Stroke Center Designation: Impact on EM

1. Stroke Center Designation:Impact on EM E. Bradshaw Bunney, MD, FACEP

2. E. Bradshaw Bunney, MD, FACEPAssociate ProfessorDepartment of Emergency MedicineUniversity of Illinois at ChicagoOur Lady of the Resurrection Hospital E. Bradshaw Bunney, MD, FACEP

3. Global Objectives • Improve patient outcome for both hemorrhagic and ischemic stroke • EM participation in protocol development • Hospital financial interest • Community education

4. Session Objectives • Stroke management from community to the ED and beyond • The history of Stroke Center designation • EM role in protocol development and Stroke Center designation

5. Clinical History A 911 call was taken by the Chicago Fire Department dispatch service at 2:25 pm. The caller stated, “My husband is having a stroke and he can not move the left side of his body”. An ALS ambulance arrived at 2:34 pm and found the 67-year-old patient to be sitting in a chair with a BP 140/85, pulse 96, respiratory rate 16 and the inability to move his left arm or leg. His wife also noticed the left side of his face was “flat”. He was able to speak and denied headache, chest pain or shortness of breath.

6. Clinical History He had a history of hypertension, was on Labetalol and Lasix, with no allergies. The paramedics noted the time of onset for the symptoms to be 2:15 pm., which was agreed to by both the patient and his wife. The patient was placed on a cart, an IV was established, oxygen was applied, and glucose was 98. The paramedics called into the base station at 2:48 pm, stating, “We have a probable stroke, with two out of three abnormal on the Cincy scale” and arrived in the ED at 2:52 pm.

7. Key Clinical Questions • Who, What, Why of Stroke Center designation? • Does my hospital need to become a Stroke Center? • Does a Stroke Team improve ED care of stoke patients? • Can an ED use thrombolytics if it is not a Stroke Center? • What is EMS role in the process? • What are the EM controversies in the care of stroke patients?

8. Stroke in Perspective: An Overview E. Bradshaw Bunney, MD, FACEP

9. Disability Due to Stroke, 1999*†‡ *Noninstitutionalized people ≥18 years old. †Total number of people with disabilities=41,168,000. ‡Numbers may not add up due to rounding. Centers for Disease Control (CDC). MMWR. 2001;50:120-125. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5007a3.htm. Accessed December 4, 2003.

10. Age-Adjusted Stroke Death Rates by Age and Gender, 2001 *Age-adjusted rate calculated using the year 2000 standard population. National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03husupdated.pdf. Accessed January 12, 2004.

11. Age-Adjusted Stroke Death Rates by State, 2001 Arias E, et al.Natl Vital Stat Rep. 2003;52:1-116. Available at:http://www.cdc.gov/nchs/fastats/stroke.htm. Accessed December 4, 2003.

12. Age-Adjusted Stroke Death Rates by Race and Gender, 2001 National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03husupdated.pdf. Accessed January 12, 2004.

13. Estimated Direct and Indirect Costs of Stroke, 2003 American Heart Association (AHA). Heart Disease and Stroke Statistics — 2003 Update. 2003. Available at: http://www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf. Accessed October 13, 2003.

14. Major Causes of Death in the United States, 2001 COPD=chronic obstructive pulmonary disease. Arias E, et al.Natl Vital Stat Rep. 2003;52:1-116. Available at:http://www.cdc.gov/nchs/fastats/stroke.htm. Accessed December 4, 2003.

15. Age-Adjusted Death Rates From Stroke: 1950-2001*† *Age-adjusted rates are calculated using the year 2000 standard population. †Data prior to 1970 includes deaths of persons not residents of the 50 states and the District of Columbia. National Center for Health Statistics (NCHS). Table 37. In: Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03husupdated.pdf. Accessed January 12, 2004.

16. Different Types of Stroke, 2000 Cerebral Embolus 24% TIA 3% Ischemic Stroke 88% Intracerebral Hemorrhage 9% Cerebral Thrombosis61% HemorrhagicStroke 12% Subarachnoid Hemorrhage 3% TIA=transient ischemic attack. American Heart Association (AHA). Heart Disease and Stroke Statistics — 2003 Update. 2003. Available at: http://www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf. Accessed October 13, 2003.

