updated ppt for 12-7-12 chicago stroke initiativeko …wcm/@mwa/documents/... · – not all...

Improving Door -To-Needle Times for Stroke Thrombolysis

7/3/2013 ©2010, American Heart Association 2Supported by funding from Genentech

Shyam Prabhakaran, MD, MSAssociate Professor

Department of NeurologyNorthwestern University

Dec. 7th, 2012

7/3/2013 ©2010, American Heart Association 3

• 1 stroke every 40 seconds in the US• 795,000 strokes annually, of which

185,000 are recurrent strokes• 200,000 TIA per year

• 1 of 6 Americans will be affected in a lifetime • Every 4 minutes someone dies of a stroke

• 133,000 per year• 4th leading cause of death

• Leading cause of major disability in adults• About 6.4 million stroke survivors• Economic burden: $74 billion/year in US

Public Health Burden

≈

Per minute of ischemia, the following are destroyed:• 1.9 million neurons • 14 billion synapses

In an average stroke after 10 hours:• A 50 y/o man ages 30 years cognitively

Saver J Stroke 2006

TIME EQUALS BRAIN!

31

20

50

38 39

26

44

32

0

10

20

30

40

50

% Favorable

NIHSS Barthel ModifiedRankin

GlasgowOutcome

Global Test OR=1.7 (1.2-2.6) p=0.008

t - PAPlacebo

Odds Ratio 1.7 1.6 1.7 1.695% CI 1.0-2.8 1.1-2.5 1.1-2.6 1.1-2.5p value 0.033 0.026 0.019 0.025

NINDS tPA Trial

Outcome after tPA

Time Dependent Results

Saver JL Lancet 2010

Every 10 minutes that goes by without tPA, 1 fewer patient experiences benefit from tPA

Intravenous rt-PA is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A).

rt-PA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B).

AHA/ASA Guidelines

EDs should establish standard operating procedures and protocols to triage stroke patients expeditiously (Class I, Level of Evidence B).

Standard procedures and protocols should be established for benchmarking time to evaluate and treat eligible stroke patients with rt-PA expeditiously (Class I, Level of Evidence B).

Target treatment with rt-PA should be within 1 hour of the patient’s arrival in the ED (Class I, Level of Evidence A).

Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009

AHA/ASA Guidelines

TPA: the Reality• Less than 5% (3% nationally) of ischemic stroke patients are treated

with IV tPA (Reeves M 2006; Kleindorfer D 2008)• Approximately 25% of stroke patients arrive within 3-hr window

• Public knowledge of stroke symptoms, risk factors, and available treatments is poor (Pancioli AM 1998)

• Less than 50% use EMS (Reeves M 2006)

– Not all eligible patients receive tPA (Barber P 2001)• Physician biases, inexperience, and hospital delays

• Only 4.0 neurologists per 100,000 persons in the US, caring for more than 700,000 strokes each year– Lack of necessary infrastructure to treat acute stroke is

widespread (Goldstein LB 2000)• 66% of hospitals did not have stroke protocols

• 82% of hospitals did not have rapid identification process

– Stroke systems are becoming more common

42.09%53.46%

65.00% 69.10% 72.65% 72.84%

0%

20%

40%

60%

80%

100%

IV rt-PA 2 Hour (eligible patients)

Baseline YR1 YR2 YR3 YR4 YR5

TPA: the Reality

Current guidelines for the management of patients with acute ischemic stroke published by the AHA/ASA include specific recommendations for the administration of IV rt-PA

Despite its effectiveness in improving neurological outcomes, many patients with ischemic stroke are not treated with rt-PA, because they arrive late or because of delays in assessment/administration of IV rt-PA

Earlier administration of IV rtPA after the onset of stroke symptoms is associated with greater functional recovery

One of the potential approaches to increase treatment opportunities and improve stroke outcomes is to provide this treatment in a more timely fashion after patient arrival (reduce the door to needle time for IV rt-PA)

Summary

1. Perform an initial patient evaluation within 10 minutes of arrival in the emergency department

2. Notify the stroke team within 15 minutes of arrival

3. Initiate a CT scan within 25 minutes of arrival

4. Interpret the CT scan within 45 minutes of arrival

5. Ensure a door-to-needle time for IV rt-PA within 60 minutes from arrival

National Time Goals

NINDS 1997

• Patients who use ambulance are more likely to arrive within 2 hours (58%

vs. 36%, p<0.001) and receive tPA (CDC 2007)

