Ontario CT/mCTA Protocol 5 series of images, in the following order: - - PowerPoint PPT Presentation

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Ontario CT/mCTA Protocol 5 series of images, in the following order: - - PowerPoint PPT Presentation

May 08, 2023 27 likes •228 views

1 Ontario CT/mCTA Protocol 5 series of images, in the following order: 1. Non-contrast CT Head (axial) 2. CTA neck and head 1.25 2 mm (axial) 3. 5 mm MIP Axial CTA head (2 nd phase of multiphase) 4. 5 mm MIP Axial CTA head (3 rd phase of

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Ontario CT/mCTA Protocol

5 series of images, in the following order:

  • 1. Non-contrast CT Head (axial)
  • 2. CTA neck and head 1.25 – 2 mm (axial)
  • 3. 5 mm MIP Axial CTA head (2nd phase of multiphase)
  • 4. 5 mm MIP Axial CTA head (3rd phase of multiphase)
  • 5. 5 mm MIP Coronal CTA neck and head

Total: Approx. 520 images

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Protocol Testing

Protocol testing through ENITS Initial transfer times, before protocol, of 16 mins Most recent tests with current protocol: 3 mins

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Imaging – Next Steps

  • 1. Continued verification of rapid upload times from a wider variety of centres.
  • 2. Education for District Stroke Centres and other sites potentially transferring for EVT
  • 3. Regional approaches to roll-out may be favoured
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SLIDE 4

Endovascular Treatment for Acute Ischemic Stroke

Where Are We Now and Where Do We Want To Go

by by Dr Dr Grant Stot

  • tts

Ne Neurologis ist, Ottawa Ho Hospital Medic ical Di Director, Ch Champlain in Regio gional l Str troke Ne Netw twork Ju July ly 5, , 2016

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  • OSN Endovascular Thrombectomy (EVT) Working Group has been

established

  • Co-Chairs: Dr. Grant Stotts and Dr. Timo Krings
  • Members include stroke Neurology and Neurointerventional teams,

Regional/District Stroke Centre and referring hospital representatives, EMS,MOH EHS, Telestroke, and CritiCall Ontario

  • Collaboration with Canadian Stroke Consortium and National HSF Stroke

Best Practice Recommendations

To Address these Challenges & Plan Implementation

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Mem embership

Nam Name Organiz izatio ion Role

  • le

Dr Tim imo Krings Univ niversit ity y He Healt alth Netw Network-Toronto Western Hos Hospital Interventio tional l Ne Neuroradio iolo logis ist, Co-Chair ir Dr Grant t Sto totts ts The he Ottawa Hos Hospital Str troke Ne Neurologis ist, t,Co-Chair ir Dr Che heemun Lu Lum The he Ottawa Hos Hospital l Interventio tional l Ne Neuroradio iolo logis ist Dr Sac achin in Pan andey Lo London He Healt alth Scie iences- Interventio tional l Ne Neuroradio iolo logis ist Dr Vic ictor Yan ang Sunn unnyb ybrook k He Healt alth Scie iences Ne Neurosurgery Dr Vit itor Pereir ira- Univ niversit ity y He Healt alth Netw Network Ne Neurosurgery Dr Walt alter Mon

  • ntanera

St Michael’s Hospital Interventio tional l Ne Neuroradio iolo logis ist Dr Lau Laurie ie Mor

  • rris

ison St Michaels ls Hos Hospit ital Eme Emergency Medic icin ine Dr Le Lean anne Cas asaubon Univ niversit ity y He Healt alth Netw Network Str troke Ne Neurologis ist, t,OSN SN Best Prac actic ice Cham ampio ion Dr Yae ael l Perez Trilli illium He Healt alth Par artners Str troke Ne Neurologis ist Dr Ric ick k Sw Swar artz Sunn unnyb ybrook k He Healt alth Scie iences Str troke Ne Neurologis ist Dr Frank Silv lver Univ niversit ity y He Healt alth Scie iences Str troke Ne Neurologis ist t (Tele lestrok

  • ke)

