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Sophisticated Prehospital Stroke Systems of Care


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Sophisticated Prehospital Stroke Systems of Care

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Sophisticated Prehospital Stroke Systems of Care

  1. 1. Kerry Ahrens, MD MS
  2. 2. Kerry Ahrens MD, MS Emergency Physician BayCare Clinic Medical Director Oshkosh Fire Dept Medflight Physician Co-Chair Wisconsin Stroke Coalition Associate Professor EM UW School of Medicine
  3. 3. MJ, 53 yo M 08:08 53 yo M pmh of obesity, mild aortic stenosis here as a interfacility transfer from County X Hospital with acute onset of L-sided weakness L facial droop. OSH did found large vessel occlusion L-MCA. Patient presumed to be out of tPA window at the time & tPA not given. Sent here for intervention. Neg ROS. He did have some right-sided neck pain earlier this week was unclear if it was related to today's events. His wife reports that he woke up 0500 was able to put his glasses on, stood, walked a few steps then collapsed. Wife called 911.
  4. 4. Why Build a Stroke System of Care? • Leading cause of serious long-term disability • $34 billion/yr • 5th leading cause of death • Over the past 15 yrs adults age 18-54 have had increased stroke hospitalizations • Estimated that 80% of strokes are preventable • We are not doing well at reversing this trend…
  5. 5. Why Build a Stroke System of Care? • Current standard of care: • tPA within 4.5 hours of LKWT • Embolectomy for large vessel occlusions (MCA, Carotid, Basilar) within 6 hours • Data consistent points to the quicker tPA & embolectomy are performed, the better the patient outcome* • Is an multinational problem, and we are still working towards a solution. * Khatri et al 2009, Khatri et al 2014
  6. 6. Why Build a Stroke System of Care? •Faster times yield improved outcomes (based on Modified Rankin Score)* • NNT for tPA • 4 tx within 90 min • 5 tx done 90-180 min • 7.5 tx done 180-270 min *Lansberg 2009
  7. 7. • Practical to implement & supported by existing clinical data • Goal: optimize patient care & improve patient outcomes • 14,000 stroke-related hospitalizations in Wisconsin* • 2,952 deaths d/t stroke in WI (2016) 5.19% of WI population Stroke continues to be a devastating disease resulting in life-changing disability. Survivors can require long-term rehabilitation as they integrate back into their community *Wisconsin Hospital Inpatient Discharge Data base, 2013, Wisconsin Hospital Association Why Build a Stroke System of Care in Wisconsin?
  8. 8. Why(bother to)Build a Stroke System of Care? • There is a great deal of ED resistance to using current standard of care (tPA) in treating strokes, so why build a system? • ED RN: “And they’ll go back in there and double- check that patient 7 times in order to say, oh, they’re improving, you know, as one of the relative contraindications….Their stroke score was 14 and now it’s 12 so they’re improving - we don’t have to give it. You know. Whew! That kind of a thing.”
  9. 9. Why(bother to)Build a Stroke System of Care? “A lot of it has to do with how much influence certain big-shots in emergency medicine have. There are some - one in particular who practices at Hospital X, just 10 miles down the road, he’s been very outspoken against the use of tPA. And if you ever go the the national [emergency medicine] meetings and listen to these…docs speak, they can be very convincing. And I think that has had some influence on some people.”
  10. 10. 1984 1st tPA use for STEMI 1995 NINDS Trial tPA for CVA tPA considered level 1A for CVA Tx by: The Great tPA Debate Timeline 2008 European Stroke Assoc 1996 FDA Approval CVA 2002 AAEM data insufficient to warrant tPA for CVA as standard of care Canadian Stroke Network, Australian Nat’l Stroke Foundation 2010 2012 Japanese Stroke Soc, ACCP Amer Acad Neuro 2002 ACEP “insufficient evidence to endorse tPA” 2013 ACEP 2017 ?
  11. 11. Emergency Medicine Physician Monthly 3/2014 on-line Poll
  12. 12. The Data is out there: tPA & Embolectomy are effective treatments for a disease that had no previous treatment
  13. 13. Our Mission Improve EMS ability to detect patients with LVO in the field 1 Understand Endovascular Therapies will improve with more data & more experience1 Despite a tPA times, improvement in field to puncture times have not improved in 10 years2 1. Stroke. 2016; DOI: 10.1161/STROKEAHA.115.011149. 2. Journal Of NeuroInterventional Surgery. 2016.
