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Minnesota Acute Stroke System Council

Minnesota Acute Stroke System Council. WebEx/Teleconference Meeting April 27, 2011. Agenda. 12:00 – Welcome and Introduction 12:10 – Model: Washington 12:30 – Model: Utah 12:50 – Discussion and Next Steps. Stroke Systems of Care. Implementation. In Development. Why Washington and Utah?.

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Minnesota Acute Stroke System Council

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  1. Minnesota Acute Stroke System Council WebEx/Teleconference MeetingApril 27, 2011

  2. Agenda • 12:00 – Welcome and Introduction • 12:10 – Model: Washington • 12:30 – Model: Utah • 12:50 – Discussion and Next Steps

  3. Stroke Systems of Care Implementation In Development

  4. Why Washington and Utah?

  5. Similar in demographics and land area Source: US Census Bureau, State & County QuickFacts, 2009 estimates.

  6. Washington’s Emergency Cardiac and Stroke System Kim Kelley, Cardiac/Stroke Systems Coordinator Heart Disease and Stroke Prevention Program Washington State Department of Health

  7. Emergency Cardiac and Stroke Care in Washington • Problem: effective treatments are available--but too many people don’t get them at all or in time • Only 4% strokes get t-PA • Only 35 of 95 hospitals administered t-PA • Estimated 39% of heart attacks get PCI • Only 55% of hospitals give lytics under 30 min • OHCA survival rates very low

  8. 30/60 Minute Drive Times for Primary Stroke Centers

  9. Emergency Cardiac and Stroke Care in Washington Solution: establish statewide emergency cardiac and stroke system similar to trauma (right patient/right place/right time) to reduce time to treatment.

  10. Emergency Cardiac and Stroke Technical Advisory Committee • Hospitals • Dispatch and EMS • Clinicians (ED MDs, Cardiologists, Neurologists, RNs, MPDs) • DOH, AHA, WSHA/RHQN, COAP, ACC

  11. Basic System Components • Public education • Standardized prehospital (dispatch and EMS) procedures and protocols: rapid dispatch, FAST, 12-lead ECG, CPR, defibrillation, triage and transport, pre-arrival notification • Hospital categorization/designation program • System goals • Data collection and QI

  12. SSHB 2396 signed by Governor Gregoire

  13. SSHB 2396 and the State ECS System in a Nutshell… • Requires EMS to take stroke, heart attack, and CPA-ROSC patients to specified hospitals based on transport times. • Built into EMS and Trauma System

  14. Working together to make it happen Evidence/data Shared vision Patient-centered Broad stakeholder participation Champions Administrative support Strategic plans and legislation

  15. Kim Kelley, 360-236-3613 kim.kelley@doh.wa.gov

  16. The Utah Stroke System Peter Taillac, MD Bureau of EMS and Preparedness Robert F. Jex, RN, MHA, FACHE Bureau of EMS and Preparedness

  17. Objectives • Describe the need for a stroke system • Describe objectives of the Utah Stroke System Plan • Describe the role of EMS and Emergency Departments in the plan • Describe the importance of rapid recognition, triage, transport to dedicated stroke facility and intervention for stroke patients

  18. The Utah Stroke System--Need • 45.7 Stroke Deaths per 100,000 population • Third leading cause of death in Utah • 3,256 visits/yr to hospitals with Dx Stroke • Stroke care is time sensitive • There is a golden 3 – 4.5 hour window for Rx • Potential benefits if eligible for treatment

  19. The Utah Stroke System--Need • Utah is very rural, all primary stroke centers clustered in the urban center of the state • Impossible to transport all stroke patients to urban centers • Utah is the first state to adopt an inclusive approach; other systems based on by-pass • Goal: improve the level of stroke care at all community EDs

  20. Brief History of Stroke in Utah • 2007-Acute Care Subcommittee of the Utah Stroke Task Force • 2008- Plan for Stroke Receiving Facility Presented • 2009- Criteria Developed-Stroke Tool Kit created • 2010- Invitation to all Utah hospitals sent

  21. The Hub and Spoke System • Hubs: Primary Stroke Centers • Act as referral and consultation centers to the SRFs • Joint Commission Certified • Spokes: Stroke Receiving Facilities • Utilize PSCs for consultation • Phone / Telestroke • May transfer patient, if desired • UDOH Verified

