Code Stroke Optimizing Stroke Care in the Field: The Alberta - - PowerPoint PPT Presentation

Code Stroke – Optimizing Stroke Care in the Field: The Alberta Experience

June 1st, 2018 Thomas Jeerakathil BSc, MD, MSc, FRCP(C) Professor Division of Neurology University of Alberta Northern Stroke Lead CV/S SCN, AHS Co-PI Stroke Ambulance Project

Disclosures

• Bayer – 2 honoraria for 2 advisory board

meetings on anticoagulants

• Grant funding from CIHR, HSFC, AHS,

Alberta Health, SCN, University of Alberta Hospital Foundation

Mitigating Potential Bias

• The topic is unrelated to disclosures

Objectives

• Identify key components of the University of

Alberta (and province of Alberta) Door to Needle Time Quality Improvement Process related to activation of Code Stroke

• Recognize the potential application of a Stroke

Ambulance in Northwestern Ontario to improve access to care

• Describe the impact of implementing Code

Stroke at Thunder Bay Regional Health Sciences in reducing door to needle time

Patient 1 - 2012

• 58 year old female accountant - 2012
• Acute onset right hemiparesis, aphasia, sensory loss and

hemianopsia

• Presented (walk-in) to the Grey Nun’s Stroke Centre in

Edmonton

• Stat-stroke protocol initiated after 20 minutes in the waiting

room after there was further progression

• Door to needle time of 80 minutes – received IV tPA
• CTA not performed with the CT scan; performed AFTER tPA

and eventually showed large vessel occlusion (LVO)

• Transferred to UAH – arrival to transfer time 2.5 hours

Patient 2 - 2015

• 60 year old female University Professor
• Acute onset left hemiparesis, neglect, sensory loss

and hemianopsia

• Presented (walk-in) to the Grey Nun’s Stroke Centre

in Edmonton

• Stat-stroke protocol initiated
• Door to needle time of 17 minutes
• Stat transfer to the University of Alberta Hospital for

possible endovascular care

– Arrival to transfer time of 60 minutes

M.L.’s brain CT scan Thrombus resolved after IV tPA Patient 2 Clot visible blocking the middle cerebral artery (inside artery)

CT at UAH demonstrated resolution of the hyperdense MCA sign; CTA showed no intracranial blockages; NIH dropped from 11 to 2

• Leading cause of

disability in adults

• Causes 10% of all

deaths in the world

• The cost to Alberta

is approximately 300-400 million per year

• Stroke will present

soon to an ED near you!

The Impact of Stroke

Chart 3–64 Age-Adjusted Death Rates* for Stroke by Country & Sex, Ages 35–74, 2006– 2009 9

* Age-adjusted to European standard. Data for years indicated in parentheses.

Hippocrates 400 B.C.

n ‘It is impossible to remove a strong

attack of apoplexy and difficult to remove a weak one.’

Intracerebral hematoma

Aneurysmal Subarachnoid Hemorrhage 2 kinds of hemorrhagic stroke:

M.L.’s brain CT scan Clot visible blocking the middle cerebral artery (inside artery) Ischemic Stroke: Patient 1

The neuron…

In a typical large vessel acute ischemic stroke… 1.9 million neurons 14 billion synapses 12 km of myelinated fibers are destroyed each minute…

(Saver et al, 2006)

5 min ~ 10 million neurons, 60km of wires 10 min ~ 20 million neurons, 120km of wires 15 min ~ 30 million neurons, 180 km of wires…

Text Pooled individual patient metaanalysis of all 9 trials of tPA; >6500

patients The evidence for tPA given < 4.5 hours from onset in ischemic stroke is compelling. The elderly benefit as much or more

Adjusted benefits of tPA by 90min epoch

NNT is number needed to treat Lees, Lancet 2010; 375;1695-703

Time and outcome

[Lees et al. Lancet 2010; 375: 1695–1703]

17

Improving Access to tPA Enter Strategy - the APSS

Telestroke link Northern Telestroke Network

Technology - Telestroke

Page

Timelines in tPA use

ED Registration CT bloodwork ST paged ST calls ER doc CT reviewed ST bedside Foley catheter Focused history Stroke protocol Family discussion Attending physician paged Attending physician Responds Bloodwork reviewed Decision Mix tPA tPA bolus NIHSS/PE

Shorter DTN = better outcomes

• Every 15 min drop in DTN associated with a

5% reduction in mortality (OR 0.95; p<0.0001)

• Those with DTN < 60 min have reduced risk
• f intracranial hemorrhage 4.7% vs 5.6%

2 4

‘ In God we trust. All others bring data.’ ‘ There is no substitute for knowledge .’

• W. Edwards

Deming

60 min 50 min

UAH Edmonton; DTNs after an intensive QI program

QUICR Project June 2017 by zone

Alberta Heatmap: Pre/Post AFTER QUICR Collaborative

Oct 2016-July 2017 Sep 2015-Feb 2016

https://doi.org/10.1177/1747493017743060

https://doi.org/10.1177/1747493017743060

Triage (swarm) ED CT EMS Stretcher Transfer

Stretcher to CT & Swarm

Physician, nurse, +/- lab

Accessing the acute stroke system -- four scenarios: (for patients presenting within 6 hours of onset or wakeups presenting within 6 hours of waking)

• 1. The patient presents to a Primary Stroke

Centre (PSC)

• 2. The patient presents to a non-PSC (walk-

in or inpatient)

• 3. The patient is with an EMS crew (ERA

Project)

• 4. The patient presents to a clinic – call

911!