  14. 14. Rise UpRise Up! • Many Healthcare Facilities have risen to this challenge ‣ Acute Stroke Ready Hospital ‣ Primary Stroke Center ‣ Comprehensive Stroke Center Accreditation granted through TJC, DNV- GL, or HFAP
  15. 15. In WI, we have already begun developing stroke systems of care within our local hospitals: • Acute Stroke Ready Hospital (ASRH) ➡ Drip & Ship Capability • Primary Stroke Center (PSC) ➡ Drip & Ship for advanced tx ➡ Drip & keep ➡ May receive drip/ship from ASRH • Comprehensive Stroke Center (CSC) ➡ Receive drip/ship for adv Tx ➡ Act as referral center for ASRH,PSC ➡ Accepts Pts w LVO for adv Tx 1 ASRH In Wisconsin 40 PSC’s In Wisconsin 4 CSC’s In Wisconsin
  16. 16. What exactly is a ‘Stroke System of Care’? 1. Community Awareness of CVA 2. Dispatch & EMS 3. Acute Stroke Care @ Hospitals 4. Post Stroke Care - primary care, rehab facilities
  17. 17. Stroke System Target Goals • 3 Critical ‘Large Picture’ Functions 1. Effective interaction & collaboration among Agencies = Services = Personnel in all aspects of identification & tx of stroke patients in their region 2. Promote use of organized, standardized approach 3. ID performance measures - process & outcomes with a mechanism to evaluate efficiency. • Acute Stroke Treatment Main Goals (EMS, ED) • IV tPA w/in 30 min • Picture (CT) to puncture for LVO <90 min
  18. 18. Step 1: Know the players •What are your regional EMS systems capabilities? • Basic, Intermediate, Paramedic, Crit Care •What are your regional hospital capabilities • not interested in stroke vs ASRH/PSC/CSC •Where are these facilities in relation to your population?
  19. 19. Wisconsin Stroke Designated Hospitals
  20. 20. Does Focus & Building an EMS Component of a Stroke System Make a Difference? • In WI 40% of stroke patients arrive via EMS1 ➡Increases the odds that patient will present w/in 3 hr time window2 ➡significant ↓ time from sx onset to CT evaluation3. ➡For Large Vessel CVA, likelihood of a good outcome decreases by 10% for every 30 min delay in recanalization4 - planning LVO destination 1.WARDS data, 2.Kothari 1999, 3.Vagal 2014, 4.Schroeder 2000.
  21. 21. The Importance of EMS in Stroke Treatment • Often are first to provide medical care for stroke patients when 911 called • Can provide public education outreach • Can provide early on triage and decipher true stroke vs mimic
  22. 22. Impact of EMS on Stroke Center Certification in California • A study on effect of EMS stroke routing protocols effect on incentivizing hospitals to become PSC accredited • Yearly rate of hospital conversion to PSC designation↑from 3.8% before EMS enacted stroke protocols to 16.2% during. Schuberg. Stroke 2013
  23. 23. Step 2: How to Build it • Training • EMS Dispatchers & Personnel • Clinical Decision Support Tool • Relationships within Regional Stroke Systems • Destination protocols • Data to drive performance & care delivery
  24. 24. Sample Stroke Protocol: •EMS Arrival </= 10 min ➡ Stroke Scale ➡ Blood glucose ➡ Blood Pressure ➡ Last Known Well Time (LKWT)
  25. 25. Training Goals: Metrics • Dispatch time < 1min • Turnout time < 1 min • EMS response time < 8 min • time elapsed from receipt of the call by the dispatch to arrival • On scene time < 15 minutes Travel time is equivalent to trauma or acute MI calls.
  26. 26. Clinical Decision Support Tools *van Gaal et al. 2017, **Brandler et al 2014 • Purpose: • Improves EMS ID stroke to 90%+ • Assist with EMS ability to identify stroke patients who should be diverted to a stroke center with 24-7 embolectomy capabilities. • Avoid the unnecessary transfer of ineligible/futile patients into the embolectomy- ready centers* • Has been implemented in 1-3 hours of paramedic training**
  27. 27. Northeast Wisconsin Embolectomy-Ready Centers Neenah Green Bay
  28. 28. Which Stroke Scale Should EMS Use?
