Organisation of stroke care - polish experience

1. The organisation of medical care of
patients with stroke – Polish experience
Jacek Staszewski MD, PhD
ACUTE STROKE EXPERT WORKSHOP
Almaty, KAZAKHSTAN

2. Disclosures
• Honoraria from Boehringer Ingelheim, Polfarma

3. Acute Stroke Unit, Military Medical Institute
Warsaw, PL
• 12 IC beds; 40 stroke beds
8 neurologists, 5 residents
3 physioterapists, 1 speech therapist, 1 psychologist
• 890 acute cerebrovascular incidents in 2014
IS: 566 TIA: 190 ICH: 134
• 18% of rt-PA (n=102)
• 521 rt-PA procedures since 2003
• 41 ia/mechanical thrombectomy procedures since 2010
• 480 ICA/CCA angioplasty with stenting since 2003
rt-PA = recombinant tissue plasminogen activator; IS = ischemic stroke; TIA = transient ischemic attack
ICH = intracranial hemorrhage; AchE-I = acetylcholinesterase inhibitor
• Stroke clinical trials: IST3, ECASS-3, Impact24, RE-LY, CHARISMA, MATCH, ENOS, SAINT1, SPARCL, …
• Stroke registries: SITS MOST, SITS EAST, POLKARD, PRUM, TUN
• Own studies: sono-rtPA, hypothermia, AchE-I in acute stroke, MRI/CT criteria for rt-PA in wake-up strokes

4. • 1996 FDA approved iv rt-PA for stroke treatment <3h
• 1999 Canadian Regulatory Agency approval
• 2002 EMEA approval
PL
• 1997 first stroke unit
• 2003 first stroke thrombolysis
• 2007 rt-PA reimbursement
• 2014: stroke units: 174
no. of rt-PA procedures: 6500
thrombectomy procedures: 77
• 2016: thrombectomy approval ?
Coming back to the beginning …
2003

5. Rószkiewicz M. Psychogeriatria Polska 2006,3 (1)
Demographics of Poland
• Average life expectancy:
» M 77,6 yrs (+7,2 in 2030)
» F 83,3 yrs (+4,5)
>65 yrs 26% >65 yrs 40%

6. Stroke incidence in Poland
 175/100 000 /yr in men
 125/100 000 /yr in women
70 000 strokes / yr
92 500 hospitalisations
Stroke epidemiology in Europe (2006)
Truelsen T et al. Eur J Neurol 2006;13:581–98

7. Changes in stroke mortality rates: PL vs EU
Stroke units
rt-PA
Better controlled vascular risk factors
In-hospital mortality: (PL vs EU): 26.8% vs 14%
Mortality in women: higher than for breast and ovarian cancer

8. http://www.worldlifeexpectancy.com
Stroke mortality rates in PL from global perpective
2014

9. • A mixed system of public and private health care financing
• Mostly based on mandatory social health insurance contributions
• Total health expenditure : €667 per capita/ yr [6.6 GDP expenditure]
• Private expenditure accounts for about 24 % of total health expenditure (2008)
System of healthcare in PL
Ministry of Health
Medical Academy
Medical Institiute
• public: (75%)
• private: (25%)
Private investors, owners
Teritorial local governments
A purchaser of health care services for social health
insurance members
Manages all revenue received through contributions
Operates within a budget that is fixed for a given yr
National Health Fund (NFZ)

10. Organisation of stroke care
Stroke chain of survival. Time of service
999
SOR
<10 min <15 min
<60 min <25 min
Czas to mózg
TK
ESO Recommendations (2004-2008), Polish National Guidelines (2008, 2012,2013)
!! Stroke is an emergency !!

11. Prehospital pathway
of stroke suspicion
Dispatch & rapid response: <1 min
Rapid
Evaluation
Early
Stabilisation
Standardi
sed
Neurological evaluation
Advance
Pre-notification of the receiving site
Rapid
Transport directly to a stroke-ready
hospital
Emergency service in Poland
1. Jauch E, et al. Circulation 2010;122(Suppl 3):S818-S828.
15 min
PL
• centralised and activated by one national emergency number
• composed by ambulances staffed by ALS paramedics (60%) or physicians
• managed by regional hospitals (nonprofit; 75%) or by commercial companies
• ambulance availability 4/ 100, 000 population
Priority

12. Milestone gains in stroke management 2001-2014 in PL
Joint professional continuous education & training for EMS
“load and go !”
FAST
accordance

13. Gladstone DJ et al. Stroke 2009;40:3841-4
FAST prehospital protocol increases rt-PA rate
Symptoms
Allergy
Medication
Past medical history
Last oral intake
Event
S
A
M
P
L
E

