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  1. 1. Andy Jagoda, MD, FACEP The Role of EmergencyThe Role of Emergency Medicine in NeurologicMedicine in Neurologic EmergenciesEmergencies Andy Jagoda, MD, FACEPAndy Jagoda, MD, FACEP Professor of Emergency MedicineProfessor of Emergency Medicine Mount Sinai School of MedicineMount Sinai School of Medicine New York, New YorkNew York, New York
  2. 2. Andy Jagoda, MD, FACEP EMS / EM and Neuro-resuscitationEMS / EM and Neuro-resuscitation • 15 million ED visits / year for15 million ED visits / year for neurologic emergenciesneurologic emergencies • Potential disability is highPotential disability is high • Potential benefit to outcome is timePotential benefit to outcome is time dependentdependent • Great opportunity to becomeGreat opportunity to become involved and establish a careerinvolved and establish a career pathwaypathway
  3. 3. Andy Jagoda, MD, FACEP Getting InvolvedGetting Involved • Clinical Policy DevelopmentClinical Policy Development • The Brain Attack CoalitionThe Brain Attack Coalition • The Brain TraumaThe Brain Trauma FoundationFoundation • The NETTThe NETT
  4. 4. Andy Jagoda, MD, FACEP NINDS TrialNINDS Trial • Successful management of acute strokeSuccessful management of acute stroke depends on emergency medicinedepends on emergency medicine • Coordinate pre-hospital careCoordinate pre-hospital care • Coordinate ED careCoordinate ED care • NINDS – SPOTRIASNINDS – SPOTRIAS • 10 Stroke Treatment Centers10 Stroke Treatment Centers • Successful applicant for NINDSSuccessful applicant for NINDS funding must have an emergencyfunding must have an emergency physician as a primary investigatorphysician as a primary investigator
  5. 5. Andy Jagoda, MD, FACEP Brain Attack Coalition:Brain Attack Coalition: Promoting the EM / Neurology InterfacePromoting the EM / Neurology Interface
  6. 6. Andy Jagoda, MD, FACEP BAC MissionBAC Mission • Formed in 1997Formed in 1997 • A group of professional, voluntary andA group of professional, voluntary and government groupsgovernment groups • Dedicated to reducing the occurrence,Dedicated to reducing the occurrence, disabilities and death associated withdisabilities and death associated with strokestroke • Goal is to strengthen the relationshipGoal is to strengthen the relationship between its member organizations andbetween its member organizations and to provide a forum to discussto provide a forum to discuss mechanisms for improving strokemechanisms for improving stroke outcomesoutcomes
  7. 7. Andy Jagoda, MD, FACEP BAC MembersBAC Members • NINDSNINDS • American Academy ofAmerican Academy of NeurologyNeurology • American College ofAmerican College of Emergency PhysiciansEmergency Physicians • American Assn ofAmerican Assn of Neurological SurgeonsNeurological Surgeons • American StrokeAmerican Stroke AssociationAssociation • National StrokeNational Stroke AssociationAssociation • Am Soc of Intervent andAm Soc of Intervent and Therap NeuroradiologyTherap Neuroradiology • American Society ofAmerican Society of NeuroradiologyNeuroradiology • Congress ofCongress of Neurological SurgeonsNeurological Surgeons • Stroke Belt ConsortiumStroke Belt Consortium • Veterans AdministrationVeterans Administration • National Association ofNational Association of EMS PhysiciansEMS Physicians • Centers for DiseaseCenters for Disease Control and PreventionControl and Prevention • American Assn ofAmerican Assn of Neuroscience NursesNeuroscience Nurses
  8. 8. Andy Jagoda, MD, FACEP JCAHO Disease SpecificJCAHO Disease Specific Care CertificationCare Certification • Joint initiative between ASA andJoint initiative between ASA and JCAHOJCAHO • Voluntary participationVoluntary participation • Approx 400 accredited hospitalsApprox 400 accredited hospitals • Premise is that accreditation processPremise is that accreditation process will drive quality measures andwill drive quality measures and improve outcomesimprove outcomes • No emergency medicine society hasNo emergency medicine society has endorsed this initiativeendorsed this initiative • t-PA controversyt-PA controversy • OvercrowdingOvercrowding • Medical legal implicationsMedical legal implications
  9. 9. Andy Jagoda, MD, FACEP EM Position StatementsEM Position Statements • Emergency physicians wereEmergency physicians were concerned of being isolated careconcerned of being isolated care providers in acute stroke with theproviders in acute stroke with the inherent liabilityinherent liability • The EM community was skeptical ofThe EM community was skeptical of the NINDS trial’s external validitythe NINDS trial’s external validity • The EM community was not convincedThe EM community was not convinced that the risk/benefit of t-PA merits itsthat the risk/benefit of t-PA merits its use in all settingsuse in all settings
  10. 10. Andy Jagoda, MD, FACEP What are the questions to be answered in the new ACEP stroke patient clinical policy? • When the NINDS criteria are met, is IVWhen the NINDS criteria are met, is IV t-PA safe and effective for acutet-PA safe and effective for acute ischemic stroke presenting within 3ischemic stroke presenting within 3 hours of symptom onset?hours of symptom onset? • Is there a subset of patientsIs there a subset of patients presenting with a TIA that can bepresenting with a TIA that can be effectively and safely managed aseffectively and safely managed as outpatients?outpatients?
