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Regionalized Stroke Care Vision for the Upper Peninsula

Regionalized Stroke Care Vision for the Upper Peninsula. Karl Meisel, MD Vascular Neurology Marquette General Hospital. Outline. Regionalized Stroke systems of care Strategies Prevention Education Drip and Ship Rescue therapy options Tele-stroke Hospital management of ischemic stroke

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Regionalized Stroke Care Vision for the Upper Peninsula

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  1. Regionalized Stroke CareVision for the Upper Peninsula Karl Meisel, MD Vascular Neurology Marquette General Hospital

  2. Outline • Regionalized Stroke systems of care • Strategies • Prevention • Education • Drip and Ship • Rescue therapy options • Tele-stroke • Hospital management of ischemic stroke • Guideline review • Secondary prevention • Anticoagulation decisions • Transitions of care

  3. Marquette General Hospital • Only Joint Commission Primary Stroke Center • Re-certification as a Stroke Center Gold Award • Michigan Stroke Registry & Quality Improvement award • About 300 stroke patients per year.

  4. Regional Stroke Impact

  5. The Opportunity • Higher stroke mortality in the UP of Michigan compared to the whole region. • Fewer Primary Stroke Centers in higher mortality area (belt) in Great Lakes region. • Marquette General is the only UP hospital with: • Neurology • Neurosurgery • Interventional radiology • Hospital rehabilitation center • Primary stroke certification • Trauma level II http://www.uic.edu/depts/glstrknet/doc/Atlas%20Revised%2004-18-08-deleted%20pages.pdf http://www.cdc.gov/dhdsp/maps/gisx/mapgallery/textonly.html

  6. The Ideal System Components ● Primary prevention ● Community education ● Notification and response of emergency medical services ● Acute stroke treatment, including the hyper acute and emergency department phases ● Sub acute stroke treatment and secondary prevention ● Rehabilitation ● Continuous quality improvement (CQI) activities Stroke. 2005;36:690-703

  7. Primary Prevention

  8. Community Education about Stroke 2011 Stroke Brief Michigan Department of Community Health

  9. 90 + Smoking + Diabetes + Hypertension 60 % Coronary Surface Covered Plasma Cholesterol Level of 200 mg/dl (5.17 mmol/L) 30 0 30 40 50 60 70 80 Age Impact of Primary Prevention • 12 point reduction in BP reduces stroke by 37% • Each 10% LDL reduction reduced risk of stroke by 15.6% • 1% reduction in HbA1C decreased hazard ratio by 21% Grundy SM, JAMA 1986

  10. Atrial Fibrillation Circulation.2012;126:860-865

  11. TIA clinics • Cost effectiveness of low risk (<5%) TIA admissions is debated. • Low agreement about TIA diagnosis • No current accepted guideline for admission • Admission rates vary 41-68% in US • Improved outcomes if neurology evaluation • Perhaps improved adherence to treatment (IMPACT) • Rapid risk factor evaluation essential • EXPRESS study < 1day RR 90d of 80% • Absolute 10.3 vs 2.1, CI 0.08-0.49, p=0.0001 • Reduced fatal and disabling strokes Stroke 2009;40:2276-2293 Stroke 2008; 39:1834-1843 Lancet 2007;370:1432-1442

  12. TIA clinics • Cost effectiveness of low risk (<5%) TIA admissions is debated. • Low agreement about TIA diagnosis • No current accepted guideline for admission • Admission rates vary 41-68% in US • Improved outcomes if neurology evaluation • Perhaps improved adherence to treatment (IMPACT) • Rapid risk factor evaluation essential • EXPRESS study < 1day RR 90d of 80% • Absolute 10.3 vs 2.1, CI 0.08-0.49, p=0.0001 • Reduced fatal and disabling strokes Stroke 2009;40:2276-2293 Stroke 2008; 39:1834-1843 Lancet 2007;370:1432-1442

  13. TIA clinics • Population education about TIA • Quick <24 hour referral to vascular neurologist • Telemedicine evaluation by neurologist • Rapid risk factor assessment • Inpatient for high risk • Outpatient for low risk • At least one neurology follow-up

  14. Stroke Centers • Stroke centers are present in only 3.6% of European hospitals • Less than 50% of the American population has access within 45 minutes. • Secondary transfers from primary hospitals cause too much delay of time-dependent recanalization • Triage directly to the most appropriate destination is important. Neurology 2012;78:1849–1852

  15. Smart Planning = Big Impact • North Carolina found that expanding the scope of stroke care services to just 6 hospitals could improve access to basic acute stroke services from 52% to 84%. • Rapid evaluation, referral, and transfer may be established through the application of stroke care protocols.