  29. 29. • 3 main exam components • Face, Arm, Speech, Score 1-3 • It’s simple - often seen as greatest attribute Cincinnati Stroke Scale, 1997 • Validated in the Field: Sn 89%, Sp 73% • Probability of acute CVA • 1 of 3 = 72% • 2 of 3 = 85% • > 2 predicts severe CVA
  30. 30. LA Motor Score (LAMS), 2000 van Gaal et al 2017 • 3 exam components • face, arm grip • Score 0-5 • > 4 = LVO • Easy to train all levels ~1-3hrs • Validated in field, multiple live sites tested, internationally accepted • feasibility confirmed through multiple large-sale implementations w/in regionalized systems for thrombolysis
  31. 31. LAMS Kidwell et al 2000 • Prospective study • LAFD, 60 min training session • 206 pts in field • 31 ID as CVA • 167 as not CVA • Sp 97%, Sn 91% • NPV 98%
  32. 32. RACE, 2007 Rapid Arterial oCclusion Evaluation 5 items, total of 10 points: • face, arm, leg, gaze-eye deviation, aphasia- agnosia
  33. 33. RACE, 2007 Rapid Arterial oCclusion Evaluation • Correlates best w NIHSS • EMS education 1hr +4 hour ‘refresher’ • >5 LVO likely, go to CSC • 85% Sn, 68% Sp, NPV 94%* • disadvantages: • more complex to learn • variable results<4 can still be a LVO but intervention is less likely *Ossa 2014
  34. 34. Last Words on Stroke Scale • Choose only 1 for your service • Studies find that choice of stroke scale is not as important… So just choose 1. • Limitation of all scales: no ability to clinically distinguish ICH vs severe ischemic stroke.
  35. 35. Final Step: Find out who your local stroke centers are & build a relationship with them… Destination Protocols
  36. 36. Stroke EMS Destination Protocols • Based on improving functional outcomes, act to avoid tPA/recanalization delays* • likelihood good functional outcome ↓ • by 3-4% for every 15min delay tPA • by 12% for every 30min delay in endovascular tx • Interventional Management of Stroke (IMS) III trial: mRankin Scale <2 at 90 days* • AHA recommends EMS bypass ASRH/PSC for a CSC IF additive transport time < 20 min⍴ *Khatri 2014, ⍴Higashida 2013
  37. 37. Wisconsin Stroke Designated Hospitals Washington Island? Boulder Jcn?
  38. 38. The PSC Bypass Debate for LVO Pro-Bypass • IV tPA not that effective on LVO, delay tPA negated • faster reperfusion = better outcome • endovascular tx is safe & effective NNT 2.5-7 Nay-Bypass • PSC selective bypass = multiple endovascular ineligible patients triaged to facilities where no additional therapy is offered • results in unnecessary delay for IV tPA
  39. 39. ?Flight Activation? “EMS systems should consider developing a policy of transporting acute stroke patients by air if the closest facility capable of treating acute stroke is >1hr away. (Yes, please) NAEMSP Position Statement Crocco 2007
  40. 40. What Rhode Island did •95 agencies, majority fire based (55%) •Est RI Stroke Task Force 2009 •Legislation mandated EMS rapidly transport patients to PSC or bypass if CSC within 30 min •Used LAMS >4 cutoff Developed a stroke diversion protocol through a collaborative approach
  41. 41. What Rhode Island did • Empowered EMS to screen rather than transport blindly • Allowed paramedics to transport patients with tPA running for interfacility transports when warranted Legislation…f or EMS stroke protocols
  42. 42. Other States Following Suit: • Wyoming: requires EMS to issue a “Notification Stroke Alert” to receiving stroke center ASAP with +FAST • Washington D.C:est prehospital care stroke protocols for stroke triage assessment, tx & pt transport to the closest, most appropriate facility (ASRH, PSC or CSC) • Missouri: “transporting suspected stroke patients by severity & time onset to the stroke center where resources exist to provide appropriate care” • Louisiana: EMS required to recognize 4 levels of stroke facilities • Nebraska: DHHS must adopt and distribute to EMS nationally recognized, standardized stroke triage assessment tool • Illinois: disseminate an ‘evidence-based statewide stroke assessment tool to clinically evaluate potential stroke patients’ CDC Policy Statement 2017
  43. 43. Mobile Stroke Units: Is the juice worth the squeeze? Alternative: Nursing home ~ $278/day, $101,470/yr (+4%/yr inflation) ~10 years = $1 million + $500,000/yr operating costs VS
  44. 44. MJ Case Conclusion Arrival @ CSC 3hr8min Large M1 Occlusion CT Perfusion 08:30 Groin Puncture 09:09 Arrival NIH: 20 Post-Procedure NIH: 8 D/C NIH: 0
  45. 45. In Conclusion: • Collaborate with local hospitals & EMS to determine capabilities, set up protocols • Know where your PSCs, CSCs are & their capabilities • Use a single, given stroke scale & stick with it • Should we wait for government to push us towards any medical behavior? • Become WI Coverdell EMS Partner
  46. 46. Become a Coverdell Stroke EMS Partner •WI 1 of 9 states with CDC Coverdell Stroke Grant •Access to many resources •best practices •building a more technical plan •community outreach material •Peer-Peer contact/mentoring •Recognition of your service on state stroke program website •Must agree to do 1 of 6 actions associated with stroke best practice behaviors •Questions: contact David Fladten • •1-800-362-2320 ext 8215
  47. 47. Thank You!