  11. 11. Andy Jagoda, MD, FACEP What are the questions to be answered in the new ACEP stroke patient clinical policy? • Initiative started with AAN in 2005Initiative started with AAN in 2005 • Three ACEP members, 3 AAN membersThree ACEP members, 3 AAN members • Evidence based methodologyEvidence based methodology • Initial MEDLINE search had over 3000Initial MEDLINE search had over 3000 citationscitations • Approx 200 abstracts reviewedApprox 200 abstracts reviewed • Approx 60 articles being gradedApprox 60 articles being graded
  12. 12. Andy Jagoda, MD, FACEP Neurological EmergenciesNeurological Emergencies Treatment Trials NetworkTreatment Trials Network • Background: Neurologists and / orBackground: Neurologists and / or neurosurgeons are not present when manyneurosurgeons are not present when many neurologic emergencies presentneurologic emergencies present • Concept: A neurologic emergenciesConcept: A neurologic emergencies network that is not disease specific butnetwork that is not disease specific but would open opportunities for clinicalwould open opportunities for clinical research on neurologic emergencies in theresearch on neurologic emergencies in the prehospital and ED arenasprehospital and ED arenas • A network would allow for pooling ofA network would allow for pooling of resourcesresources
  13. 13. Andy Jagoda, MD, FACEP The Hub and Spoke ModelThe Hub and Spoke Model • Clinical Coordinating Center – providesClinical Coordinating Center – provides executive and steering committeeexecutive and steering committee governance, and management services togovernance, and management services to research centers. Facilitates rapid andresearch centers. Facilitates rapid and rigorous completion of trialsrigorous completion of trials • Hub – (10 – 20 per CCC) backbone of theHub – (10 – 20 per CCC) backbone of the network; regional and provide researchnetwork; regional and provide research and clinical infrastructure forand clinical infrastructure for collaborating centers (spokes)collaborating centers (spokes) • Spoke – (2 – 10 per hub) smaller centersSpoke – (2 – 10 per hub) smaller centers which either provide on site research orwhich either provide on site research or refer to a hubrefer to a hub
  14. 14. Andy Jagoda, MD, FACEP NETT Research AgendaNETT Research Agenda • High prevalence neurologicHigh prevalence neurologic diagnosesdiagnoses • Stroke / SAHStroke / SAH • SeizuresSeizures • TBITBI • Low prevalence but high morbidityLow prevalence but high morbidity and high mortality neurologicand high mortality neurologic diagnosesdiagnoses • Spinal cord injurySpinal cord injury • MeningitisMeningitis
  15. 15. Andy Jagoda, MD, FACEP SummarySummary • EMS and Emergency Medicine are on the frontEMS and Emergency Medicine are on the front line for diagnosing and managing neurologicline for diagnosing and managing neurologic emergenciesemergencies • Outcomes in these patients are dependent onOutcomes in these patients are dependent on the quality of the initial resuscitative carethe quality of the initial resuscitative care providedprovided • We are entering a new era in research that willWe are entering a new era in research that will benefit our specialtybenefit our specialty • There is a great need from our specialty toThere is a great need from our specialty to take a leadership role in clinical care,take a leadership role in clinical care, research, and education in neurologicresearch, and education in neurologic emergenciesemergencies
  16. 16. Andy Jagoda, MD, FACEP Questions?Questions? www.FERNE.org Andy.Jagoda@msnyuhealth.org ferne_emra_2007_caseconf_jagoda_em_involvement_100907_finalcd 01/29/15 11:16