  16. Acute Stroke Care • Using a regionalized system for acute stroke • Hub and spoke • Time is brain/Increasing tPA use safely • Telemedicine • Drip and Ship • Rescue Therapy • Hospital care • Transitions of care

  17. Hub and Spoke • Identify roles of each hospital in the system • Define the responsibilities in those roles. • Formal transfer agreements • Stroke Unit established at the hub • Continuity of care between centers • Standard forms and protocols to improve communication during transitions of care

  18. Quality Improvement Tasks • Effectiveness of primary prevention strategy • Measure knowledge of stroke in community • EMS and hospital information exchange • Timeliness of acute stroke evaluation and care • Secondary prevention effectiveness • Avoidance of complications, readmissions • Rehabilitation access and outcomes Stroke. 2005;36:690-703

  19. Strategies to Improve Care • Faster identification of stroke symptoms • Fast emergency services access and evaluation • Vascular neurology acute consultative services • Comprehensive and timely risk factor evaluation • Access to appropriate rehabilitation services • Adherence to secondary prevention therapies

  20. Faster Door to Needle Times • 1,082 hospitals were in the GWTGS 2003-09. • Less than 1/3 of patients treated with IV rtPAhad door-to-needle times < 60 minutes. • Pre-hospital delay is the largest proportion of delay in time. • The likelihood of receiving intra-arterial therapies decreases rapidly with increasing transfer time. • Every 15 minute reduction in DTN = 5% lower odds of in-hospital mortality Neurology 2012;78:1809–1810 Fonarow GC et al. Circulation. 2011;123:750-758

  21. Normal/near normal = NNT 8.3 • Improved = NNT 3.1 • For 100 patients treated with tPA 32 benefit and 3 harmed • 3 – 4.5 hrs (not FDA approved) but 16% more have good outcome Hacke, W., G. Donnan, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74.

  22. 3 – 4.5 Hours of Last Normal • Not FDA approved but is supported by guidelines • Suggest some attempt at obtaining consent • Trial exclusion criteria • Age >80 • Baseline NIHSS >25 • Any oral anticoagulant • Previous stroke and diabetes

  23. NIHSS • LOC: Responsiveness, Questions, Commands • Eye Movement • Visual fields • Facial Palsy • Motor Arm : left and right • Motor Leg: left and right • Ataxia • Sensory • Language • Speech • Extinction and inattention • Minor is 1 - 4 • Moderate 5 - 15 • Moderate to severe 16 - 20 • Severe 21 - 42

  24. Timing of Acute Stroke Evaluation • Initial ED Evaluation within 10 minutes • Notify stroke team within 15 minutes of arrival • CT scan within 25 minutes • Read on CT within 45 minutes • IV tPA within 60 minutes • Other studies: glucose, O2 sat, BMP, cardiac enzymes, INR/PT/PTT, EKG. AHA website strokeassociation.org/targetstroke

  25. Acute neurology consultative services

  26. Telestroke • The level of agreement between telestroke and face-to-face evaluations was identical to 2 face-to-face exams • except eye movements • Class IIa, level B • Assessment of occupational, physical, or speech disability in stroke patients is recommended by telemedicine • Class I, level B Stroke. 2009;40:2616-2634

  27. Telestroke • AIS pt in a rural ED is 10 times less likely to receive tPA than urban primary stroke center. • There is a gap in access to stroke specialists in rural communities. • Telemedicine can minimize this gap with immediate and appropriate access to care. • STRokE DOC trial found significant benefit of telemedicine over telephone to correct decision • 98% vs 82%; OR 10.9; 95% CI 2.7–44.6; p = 0.0009 • The rt-PA subset of subjects • 97%vs 76%; OR 7.4; 95% CI 1.03–53.2; p = 0.0466 • ICH rate 7% vs 8%; OR 0.8;95% CI 0.1–6.3; p = 1.0 Telemedicine and e-health. 2012; 18(3): 5.

