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  • Thank NINDS
    Presenting work of the Provider Support System Task Force
  • I would also like to thank all of the members of the task force for their generous contribution of Time…
    AND COMMENTS, over the past two months
  • We began the process in October and began by defining the term “support system”
    Recognizing quickly that this definition could grow to include anything in assisting the delivery of improved stroke care we then artifically imposed limits of …
  • The “golden hour” in trauma has reduced morbidity and mortality
    Systems to improve door-to-needle time in AMI have substantially improved cardiac outcomes
    And our colleagues in oncology have developed a successful system of sequentially testing chemotherapeutic agents to improve quality of life and survival in patients with cancer.
    And the development of Support Systems reflects our core beliefe that…
    Not every hospital has to deliver all therapies, but must have plans to deal with all patients…
  • And finally, the need for support systems is underscored by the ACEP statement you briefly saw yesterday…
  • What are the challenges support systems must address??

  • Our task force then prioritized the areas where support systems may be most beneficial in enhancing stroke care, arriving at the following major distictions…
    Please recognize that a single support system methodology may overlap one or more of these areas
  • Beginning with the Pre-hospital area and EMS Training and Diagnostic support…
    Our group advocated the incorporation of educational modules on the sign/symptoms of stroke in EMS education
    The use of prehospital stroke identification instruments
    And incorporation of guideline for early contact with…
  • In terms of management, guidelines should exist to enhance early stroke management in the field, …
  • Clear EMS transfer support systems should exist for patients with acute stroke…
  • On the hospital side, our task force recommends the expanded use of stroke identification tools in ED triage
  • Our group would like to demonstrate the potential of new technologies in stroke diagnostic and management support. For this, I would like to introduce Dr. Lee Schwamm, the associate director of harvard’s acute stroke service with extensive telemedicine/telestroke experience…
  • <number>
  • Thank you, Lee
    Your EMS system has applied their pre-hospital assessment tools, you’ve received advance notice, you triaged the patient highest priority and have completed the initial evaluation and lab/CT studies. Utilizing a local or remote based specialist you’ve confirmed the diagnosis clinically and interpreted the CT.
    It appears to be an ischemic stroke, the patient is NINDS eligible, and now, there is a binary decision to be made… treat or not.
    There is only one problem…
    it has been one-year since you treated a patient…
  • This is not unusual, in UM’s series of over 160 EP treated patients, the maximum treated by a single physician was 3… over 5 years…
    Support is needed..
    Local options include…
  • You’ve determined you need to evaluate your stroke care delivery and and improve your performance with one or more of the above tools/systems…
    How do you determine which ones, how do you implement them, and how do you evaluate them…
  • PowerPoint show only

    1. 1. Provider Support System Development NINDS Stroke Symposium “Improving the Chain of Recovery for Acute Stroke in Your Community” December 10-11, 2002 Arlington, VA PAS
    2. 2. NINDS Symposium 2002: Provider Support Sys Task Force Members • Sidney Starkman, MD – Task Force Chair • Phillip A. Scott, MD – Co-chair • John Choi, MD • Brian F. Connolly, MD • Karen L. Furie, MD • J. Stephen Huff, MD • Walter N. Kernan, MD • Marian LaMonte, MD • Dennis Landis, MD • Steven R. Levine, MD • David B. Matchar, MD • Brett C. Meyer, MD • Debra G. Perina, MD • Jeffrey L. Saver, MD • Lee H. Schwamm, MD
    3. 3. NINDS Symposium 2002: Provider Support Sys Support Systems: Definition • “The organization of human and material resources necessary to solve a clinical problem” • Artificially imposed limits of first 24 hours of care
    4. 4. NINDS Symposium 2002: Provider Support Sys Why Develop Support Systems? • Effective in improving medical care in other delivery systems – Trauma – AMI – Cancer • Core Belief: Every health care delivery system providing care for patients with acute stroke has a responsibility to develop and implement plans for meeting the requirements of each phase of stroke care.