17. HISTORY • 1995- NINDS- TPA therapy for ischemic stroke • 1996- EM controversy over use of TPA in stroke • 1997- Brain Attack Coalition (BAC) formed • 2000- Primary Stroke Center criteria published • ?- Comprehensive Stroke Center criteria published

18. Stroke-site.org

19. BAC Members • NINDS • American Academy of Neurology • American College of Emergency Physicians • American Assn of Neurological Surgeons • American Stroke Association • National Stroke Association • Am Soc of Intervent and Therapy Neuroradiology • American Society of Neuroradiology • Congress of Neurological Surgeons • Stroke Belt Consortium • Veterans Administration • National Association of EMS Physicians • Centers for Disease Control and Prevention • American Assn of Neuroscience Nurses

20. Brain Attack Coalition • Stroke scales • Guidelines • Pathways • North Carolina • Stanford • Thomas Jefferson • www.stroke-site.org

21. Strokeassociation.org

22. American Stroke Association • Acute Stroke Treatment Program • Operation Stroke • Get with the Guidelines-Stroke • Stroke Center Certification • www.strokeassociation.org

23. Stroke.org

24. National Stroke Association • Public Health Stoke Summit • CDC sponsored • Increase public awareness • Develop state programs to decrease the incidence and death rate • National Tutorial on Stroke

25. Why Were Stroke Centers Developed? E. Bradshaw Bunney, MD, FACEP

26. TIME IS BRAIN E. Bradshaw Bunney, MD, FACEP

27. Time is Brain • Narrow therapeutic window • t-PA within three hours of symptom onset • Rapid identification, transport, diagnosis and treatment • Stroke “chain of survival” (AHA)

28. Trauma Center Model • Military experience with rapid evacuation • 1966: Accidental Death and Disability: The neglected disease of modern society • National Academy of Sciences document • Strong government leadership proposed • Called for improved training, education, and research • Role of prehospital care emphasized • Radio communication • EMS training • Categorize hospital capabilities: 4 categories • Resulted in the National Highway Safety Act

29. Trauma Center Model • 1993 report: 20 states had trauma systems with legal authority • 5 States had full implementation: many states failed to enforce limitations on the number of centers based on need (due to political obstacles • Financial Crisis: decreased federal support, managed care, DRGs, staff retention • Trauma center implementation has provided an infrastructure for the provision of emergency care

30. Who is Designating Stroke Centers? • American Stroke Association • Joint Commission

31. ASA GWTG Measures Focus is quality of care • Ischemic Stroke Prevention: • Smoking Cessation Counseling • Lipid Lowering Therapy • Blood Pressure Treatment • Weight and Exercise Management • Diabetes Management • Atrial Fibrillation Management • Acute Stroke Treatment: • Time of symptom onset • Time from EMS receiving call to EMS arrival • Time patient arrived at Emergency Department (ED) • Time of CT/MRI Scan • Time of thrombolytic therapy

32. Disease Specific Care Certification JCAHO • Premise is that certification process will drive quality measures and improve outcomes • No emergency medicine society has endorsed this initiative • t-PA controversy • Overcrowding • Medical legal implications

33. Accreditation vs. Certification JCAHO • Accreditation • Surveys are organization-based, focused on quality and safe care processes and functions • Traditional JCAHO evaluation product • 50 years establishing expertise in evaluating health care organizations • Certification • Reviews are service-based, focused on quality, safety, and outcomes of improving clinical care • Voluntary—not an add-on to accreditation

34. Brain Attack Coalition Recommendations for Developing Primary Stroke Centers E. Bradshaw Bunney, MD, FACEP

35. Major Elements Patient care areas Acute stroke teams Written care protocols Emergency medical services Emergency department Stroke unit Neurosurgical services Support services Stroke center director Neuroimaging services Laboratory services Outcome and quality improvement activities Continuing medical education of a Primary Stroke Center Alberts MJ, et al. JAMA. 2000;283:3102-3109.

36. Anticipated Benefits of a Primary Stroke Center • Increased patient-care efficiency • Fewer peristroke complications • Increased use of therapies for acute stroke • Decreased morbidity and mortality • Improved long-term outcomes • Decreased costs to the healthcare system • Improved patient satisfaction Alberts MJ, et al. JAMA. 2000;283:3102-3109.