14. Air ambulance for stroke
Routine link in chain of survival
50% coverage

15. • 1 ED per 150-300,000 population (WHO)
• 1 ED per 163,500 population (PL)
Requirements for ED in PL
• airstrip in localisation or within 5 min distance
• 24/7 provided areas of service:
1) medical triage 2) consultations 3) resuscitation
4) monitoring 5) intensive care
• personnel
 ≥ 2 emergency physicians, 1 surgeon, 1 anesthesiologist
specialist consultations on call
Emergency department network
Activation of “Code Stroke”
Adapted from: Tai YJ, et al. Intern Med 2012;42:1316-1324.
Triage in ED
Clinical evaluation by
emergency physician
Time from symptom onset <6 h
IV rt-PA administration upon
consent
Standard stroke
care
Has patient met requirements for
IV rt-PA administration?
Code Stroke aims to achieve
rapid stroke assessment
and treatment
Retrospective data from 98
patients pre-code stroke and
from 189 code stroke patients
showed an 18-min
improvement in door-to-
needle time for the code
stroke patients (p<0.001)
15
DTN, door-to-needle; ED, emergency department EMS, emergency medical services NIHSS, National Institutes of Health Stroke Scale
Onset of stroke symptoms
Call EMS Self-presentation to ED
Activate Code Stroke
Code Stroke team and patient arrive directly in imaging department
History, physical examination, NIHSS assessment
CT / MRI scan, ECG, blood tests
Ischaemic stroke?
Triage in ambulance
On the way to hospital
Time from symptom onset <6 h
Speech/motor/facial
disturbances
Early pre-hospital Code
Stroke notification
Yes
Yes
No
No
Each ED must have own procedures to triage stroke patients and to activate stroke team

16. • all groups of patients benefit from organised stroke unit care
• stroke patients presenting late require the same amount of care
• every stroke patient must be hospitalised at Stroke Unit (NFZ requirement)
Aim of stroke unit and target patients
Ringelstein EB, et al. Stroke 2013;44:828-840.
Ischaemic and
haemorrhagic
stroke
Transient
ischaemic attack
Cerebral venous
thrombosis &
Subarachnoid
haemorrhage
Minimise the
volume of brain
tissue that is
irreversibly
infarcted
Prevent
complications
Prevent stroke
recurrence
Reduce disability
and handicap

17. How do stroke units work?
Main areas of service
Early assessment + acute treatment
CT scanning
Early assessment of
therapy needs &
nursing
Neurological
& medical
assessment
Monitoring and early management policies
Prevention of
complications
(e.g. pressure area care,
careful positioning and handling)
Early mobilisation
Treatment of hypoxia,
hyperglycaemia,
pyrexia & dehydration
Early mobilisation
Early assessment
of needs after
discharge
Coordinated
multidisciplinary
team care

18. The optimal stroke team
Organisation of services in acute + rehabilitation phase
Ringelstein EB, et al. Stroke 2013;44:828-840.
• Neurologist
• Neuroradiologist
• Emergency physician
• Stroke nurse
• (Neurosurgeon)
• (Cardiologist)
• Stroke unit/centre director
(experienced physician)
All staff members should have ongoing
training in stroke management and certified
medical education at least once a year
• Physiotherapist
• Occupational therapist
• Speech & swallowing
therapist
• Neuropsychologist
• Social worker
• (Nutrition specialist)
These professionals must be available on-
site during each working day, even if they
are not dedicated to the stroke unit/ stroke
centre full-time
Collaboration
Communication
Education
ESO/AHA/ASA recommendations: (+) (+)
Poland: lack of implementing rules Required by National Health Fund

19. Clinical benefits of stroke units
1. Stroke Unit Trialists’ Collaboration. Cochrane Library 2013, Issue 9; 2. Seenan P, et al. Stroke 2007;38:1886-1892; 3. Tamm
A, et al. Stroke 2014;45:211-216; 4. Schouten LM, et al. Stroke 2008;39:2515-2521; 5. Lannon R, et al. Ir J Med Sci 2011
Mar;180:37-40. 6. Ingeman A, et al. Stroke 2011;42:3214-3218.