Dr Jennif ifer Man andzia ia Lo London He Healt alth Scie iences Str troke Ne Neurologis ist Dr Al Jin King ngston Gene neral l Hos Hospital- Str troke Ne Neurologis ist Dr Jas ason Prpic ic Chair air EHS EHS MAC Bas ase Hos Hospit ital l Medic ical l Dir irector, Eme Emergency MD, Beth th Li Linkewic ich Nor North and nd Eas ast Tor

  • ronto Str

troke Ne Netw twork Regio ional l Prog

  • gram Dir

irector Jac acqueli line Wi Wille llem South Eas ast Toronto Regio ional l Prog

  • gram Dir

irector Rhon

  • nda McNic

icoll ll-Whit iteman Ham Hamilt ilton He Heal alth th Scie iences Clin inic ical l Nur Nurse Spe pecialis list- Str troke Best Prac actic ice Coo

  • ordin

inator Caterina Kmill mill Nor North West Ontario io Str troke Ne Netw twor

  • rk

Regio ional l Prog

  • gram Dir

irector Denis ise St. Lo Louis is Wi Windsor Regio ional l Hos Hospital Distric ict Str troke Coo

  • ordinator

Gina Tom

  • maszewski

ki Acute Car are Best Prac actic ice Coo

  • ordin

inator SW SWO Str troke Netw Network Li Lind nda Kello loway Best t Prac actic tice Le Lead ader Ontario io Stroke Netw Network

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Implementation Planning Working Group

To develo lop an im imple lementatio ion str trategy to:

  • Estimate patient volumes at provincial, LHIN, stroke centre and facility levels to inform

planning/impact

  • Identify facility capacity (focus on physicians and staff expertise and imaging

resources)

  • Determine role of Provincial Telestroke Program
  • Determine impacts to Emergency Medical Services and current Provincial Paramedic

Acute Stroke Protocol

  • Develop protocols for treatment and transfer
  • Identify strategies for knowledge translation
  • Evaluate processes/outcomes (with minimum data set)
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SLIDE 8

EVT Ce Centres in in Ontario io Ju July ly, 2016

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SLIDE 9

Current EVT Centres

WITH ITH 24/7 /7 COVERAGE

1. London Health Sciences 2. Ottawa Hospital 3. St Michael’s Hospital 4. Sunnybrook Health Centre 5. Toronto Western Hospital 6. Hamilton Health Sciences

WITH ITHOUT T 24/7 /7 COVERAGE

1. Thunder Bay Regional Health Centre 2. Trillium Health Partners 3. Windsor Regional Hospital 4. Kingston General – in planning

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SLIDE 10

Transfer Process for EVT

Subgroup:

  • Drs. Mandzia, Silver, Stotts, Prpic

Linda Kelloway Desmond Bohn (Criticall)

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SLIDE 11
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SLIDE 12
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SLIDE 13

TIME MATTERS

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Patient Transfer Time Verification

OSN currently partnering with Criticall, Ornge and EMS to identify sites within 2 hour transfer window to EVT centres Clinical emphasis should still involve rapid thrombolytic treatment Regional analyses will guide decisions to bypass or treat with tPA first at non-EVT sites Communication is key in the decision process to transfer

Multiple factors: imaging (infarct, collateral flow), road conditions, patient wishes

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Stroke Code Process at Sites Not Bypassed

Stroke treatment effectiveness is time-dependent Rapid times to thrombolysis remain important How would an ideal transfer look? Do Door In In/Door Out Ti Time Can we aim for 45 min?

5 mins for initial assessment/lab draw 20 mins to scan – avoid need to return for CTA 20 mins to review with telestroke/EVT site

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Transfer Process Details

A standardized Drip and Ship Protocol is being investigated Complication rates are low but require need to address anaphylaxis, hypertension and deterioration in level of consciousness

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Regional Approaches

In addition to provincial strategies

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Need for regional approaches

Multiple factors mandate that regional systems will need to be developed:

  • EMS coverage
  • Distance and number of referring sites.
  • Stroke team compositions.
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Regional EVT Working Groups

Coordination of:

  • EMS systems (urban and rural)
  • Radiology
  • ED communications
  • Repatriation agreements
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Regional EVT Working Groups

Ontario strategies can be used as a template CT/CTA protocol can be used by all sites. EMS prompt card can be adapted locally. OSN webinars will be archived. OSN personnel can be contacted for assistance.