  28. Telestroke • Summary of 12 telestroke networks found the thrombolysis administration rate increase 23% • 10-fold from baseline • without protocol violation or hemorrhagic rates. • AHA recommends the use of telestroke if on-site stroke expertise is insufficient for 24/7 coverage • Class I, Level A • In 3 years the risk of a poor outcome was 18% lower for telestroke hospitals vs non-telestroke linked hospitals. • The cost of telestroke over a person's lifetime was less than $2500 per quality-adjusted life year. Stroke 2009;40:902-8. Neurology 2011;77:1590-8.

  29. Example of Telestroke Network • REACH-MUSC study provided acute stroke coverage 24/7 to 12 community hospitals in South Carolina located 61 to 187 miles away • 35.7% were treated with tPA • 64.3% were transferred to the hub • 2.9% received combination of IV and IA/thrombectomy • 2.1% were treated with IA therapy alone

  30. Keys to Success • Privileges at all the spoke hospitals • Stroke pathways • Algorithms, step-by-step flow charts • Order sets to rural hospitals • Common thrombolysis eligibility checklist • On-site education • ED nurses and MD certified in NIHSS • Hub neurologists encouraged to visit spokes

  31. When IV tPA fails • Recanalization Rate: • ICA terminus – 6% • M1 – 30 % • Basilar – 33%

  32. Drip and Ship • Transfer to tertiary center while IV tPA drips • Goal to receive patients within 5 – 6 hours of symptom onset. • Tertiary center obtains CT angiogram of head and neck • Determine eligibility for intra-arterial tPA or mechanical embolectomy. • IA tPA time limit is about 6 hours • Mechanical embolectomy about 8 hours • Basilar artery thrombus about 12 hours

  33. New Guidelines • If excluded from IV tPA and < 6 hrs Class I, Level of Evidence B • Rescue therapy if large artery occlusion and not responded to IV tPA Class IIb, Level of Evidence B • Newer stent retrievers are recommended over coil retrievers Class I, Level of Evidence AHA Guidelines published in Stroke 2013; 44: 870-947.

  34. Breaking News • SYNTHESIS trial – IV vs IA tPA (34.8 vs 30.4%) • Delay in IA tPA by about 1 hr likely reduced effect • Message is do not delay IV tPA • MR RESCUE trial – used perfusion imaging to predict who might benefit from embolectomy • No difference between groups • Limitation was > 6 hours to treatment and used old devices • Stroke (IMS) III – IV tPAfull dose vs partial dose with endovascular found no difference • Limited because not screened for large artery occlusion • Long interval between tPA and endovascular 126 min N JEM 2013;368(10): 893-903, 904-913, 914-923.

  35. My Opinion • No clear algorithm for endovascular therapy • Do not delay IV tPA, give full dose • If a young patient < 60 strongly consider • If > 8 NIHSS • Basilar artery involvement • Suspicion for dissection

  36. Admitting the Stroke Patient Post tPA • ICU for frequent Neuro and Vital Sign monitoring • Every 15 minutes for 2 hours • Every 30 minutes for 6 hours • Every 1 hour until 24 hours post tPA • Stop tPA if severe HA, worsening exam • BP goal < 180/105 • No heparin products, anti-platelets for 24 hours • Obtain HCT or MRI in 12-24 hrs before starting aspirin 325mg • Avoid or delay invasive procedures (NG, Foley) • NPO unless passes swallow screen • TEDs/SCDs

  37. Admission Orders for non-tPA • Aspirin 325mg or 300mg rectal if no NG or NPO • Permissive blood pressure < 220/120 for 48 hours • Can consider ICU vs Medical/Stroke Unit with telemetry based on clinical scenario • Lovenox for DVT prophylaxis • NG if fails formal speech evaluation

  38. All Patients • Early mobilization • PT/OT/Speech/Rehabilitation Medicine if appropriate • Only isotonic IV fluids (0.9%NS) • Euthermia • Euglycemia 100-200 goal glucose, avoid hypoglycemia • Coronary risk panel, goal LDL is < 70 • Consider A1C, goal is < 7 • Stroke education • Smoking cessation • Avoid Foleys or minimize use < 24 hours My opinion: • Avoid hyponatremia