More blue areas meaning maximize time to EVT Examine why in next slide Yellow becomes grey meaning MS ground better Examine why in next 2 slides

HEADS UP follow-up

Stroke CFM Notes: If this is a HEADS UP call, ensure the caller has the pt ULI, LSN (if known)

Call to RAAPID HEADS UP? Age? >18 GEN PEDS CFM <18 Collect ULI, LSN, LAMS Yes LSN? Page EDM XXXX CAL XXXX No >6hrs LAMS? <6hr & wake-up Red Referral >4 Page EDM XXXX CAL XXXX <4 Provide ULI, referring site and MD name if known Call-back to RAAPID post-CT Page EDM XXXX CAL XXXX RAAPID joins audio-bridge (if required) Start a CRIS chart

The critical care line (or 911) is usually the first place to call for acute stroke. The LAMS can help identify motor symptoms that predict LVO

More blue areas meaning maximize time to EVT Examine why in next slide Yellow becomes grey meaning MS ground better Examine why in next 2 slides

The NIHSS is A 42 point scale to grade stroke severity. A score of >6-10 could predict LVO. Prehospital scales do NOT replace the NIHSS.

Page

Timelines in tPA use – PSCvOct4/17

ED Registration CT bloodwork

RAAPID Heads UP to Telestroke

Telestroke Calls RAAPID back

ER doc Sees (10 min)

CT reviewed Foley +/- Focused history Stroke protocol Family discussion Telestroke Connects with ED Doc Telestroke Videoconf Bloodwork reviewed Decision Mix tPA tPA bolus NIHSS/PE EKG +/-

Do, but not always pre-lytic

Tips on Door in Door Out (DIDO)

• Door in door out time (DIDO)
• Keep the incoming EMS crew on site if possible

to avoid delays in transfer of care

• In return, nonPSCs and PSCs should have a fast

turnaround

• The expectation of physician assessment within

10-15 minutes (like an MI) for a STATstroke (or Code stroke)

• PSCs - Speed up your CTA process to <5-10 min

so that you can do the CTA right after the plain CT

• Goal DIDO – 25 min for nonPSC; 45 min for PSC

Patient presents to non-PSC – walk-in

• Fast physician assessment (within 10-15 min – like an

MI); Call RAAPID immediately

• Determine the LAMS score (RAAPID will be able to

assist)

• If LAMS >= 4 then conference in the telestroke

physician, STARS, Provincial Flight, CCC (EMS Dispatch)

• A decision may be made for diversion from local PSC to

Comprehensive Stroke Centre (CSC) instead for faster EVT

• If LAMS <4 then contact the closest PSC activating

STATStroke Protocol (not just arranging a CT with DI)

• Fast DIDO time (ideally less than 25 minutes – rarely

achieved)

Patient presents to a non PSC with tPA capability

• Fast physician assessment (within 10 min – like an MI);
• Then call the stroke system immediately (usually via a

critical care line)

• Arrange stat transfer – consult with stroke physician
• Stat CT (within 15-20 minutes); and fast CTA (within

10min of plain CT being done); can be done while waiting for transport;

• A decision may be made for stat transfer to tertiary:
• post tPA or FOR tPA or EVT
• Transport priority RED (or local term) (v important if

being transferred for EVT or tPA)

• Ideal DIDO (door in door out or recognition to transfer

time) of 45 minutes (although not always realistic);

Example of a Non-PSC Walk in stroke protocol

tPA treatment window 4.5 hours Door-to-needle times of 30-60 minutes Northern and Central Alberta … “dead zones” Very difficult to achieve timely thrombolysis

Non-PSC Northern Alberta – Stroke Ambulance

• If within a 250 km range around Edmonton and

during the weekday hours of 8-4 call RAAPID with any acute stroke regardless of LAMS

• The patient may be a candidate for a Stroke

Ambulance dispatch which might allow the fastest thrombolysis as well as transport to Edmonton for EVT

• We have activated phase 2 – (response to in-

Zone Edmonton Hospitals)

• Transport doc should involve telestroke in the

field call in this radius during operational hours

• Phase 4 is being considered - 911 co-dispatch

Stroke physician at UAH, collects the information and advises on recruitment and dispatches CT mobile unit Physician on duty attends and contacts stroke expert at UAH through Rapid

• North. Obtains

consent Patient comes to the local hospital with stroke symptoms

Data collected and processed

ACHIEVE STUDY

Blood work done at local hospital and report sent

• ver to UAH

CCT equipped mobile unit with stroke fellow dispatched towards the local hospital Patient transferred to UAH by ambulance The CT mobile meets ambulance at predetermined location CCT completed in the field ICH ruled out, meets inc/exc criteria, NIHSS, mRS rt-PA therapy initiated in the ambulance Patient arrives at UAH for continued care CCT, NIHSS, mRS, Repeat assessment after 24 hr (CCT, NIHSS, mRS, Barthell Index) Follow up after 7, 30 and 90 days (Follow up

• n phone if patient is

discharged)

UAH

communication Telestroke

Northwestern Ontario

Northwestern Ontario

Take Home Points

• Stroke remains a highly morbid disease
• Have a systematic approach to acute

stroke and seek consultation immediately

• IV tPA is a highly effective treatment for

ischemic stroke and time – limited

• EMS and nonPSCs still play a critical role

in brain survival

Thank-you