  48. 48. References • American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p. 137. ISBN 978-1-61669-010-6. • Khatri et al. Good clinical outcomes after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009: (73) 1066-1072. • Khatri et al. Time to Angiographic Reperfusion & Clinical Outcome after Acute Ischemic Stroke in the Interventional Management of Stroke Phase III (IMS III) Trial: A Validation Study. Lancet Neurol. 2014: 13(6). 567-574. • Lansberg et al. Treatment time-specific number needed to treat estimates for tissue plasminogen activator therapy in acute stroke based on shifts over the entire range of the modified Rankin Scale. Stroke. 2009: 40. 2079-84 • Vagal et al. Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke. 2014: (45). 3625-30. • van Gaal et al. Approaches to the filed recognition of potential thrombectomy candidates. International Journal of Stroke. 2017: 0(0). 1-10. • Brandler et al. Prehospital stroke scales in urban environments: a systematic review. Neurology. 2014; 82: 2241-2249. • Crocco et al. EMS Management of Acute Stroke-Prehospital Triage (Resource Document to NAEMSP Position Statement). Prehospital Emergency Care. 2007. 11(3): 313-317. • Kothari et al. Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med. 1999. 33(1): 3-8 • Schroeder et al. Determinants of use of emergency medical services in a population with stroke symptoms: the second delay in accessing stroke healthcare study. Stroke. 2000(31): 2591-96 • Kidwell et al. Identifying Stroke in the Field: Prospective Validation of Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000 (31): 71-76. • Schuberg et al. Impact of Emergency Medical Services Stroke Routing Protocols on Primary Stroke Center Certification in California. Stroke. 2014 (44). 3584-3586. • Higashida et al. American Heart Association Advocacy Coordinating Committee. Interactions within stroke systems of care: a policy statement from the American Heart Association. 2013 (44): 2961-2984 • Ossa et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014(45)1: 87-91
  49. 49. Acute Stroke Ready Hospital (ASRH) 51 • Requirements vary according to region • Ability to triage, treat, and transfer acute stroke patients • Written stroke protocols • ED Management for acute Stroke • Transfer agreement with PSC or CSC for acute Ischemic & Hemorrhagic • Cerebral and cerebral vascular imaging • Administrative and org support • Outcomes and quality improvement • Belong to stroke registry • Educational programs 1 ASRH In Wisconsin
  50. 50. • experts recommended improving stroke systems of care to increase timely and equitable access to this therapy
  51. 51. Coverdell helps bridge the gap between EMS and Healthcare Facilities
  52. 52. Arkansas Stroke Systems of Care
  53. 53. In Illinois - hospitals can now apply for the new designations; your respective Regional Stroke Advisory Subcommittee, should be meeting to update protocols in recognition of three tiers of stroke care and to reflect the capabilities and best interests of your specific EMS Region. Regions differ drastically around the state, it is imperative that any triage and transport protocols are established locally. State of Illinois
  54. 54. • Southerland, A.M., Johnston, K.C., Molina, C.A., Selim, M.H., Kamal, N. Goyal, M.(2016). Suspected Large Vessel Occlusion: Controversies in Stroke • Gupta, R., Xiang, B., Ge, S., Sun, C.H., Yoo, A.J., & Mehta, B. (2014) Stagnation of Treatment Times over a decade: Results of a poold analysis from the MERCI registry, MERCI, TREVO, and TREVO 2 trials. • Wisconsin Coverdell Stroke Program : Facts and Figures http// • Higashida, R., Alberts, M.J., Alexander, D.N., (2013) Stroke. • Higashida, R. Alberts, M.J., Alexander, D.N., et. Al Interactions Within Stroke Systems of Care: A policy statement from the AHA/ASA. Stroke. 2013; 44:2961-2984