided STK-10 Assessed for rehab needs PSC-7 Bedside swallow screen prior to any PO PSC-9 Tobacco cessation provided during hospital stay
Public Comment Providing public comment to SC DHEC - deadline October 23 http://www.scdhec.gov/agency/regulationsand Updates/PublicComments/
Stroke Systems of Care Does it make a difference? Compared to general hospitals, Primary Stroke Centers have: Higher tpa treatment rates Lower death rates Improved outcomes Being certified by an independent licensing body increases effectiveness of overall stroke care. The focus is on the entire continuum.
GHS Leading the Way in the Upstate
Cerebrovascular and Stroke Center
Cerebrovascular and Stroke Center
Cerebrovascular and Stroke Center
Cerebrovascular and Stroke Center
The Cerebrovascular and Stroke Service Line supports the Neurosciences/Post-Acute Services with the following GHS directives: GHS Vision: Transform health care for the benefit of the people and communities we serve. GHS Mission: Heal compassionately. Teach innovatively. Improve constantly. GHS Values: Together we serve with integrity, respect, trust and openness. CEREBROVASCULAR AND STROKE ADVISORY COUNCIL MISSION -Support Cerebrovascular and Stroke strategy and provide feedback -Improve effectiveness of patient experience -Develop increased capabilities of Caregivers -Advance awareness of Cerebrovascular and Stroke in the community -Explore advocacy engagement of organizations, both internal and external
Cerebrovascular and Stroke Fund
QUESTIONS?
Questions?
Donations can be made: Office of Philanthropy and Partnership 1. Online: http://www.ghsgiving.org/ 2. Check payable to: Greenville Health System and mail to: Greenville Health System Office of Philanthropy and Partnership Greenville Health System 300 East McBee, Suite 503 Greenville, SC 29601 3. Call the Office Of Philanthropy: 864-797-7757 If you want to discuss additional options contact: Dianne Dillon the Neuroscience and Post- Acute Philanthropy Representative at ddillon@ghs.org or 864-797-7733.