Mortality1,2

Dependency1,2

Complications6

Independence2

Discharge
Home2,3

Length of stay
(LOS)1,4,5

20. IS = ischemic stroke; ICH = intracranial hemorrhage
Efficacy of stroke units vs other treatment modalities
20
% pts with
benefit
RRR of mortality and
disability
Stroke Units
(IS/ICH)
90% 19%
ASA
0-48 h
65% IS 1%
iv tPA
0-3 h
10% IS
(25% <4.5h)
12%
Thrombectomy 1-15% IS

21. Milestone gains in stroke management in PL
Organization of Independent Stroke Units
Year : 1997 2000 2003 2005 2007 2014
SU: 3 12 97 105 111 174
• 2000 - National Programme of Stroke Treatment and Prophylactics
• EUSI Recommendations, central funding
•  80 km, 2h to reach by ambulance
• 3 intensive beds, 24hrs CT
• 2004 – Brain Attack Coallition
• Primary and Comprehensive SU concept
• POLKARD: 2003-2012 „to reduce mortality by 30%”
• 2004 – NFZ Requirements for SU
• coverage of 200 000 population
• SU establishing financed by funding bodies
• 2014 – NFZ ordinance
• at least 5% of IS to receive rt-PA in SU
Requirements for establishing SU
≥ 4 intensive beds + ≥ 12 beds for subacute stroke phase
Equipment
24h access to CT, laboratory, DD, TTE, holter ECG, RR
Multidisciplinary staff
≥ 5 doctors, 2 specialists in neurology
12 nurses, 4 physiotherapists, 1 neurologopedics
1 consultant cardiologist, 1 in rehabilitation medicine in place
neurosurgeon or vascular surgery specialist on call
Documentation
Stroke specific hospital charts
SU = stroke unit; NFZ = National Health Fund
80% population

22. Primary vs comprehensive stroke centres in PL
Range of stroke centre capabilities*
158 Primary stroke
centres
≈ 60%
• 24-h CT, DD
• EBM stroke care
• iv rt-PA 24/7
• M/disciplinary stroketeam
• Specially trained nurses
• Early SU rehabilitation
Acute stroke facility
Internal Medicine ≈ 10%
Neurosurgery Dept ≈ 10%
Effective diagnosis and
treatment in the very
acute phase, with
transfer for further care
no rt-PA allowed
16 Comprehensive
stroke centres
≈ 20% stroke pts
• 24-h CT, DD
• MRI/ MRA /CTA/DSA/ TEE
• Neurosurgeon & access to
neurosurgical facilities
• iv ia rt-PA
• thrombectomy
• PSC and CSC division is recommended but range of responsibility is not formally approved
• thrombectomy allowed in „experienced SC” by „experienced doctors in vascular medicine”
• accreditation criteria announced (2016)
* according to ESO 2008 Guidelines and Polish Guidelines 2008,2012,2013

23. Milestone changes
Payment for therapeutic procedures
• <2007: one quote for each stroke patient (≈ $ 850)
• 2007: rt-PA approval; standard stroke treatment vs rtPA treated patients ($1700)
• 2010: Diagnosis Related Groups Reimbursement System (JGP)
– pt treated in SU with or without rt-PA (252p vs 142p, financial settlements: $3640 vs $2069)
– pt not treated in SU (30p, $ 437)
– length of stay in SU <8 days ($ 1267)
– number of diagnostic procedures <3; <5
686
1204
2285
3182
5200
0
1000
2000
3000
4000
5000
6000
YR 2009 YR 2010 YR 2011 YR 2012 YR 2013
Rt-PA procedures
7%
4%
AIS
AIS = acute ischemic stroke

24. Reimbursement vs costs of stroke treatment
2008 profitability index

25. Rt-PA rates per province and no. of Stroke Units
Large variability and nonproportinal distribution
10
8
8
13
3
11
21
3
15
2
12
23
7
6
12
4
5/16  10-20%
11/16  >20%

26. In-hospital mortality rates in rt-PA pts per province depend on
the organisation of care
10
8
8
13
3
11
21
3
15
2
12
23
7
6
12
4
5/16  >10%
11/16  >10%

27. ESO recommendations
Quality management indicators
* According to most recent ESO guidelines
Ringelstein EB, et al. Stroke 2013;44:828-840.
The practical documentation of the quality of stroke care is routinely
guaranteed by
› Multidisciplinary meeting group once a week
› Annual teaching courses for nurses & non-medical staff
› Written stroke care protocol for acute stroke intervention
› Written stroke care protocol for early secondary prevention*
› A local stroke register and transfer of patient data into regional or national
databases is also recommended
 assessed data include age, sex, initial stroke severity, thombolysis,
discharge conditions and quality indicators (next slides)
Obligatory required by NFZ (National Health Fund)