    5. 5. NINDS Symposium 2002: Provider Support Sys ACEP Policy Statement • “There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical practice when systems are not in place to ensure that … the NINDS guidelines for tPA use in acute stroke are followed. • Therefore, the decision [for tPA use] should begin at the institutional level with commitments from administration, the ED, neurology, neurosurgery, radiology and laboratory services to ensure that the systems necessary for the safe use of tPA are in place”
    6. 6. NINDS Symposium 2002: Provider Support Sys Specific Challenges for Support Systems • Stroke is a clinical diagnosis • Majority of patients present to ED without immediate access to “stroke expert” • In-hospital barriers to stroke care • Barriers exist for both fibrinolytic therapy and non-fibrinolytic stroke management
    7. 7. NINDS Symposium 2002: Provider Support Sys Areas for Support Systems Development • Pre-hospital care • Hospital-based care – Diagnosis • Radiologic / Imaging Access & Expertise • Stroke Diagnostic Expertise – Management • Systems Implementation and Evaluation
    8. 8. NINDS Symposium 2002: Provider Support Sys EMS Training & Diagnostic Support • Education on signs / symptoms of stroke • EMS stroke identification instruments – Cincinnati Pre-hospital Stroke Scale – LAPSS – Consideration to others in development • Guidelines / Policy and Procedures – Early contact with receiving hospital for patients with possible stroke
    9. 9. NINDS Symposium 2002: Provider Support Sys Pre-Hospital Management Support • Guidelines / Policy and Procedures – IV access – Glucose assessment – BP management avoidance – Avoidance of unnecessary glucose – Early notification
    10. 10. NINDS Symposium 2002: Provider Support Sys EMS Transfer Support Systems • Increased importance of early care – Transport without delay – To closest appropriate facility • Pre-established EMS agreement – Hospitals – ED – EMS – Medical Director • Aeromedical teams
    11. 11. NINDS Symposium 2002: Provider Support Sys Hospital Diagnostic Support • ED triage stroke identification tools • Pre-defined access to local expertise – Neurology – Neurosurgery – Radiology • Remote Diagnostic Support
    12. 12. Hospital Diagnostic Support: Teleradiology and Teleconsultation Support Systems
    13. 13. Remote Image Review: Compressed DICOM images in a browser- based viewer on a PC ED Teleradiology Images Subacute Follow-up
    14. 14. NINDS Symposium 2002: Provider Support Sys Potential Teleconsultation Support Benefits: • Improving diagnostic accuracy • Facilitating delivery of t-PA in identified acute strokes • Identifying patients for enrollment into acute treatment studies • Improving non-thrombolytic acute stroke care
    15. 15. NINDS Symposium 2002: Provider Support Sys Technology Issues • Bandwidth, Security, Reliability • Image quality and transmission • Data capture and review • Multimedia integration • Decision support • Medical documentation • Continuous quality assessment
    16. 16. . Tertiary Care Center Community Emergency RoomPROVIDER SUPPORT NETWORK: Acute Stroke Location- Independent Stroke Consultant
    17. 17. Management Decision Support
    18. 18. NINDS Symposium 2002: Provider Support Sys Local Decision Support Options • Protocol development – Paper-based, PDA, Web based tools – Thrombolytic treatment – Complications – Non-thrombolytic stroke management • Access to responsive “in-house” specialty consultation – Standard consultation arrangements • Development of “Code Stroke” teams
    19. 19. NINDS Symposium 2002: Provider Support Sys Remote Decision Support Options • For sites without consistent specialty consultation • Identified in advance • Access to regional stroke centers – standard telephone consult – Telemedicine – “Commando” systems
    20. 20. NINDS Symposium 2002: Provider Support Sys Hospital Transfer Protocol Support • Existence of clear transfer protocols • Pre-established contact with referral centers • Avoidance of EMTALA violations – transfer of medical records – Radiographic studies – Pre-packaged transfer forms
    21. 21. NINDS Symposium 2002: Provider Support Sys Clinical Trial Access • Encourage participation in regional clinical trial networks • Access to listing of active studies and their inclusion/exclusion criteria • Ideally, clinical trial consideration should be integrated into clinical management algorithms
    22. 22. Implementation & System Evaluation
    23. 23. NINDS Symposium 2002: Provider Support Sys Delivery System Analysis/Implementation • Focus groups with broad representation • Checklists for resource availability • Patient simulations “Mock Code Stroke” – Multiple stroke types – Variety of scenarios • External review
    24. 24. NINDS Symposium 2002: Provider Support Sys Educational Programs • CME • Use of “code stroke” drills • Email • Academic Stroke detailing • New-hire training • Integration into Procedures and Policies
    25. 25. NINDS Symposium 2002: Provider Support Sys Credentialing as a Support Tool • Staff – New-hire – Recurrent process • Institutional – Demonstration of resources – External review – Stroke center level
    26. 26. NINDS Symposium 2002: Provider Support Sys Establishing Effectiveness • Conformance to acute treatment guidelines, care pathways • Performance evaluations – Door to CT – Door to tPA – Mock codes • Registries
    27. 27. NINDS Symposium 2002: Provider Support Sys Summary • Numerous support systems and tools exist • Enhance the chain of survival • Provided from resources at multiple levels to assist diagnosis, management and delivery system evaluation – Pre-hospital – Local hospital based – Remote based (hospital or elsewhere) • Advance selection of needed elements is crucial
    28. 28. NINDS Symposium 2002: Provider Support Sys Comments and Questions