37. Acute Stroke Team • Personnel with expertise in diagnosing and treating cerebrovascular disease (may include neurologist or neurosurgeon)1 • Minimum team would include a physician and another healthcare provider (nurse, physician’s assistant, nurse practitioner)1 • National Stroke Association (NSA) organizational recommendations2 • Stroke center team should include a specialist and support in: • Neurology, neurological surgery, neuroradiology, as well as emergency medicine and rehabilitation medicine • Stroke center team should include, on an as-needed basis, a specialist and support in: • Cardiology, critical care, gastroenterology, hematology, infectious disease, internal medicine, pathology, primary care, and vascular surgery 1. Alberts MJ, et al. JAMA. 2000;283:3102-3109. 2. Furlan AJ, et al, 1997. Available at http://199.239.30.192/NR/rdonlyres/exkgdlqimjxtunrlwtsd7tpge3i23nwqm5r5uxw3cby4zk6fe3t3ubvtek2kpnp5ocmymjutwyyofb/StrokeCenterRecommendatio.pdf.

38. Acute Stroke Team (cont’d) • Someone from the team should be available 24/7 • Need system for quick notification and activation of the team • One member of the team should see patient within 15 minutes • Written document should be developed to provide information on stroke team guidelines • Logbook should be established to document call and response times, diagnoses, treatments, and outcomes Alberts MJ, et al. JAMA. 2000;283:3102-3109.

39. Written Care Protocols • Reduce tPA–related complications • Protocols should include • Emergency care of ischemic and hemorrhagic strokes • Stabilization of vital functions • Initial diagnostic tests • Initial use of medications • Protocols should be available any place where patients with stroke may be evaluated or treated • Should be reviewed and updated once per year Alberts MJ, et al. JAMA. 2000;283:3102-3109.

40. Emergency Medical Services • Assigned a high priority • EMS should be integrated with the stroke center • During transportation, EMS and the stroke center need to communicate • Quickly triage patients with a stroke upon arrival • Educational activities should include stroke center and EMS staff and occur at least twice a year Alberts MJ, et al. JAMA. 2000;283:3102-3109.

41. Emergency Department • ED personnel should be trained to diagnose and treat all types of acute strokes • ED staff should access the stroke team • Communicate with EMS and be prepared for arrival of stroke patients • Written protocols for stroke management and triage • Educational activities should occur at least twice a year to reinforce stroke diagnosis and treatment Alberts MJ, et al. JAMA. 2000;283:3102-3109.

42. Additional Hospital Units and Services • Stroke Unit • Does not need to be a distinct unit in the hospital • Personnel should have expertise in managing cerebrovascular disease • Additional infrastructure includes: continuous telemetry, written care protocols, and ability to continuously, noninvasively monitor blood pressure Alberts MJ, et al. JAMA. 2000;283:3102-3109.

43. Additional Hospital Units and Services • Neurosurgical Services • Neurosurgical care should be available within 2 hours of determination that surgery is necessary (patients can be transferred) • Hospitals providing the neurosurgical care should have 24-hour–staffed operating room Alberts MJ, et al. JAMA. 2000;283:3102-3109.

44. Additional Hospital Units and Services • Neuroimaging (CT or MRI) Imaging within 25 minutes • Image evaluation within 20 minutes • Standard laboratory tests should be available 24/7 Alberts MJ, et al. JAMA. 2000;283:3102-3109.

45. Outcomes and Quality Improvement • Database or registry of all stroke patients • Benchmarks for comparison • Can be selected from treatment guidelines • Each year, at least two patient-care issues • Pre-specified committees meet at least three times a year to review and modify practice patterns Alberts MJ, et al. JAMA. 2000;283:3102-3109.

46. Educational Programming • Stroke center staff should earn at least 8 hours of CME credit per year related to cerebrovascular disease • The stroke center should hold at least two programs per year to educate the public • Prevention and recognition of stroke symptoms • Availability of acute treatments Alberts MJ, et al. JAMA. 2000;283:3102-3109.

47. Stroke Center Certification JCAHO • Certification review will assess • Compliance with consensus-based national standards • Effective use of primary stroke center recommendations and clinical practice guidelines to manage and optimize care • Performance measurement and improvement activities • Certification for a 1-year period • A 1-year extension is available Joint Commission Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Disease-Specific Care: Update [JCAHO Web site]. Issue 1, June 2004. Available at: http://www.jcaho.org/dscc/dsc/dsc+update/dsc_update.htm. Accessed September 15, 2004.

48. Does my Hospital Have to Become a Stroke Center? E. Bradshaw Bunney, MD, FACEP

49. Opportunity Exists

50. Hospitals That are Stroke Centers • Approximately 5,000 hospitals in the US • As of Feb. 2005 there are 88 certified Stroke Centers • 50 more in the pipeline • California, Florida, Ohio and Pennsylvania each have 7 • State certification in Massachusetts and New York