28. Required by NFZ for contracting of services and reimbursement since 2012
Protocols to ensure a thorough, co-ordinated approach
Protocol S1 (EMS)
Capture all data,
perform care and
transport patient
Protocol S4
(stroke nurse)
rt-PA administration
standing order
Protocol S7
(stroke specialist)
Manage complications
Protocol S9
(stroke nurse)
Nursing care
Protocol S2 (RN)
Confirm stroke and
carry out physical exam
Protocol S5
(stroke nurse)
Post rt-PA standing
order
Protocol S8
(stroke nurse)
Initiate general stroke
management
Protocol S10
ICH management
Protocol S3 (EP)
NIHSS, MR, contra-
indications, CT/MRI &
initial diagnosis
Protocol S6
(stroke nurse)
Post rt-PA standing
order (Day 2 & 3)
rt-PA
Dosing and
administration guide
Discharge checklist
(stroke specialist)
Informed consent
(stroke specialist)
Clinical decision
(stroke physician)
Each step and action in stroke managements at every level must be well described and documented

29. Example of local stroke treatment process flow protocol at ED
Range of
responsibility*
Upper time limit
of actions*
* To streamline the process of management and secure eventual claims from the patients side

31. Required by NFZ since 2012
Fine imposed against the hospital that fails to timely report is 10% of the annual contract!
Official recommendations for quality control
Individual data input for National Stroke Registry

32. Local registry: prehospital delays
2004r
n=379
2008r
n=495
2011r
n=556
< 4.5h
2004r : 15%
2008r : 25%
2011r : 30%
Factors associated with early arrival:
• weekend / bank holidays
• onset between 6-9.00 i 16-20.00
* 01-09-13
Employment:
1 neurologist on duty 2 neurologists

33. Six quality indicators are regarded as compulsory
ESO recommendations
Quality indicators of organised stroke care
Ringelstein EB, et al. Stroke 2013;44:828-840.
1. Percentage of acute stroke patients treated with i.v. thrombolysis having a door-to-
needle time <60 min
2. Percentage of all acute patients with stroke as the predominant pathology admitted
to the hospital treated on the stroke unit (or the ICU, if appropriate)
3. Percentage of brain imaging by CT or MRI in every suspected stroke
4. Percentage of ischaemic stroke patients with antithrombotic therapy (antiplatelet
medication) at discharge
5. Corresponding antithrombotic therapy (anticoagulation) at discharge in patients with
atrial fibrillation
6. Percentage of stroke unit patients screened for swallowing disorders

34. 1. Vascular imaging in patients with ischaemic stroke or TIA
2. Early brain imaging within 1 hour of admission in patients arriving within
2 hours after stroke onset
3. Percentage of eligible patients receiving i.v. thrombolytic therapy
4. Carotid revascularisation for ≥50% symptomatic carotid stenosis
(according to NASCET*-criteria)
5. Statin treatment at the end of hospital stay in atherothrombotic ischaemic
strokes
6. Antihypertensive treatment at the end of hospital stay for hypertensive
patients
7. Pre-hospital awareness and training program for laypersons and medical
personnel aiming at rapid recognition of stroke signs and immediate
emergency admission to a stroke unit/stroke centre
ESO recommendations
Additional quality indicators
Every ESO Stroke Unit or ESO stroke centre should at least work on 3 of the
following 7 additional quality indicators
* NASCET, North American Symptomatic Carotid Endarterectomy Trial
Ringelstein EB, et al. Stroke 2013;44:828-840.

35. TEMPiS = The Telemedical Pilot Project for Integrative Stroke Care
CSC = Comprehensive Stroke Centre (hub); SH = spoke hospital
Telestroke system
• currently under development in PL
• receives financial support from EU
• based on a-video/CT images transmition between CSC & SH
• allows a joint decision reg. rt-PA & drip-and-ship regimen
• telephone consultation between rural and SCS increased rt-PA by 72%!

36. Neurol Neurochir Pol 2013; 47,1 (supl.1)
Milestone changes in acute stroke management 2001-2014 in PL
National Guidelines: 2006, 2008, 2012, 2013
• a most up to date evidence based information and standards of stroke care in PL
• practical tool for every day practice
• instrument for increasing awareness among governing bodies / Ministry of Health

37. Courtesy of Valeria Caso, Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
Role of the patient in the stroke chain of survival

38. Milestone changes
Public awareness campaignes, Stroke Patients Foundations / Associations
Stroke symptoms 2010 Polish pts
(n=460)
%
Australian pts
(n=100)
%
One sided weakness 55 72
Speech difficulties 48 50
Headache 15 25
Vision disturbances 14 15
Face assymetry 12 14
Vertigo 7 26
Parestesias 6 45
http://www.udarowcy.beep.pl/home

39. Dark side of the moon:
Medical malpractice claims or attemted extortions

40. Get rid of theraputic nihilism!
Belief in the drug
rt-PA better

41. ACT FAST !
Thank you for your attention