  39. Inpatient Emergency • Stroke patient decompensates • Coma exam: respiration, pupils, occulocephalics, corneals, gag, posturing • Mannitol 1 gram / kg • Head of bed, neck straight • If on ventilator hyperventilation to pCO2 30-35 • Emergent CT • Decompressive craniotomy Class I, B • NNT 2 mortality, NNT 4 to be ambulatory • Advanced age and patient/family values may change this • Evaluate for EVD

  40. Secondary Stroke Prevention • What is the etiology: • Artery-to-artery embolism (carotid disease) • Cardioembolic (atrial fibrillation) • Small vessel disease (diabetes, hypertension) • Hypercoagulable • Studies: • Carotid Ultrasound if anterior circulation • CT or MR angiogram if posterior circulation • Echocardiogram (TTE bubble study usually) • Telemetry (must be reviewed by physician daily) • Lupus anticoagulant, anticardiolipin, HC, MTHFR

  41. Carotid Endarterectomy • Did ultrasound find >70% stenosis or 50-69% stenosis on ipsilateral side of infarct? • Then confirm with CT or MR angiogram • If occlusion is present is it focal (acute) or long-segment (chronic)? • If focal (acute) occlusion then cerebral angiogram to confirm. • If >70% stenosis confirmed or critical stenosis but not occlusion then endarterectomy within 2 weeks

  42. Treatment • Hypertension: • Avoid venodilators (nitro, hydralazine) • Prefer: Diureticand ACE-I • Dyslipidemia: • Statin (atorvastatin) goal LDL <70 • Antiplatelet • Aspirin (15% RR), clopidogrel, or dipyridamole-aspirin • Clopidogrel and dipyridamole-aspirin are superior to aspirin and non-inferior to each other

  43. Atrial Fibrillation • At least 15% of ischemic stroke • Likely 30% of cryptogenic stroke if prolonged monitoring performed • Average time to detection was about 1 month • Anti-coagulate about 1 – 2 weeks post large territory infarct. • Consider sooner if small infarcts or mechanical heart valve • No heparin bridging required

  44. Choice of Anticoagulation • Warfarin – INR goal 2-3, only 60% are in range • Dabigatran - 150mg twice daily • Superior to warfarin in RE-LY study. • Major bleeding same, but less intracranial bleeds • Apixaban – 5mg twice daily • Superior to warfarin in ARISTOTLE study. • Fewer major bleeding events and lower mortality • Rivaroxaban- 20mg daily • Non-inferior to warfarin in ROCKET-AF trial • No difference in bleeding and less intracranial bleeds NEJM 361(12),1139-1151; NEJM 365(11),981-992; NEJM 365(10), 883-891

  45. Special Circumstances • Warfarin • Rheumatic heart disease • Cardiac thrombus • Thrombophilias • Mechanical heart valves • Dissection of vertebral or carotid artery • LMWH • Neoplasm related hypercoagability • Pregnant women • Avoid if MRI evidence of amyloid angiopathy

  46. Discharge • Communication • Send discharge summary to primary care • Contact primary care directly • Stroke education • Medication education • Smoking cessation • Follow-up appointments/INR/Holter • Alert family to signs of decompensation and post-stroke depression • Follow-up phone call • Rehab arrangements

  47. Adherence to Secondary PreventionThe Problem • 1/3 of stroke patients discontinued >1 secondary prevention medications within 1 year • Never seen by a neurologist • Communication lacking from the inpatient to rehabilitation to outpatient primary physician • 2/3 of Medicare patients who had a stroke died or were rehospitalized within 1 year Stroke2011;42:159-66. Neurology 2011;77:1182-1190

  48. Ideas for Improvement • Rural community presents challenges of distance and lack of specialists • Unlikely to have neurology evaluation, especially TIA • Reduced rehabilitation expertise • Unlikely to have neurology follow-up • Decreases communication with other physicians • Internet program to link various stages of care • Patient/family • Neurologist • Rehab specialist • Primary physician

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