EMS and Time

EMS and Time

Lin C Circulation 2012

EMS and Time

Lab Delays

Labs Delays

2%

Rost Neurology 2006

Rapid Triage in ED

Lindsberg PJ Neurology 2006

Helsinki ExperiencePre-notification and pre-mixing

Direct to CT

Merotjia Neurology 2012

Wash U Experience

Ford Stroke 2012

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00% Percent CT completed < 25 minutes in GWTG-S nationa l registry

Delays to CT scan

Best Practice Strategies

Ideal stroke code

Chicago PSCs

QUESTS Initiative• QUality Enhancement for Speedy Thrombolysis

for Stroke (QUESTS) has 3 main goals:• Provide professional education using the AHA’s Target: Stroke

Initiative for physicians at PSCs to improve use of thrombolysis and improve its timely delivery in ischemic stroke patients• 20% of IS treated with tPA • > 50% achieve DTN < 60 min

• Provide EMS education to improve field diagnosis and increase pre-notification of suspected stroke patients being transported to Chicago PSCs• > 95% EMS pre-notification

• Mount a comprehensive multi-lingual education program on stroke awareness for Chicago’s residents, targeting at-risk and minority groups specifically, that will result in a greater understanding of stroke symptoms and lead to an increase in 911 calls for stroke• > 50% of strokes call 911 (EMS)

QUESTS Initiative

• Goal 1 (Professional Education)

• Survey best practices at each PSC

• Share best practices and guidelines to find ways to reduce DTN time

• On-site group discussion using FMEA approach to find opportunities

• Provide monthly feedback on performance

• Engage in quarterly meetings as a group to discuss successes/failures

• Goal 2 (EMS Education)

• Develop content for webinars, simulations, and feedback letters

• Deliver content via web, in-person training

• Survey retention and knowledge

Goal 3 (Community Education) • Launch mulit-media educational campaign to increase awareness of stroke sign

and symptoms and importance of calling 911

• Target high risk, diverse communities

• Support hospital community event participation

• Survey stroke awareness

QUESTS Initiative

• ~$5000 per site for GWTG-S (pre & post project

measurement), super-user participation, & EMS pre-hospital

data elements

• ~$1000 per site for community stroke education event

• ~$1500 Target Stroke Honor Roll Incentive

• Current non-GWTG hospital stipend for GWTG-S (Stroger,

UIC, Swedish Covenant & Holy Cross)

Funding Available for Hospitals:


QUESTS Initiative

• GWTG-S “super-user” account allows aggregation of all de-identified data

by AHA staff

• Contract amendment to be provided for current GWTG-S users. No cost to

hospitals.

• New GWTG-S hospitals will receive contract & super-user contract

amendment

• Complete all EMS data elements for all CFD stroke patients. (Work with

EMS coordinators to locate run sheets if needed)

• All GWTG-S hospitals will have access to Region Xl benchmark group

Get With The Guidelines-Stroke Registry & PI Tool


QUESTS Initiative

• $1000 stipend to support stroke education & awareness event targeting

high risk, diverse Chicago communities

• Stipend may be used to support one FTE and educational materials

• Notify project coordinator of event date, location & target audience

• Work with coordinator to secure appropriate stroke educational materials

• Distribute and collect community stroke assessment survey to attendees

• Provide summary of event to project coordinator including number of

attendees and/or materials distributed

Community Stroke Education Event


QUESTS Initiative

• Create project key hospital contact distribution list including: stroke coordinator,

administrator, ED physician champion & neurology physician champion

• Distribute supporting publications and resources

• Distribute GWTG “super-user” contract amendments to current users

• Meet with non-GWTG hospitals to assess interest & answer questions

• Register your hospital for Target Stroke

• Schedule one-on-one stroke team meeting with project staff

• AHA to develop & distribute funding contract, W-9 forms, etc., based on hospital’s level of

participation

• Hospitals to plan and communicate their community education event to project staff

Next Steps:


QUESTS Initiative

• Participate in project calls & meetings

• GWTG-S & pre-hospital EMS data collection

• Participate in GWTG-S Region Xl “super-user” account

• Register your hospital for Target Stroke (Free)

• Schedule & conduct community stroke education event

• Participate in Region Xl Regional Stroke Advisory Committee meetings

• Provide key hospital stroke contacts to project coordinator

• Schedule one-on-one site visits w/ project staff and hospital stroke team

Hospital Project Requirements :


QUESTS Initiative

Kathleen O’Neill,MHARegional VP, Quality & Systems Improvement

[email protected]

Shyam Prabhakaran, MD, MSProject Medical Director

[email protected]

Questions?


QUESTS Initiative

QUESTS Initiative

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