  22. Hub Hospitals (JC Designated PSCs) U of U IMC McKay-Dee Utah Valley Regional Ogden Regional Spoke Hospitals(State Verified SRFs) St. Marks Park City Jordan Valley Pioneer Valley Lakeview Timpanogos San Juan Dixie Regional Alta View American Fork Cache Valley Mountain View Spoke and Hub Total: 17 of 45 Utah Hospitals voluntarily participating so far

  23. Stroke Tool Kit Stroke Receiving Facility Toolkit Utah State Stroke System

  24. Stroke Receiving FacilityStandards • Voluntary system • Hospitals and EMS agencies work together • EMS preferentially delivers suspected stroke patients to PSCs or SRFs

  25. Stroke Receiving FacilityStandards • Stroke Team available 24/7 • Phone or Telestroke consultation with Primary Stroke Center available • 24 hr MD and RN in ED authorized to begin stroke protocol using standard forms and protocol • CT and Lab available 24/7: results in 45 minutes • Thrombolytic (rt-PA) available in/to ED • Stroke Coordinator and administrative support • Ad

  26. Stroke Receiving FacilityStandards • Site visit by UDOH team • Verifies: • Stroke protocols, resources, equipment • Stroke Team organization • Physician and administration support • Process improvement, data collection, stroke education (including EMS education) • If verified, local EMS agencies notified that the hospital is “stroke ready” to receive stroke patients via EMS

  27. EMS Stroke Guidelines • Goals: Ensure rapid identification of strokes and transport to appropriate Stroke Center or Stroke Receiving Facility • Utilize standardized stroke scale (e.g. Cincinnati) and specific stroke treatment protocol • Blood sugar determination critical • Early notification of receiving hospital to allow time for Stroke Team to prepare

  28. EMS Stroke Guidelines (con’t) • EMS must determine the exact time of onset as accurately as possible (or the time the patient was last seen well) • Preferentially transport to Stroke Center or Stroke Receiving Facility • Time = Brain Tissue

  29. Continuity of Stroke Care Team Approach • Detection • Importance of early recognition by lay public • Dispatch (9-1-1) • Obtains pertinent info; identifies urgency • Delivery (EMS) • Evaluates, obtains symptom onset, minimizes on scene time; immediate transport and pre-notification to PSS or SRF as soon as possible!

  30. Continuity of Stroke Care Team Approach • Door (ED) • Pre-alerts stroke team, performs patient exam & assessment (NIH Stroke Scale), rapid CT scan • Data • Reviews all pertinent patient information • Decision • determines if thrombolytic therapy candidate • may utilize PSC neurologist (phone/telestroke) to assist • Drug • administers treatment <60 min of arrival

  31. The Utah Stroke SystemMeasurement • Length of stay • Cost/charge per stroke patient • Diagnostics/bed utilization • Clinical outcomes (improvement in stroke scales after treatment) • Percent of eligible patients treated with TPA • Time data (door-to-needle time, door-to-CT time • Complications (intracranial hemorrhage, other hemorrhage, etc.) • Customer satisfaction

  32. The Utah Stroke SystemData Submission • Total number of “stroke” admissions to ED • Both EMS and walk-ins • Total number with Dx ischemic stroke • Percent of eligible patients treated with TPA • If not treated, why not? • Time data (door-to-needle time)

  33. The Utah Stroke SystemOutcome Goals • Provide nationally-accepted, evidence-based best practice emergency stroke care at as many community level EDs as possible • Increase systematic approach to stroke care • Reduce morbidity and mortality due to acute ischemic stroke • Increase quality of life for stroke survivors

  34. Questions? Thanks to: Utah Stroke Task Force Utah Hospital Association American Stroke Association Utah Stroke Advisory Committee Utah Bureau of Stroke and Heart Disease Prevention

  35. Discussion • Questions, Comments • Next: Subcommittees • Around what topics should we organize? • Suggestions for process going forward?

  36. Next Steps • Comment at www.health.state.mn.us/cvh • Respond to evaluation (to be emailed) • Next Meeting: May 25, 2011 Noon Contact: albert.tsai@state.mn.us (651) 201-5413

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