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

Patient 2 Clot visible blocking Thrombus resolved the middle cerebral after IV tPA artery (inside artery) M.L. ’ s brain CT scan CT at UAH demonstrated resolution of the hyperdense MCA sign; CTA showed no intracranial blockages; NIH dropped from 11 to 2

The Impact of Stroke • 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!

Chart 3–64 Age-Adjusted Death Rates* for Stroke by Country & Sex, Ages 35–74, 2006– 2009 * Age-adjusted to European standard. Data for years indicated in parentheses. 9

n ‘ It is impossible to remove a strong attack of apoplexy and difficult to remove a weak one. ’ Hippocrates 400 B.C.

2 kinds of hemorrhagic stroke: Aneurysmal Intracerebral hematoma Subarachnoid Hemorrhage

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

The neuron … In a typical large vessel acute ischemic stroke … 1.9 million neurons 14 billion synapses 12 km of myelinated fibers 5 min ~ 10 million neurons, are destroyed each 60km of wires minute … 10 min ~ 20 million neurons, (Saver et al, 2006) 120km of wires 15 min ~ 30 million neurons, 180 km of wires …

Text The evidence for tPA given < 4.5 hours from onset in ischemic stroke is compelling. The elderly benefit as much or more Pooled individual patient metaanalysis of all 9 trials of tPA; >6500 patients

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

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

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 of intracranial hemorrhage 4.7% vs 5.6%

‘ In God we trust. All others bring data.’ ‘ There is no substitute for knowledge .’ W. Edwards Deming 2 4

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 Sep 2015-Feb 2016 Oct 2016-July 2017

https://doi.org/10.1177/1747493017743060

https://doi.org/10.1177/1747493017743060

Triage Physician, Stretcher to CT (swarm) nurse, & Swarm +/- lab EMS Stretcher ED CT Transfer

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!

Stroke CFM Notes: If this is a HEADS UP call, ensure the caller has the pt ULI, LSN (if known) More blue areas meaning maximize Page Call to RAAPID Age? >18 HEADS UP? No LSN? >6hrs EDM XXXX time to EVT CAL XXXX <18 Examine why in next Yes <6hr & wake-up slide GEN PEDS CFM Collect ULI, LSN, LAMS? >4 Red Referral LAMS Yellow becomes grey The LAMS can Start a CRIS chart meaning MS ground <4 The critical care better help identify motor Page EDM XXXX line (or 911) is CAL XXXX Examine why in next symptoms that predict 2 slides usually the first place to LVO Provide ULI, referring site and MD name if known call for acute stroke. HEADS UP follow-up Page RAAPID joins Call-back to EDM XXXX audio-bridge RAAPID post-CT CAL XXXX (if required)

The NIHSS is A 42 point More blue areas scale to meaning maximize time to EVT grade stroke Examine why in next severity. slide A score of Yellow becomes grey meaning MS ground >6-10 could better predict LVO. Examine why in next 2 slides Prehospital scales do NOT replace the NIHSS.

Timelines in tPA use – PSC vOct4/17 Do, but not always pre-lytic ED Registration Telestroke Connects CT with ED Doc RAAPID Heads reviewed UP to Telestroke Telestroke Videoconf Focused Telestroke history Calls RAAPID Mix tPA back tPA bolus Decision ER doc bloodwork NIHSS/PE Sees (10 min) Bloodwork CT Foley +/- Family reviewed Stroke protocol EKG +/- discussion Page

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