PIN Stroke Study

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PIN Stroke Study
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How Serious is Stroke in the US?

• 7000,000 strokes each year in the US
• Over 167,000 deaths
• 4.7 million stroke survivors alive today
• 3 killer
• 2004 cost of stroke was estimated at 53.6 billon
  (direct and indirect costs)
• Mean lifetime cost at 140,048
• Leading cause of serious long-term disability in
  adults

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Definition of Stroke

• A stroke is a neurological impairment caused by
  disruption in blood supply to a region of the
  brain.

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Hospital stroke discharges, by county, Montana,
2005
(24)
(22)
(42)
(14)
(29)
(19)
(15)
(25)
(19)
(284)
(36)
(7)
Range
Hospitalizations for stroke and transient
ischemic attack (TIA) among Montana residents,
Montana, 2000 to 2005.
Primary diagnosis for stroke (ICD
430.xx-437.xx), ischemic stroke (433.xx-434.xx
and 436.xx-437.xx), hemorrhagic stroke
(430.xx-432.xx), and transient ischemic attack
(435.xx).
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Hospital stroke discharges by county 2005
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Difficulties in Treating Stroke - Rural Nature
of Montana

• Less than 40 of the states population live
  within a one-hour drive time to a stroke center
• MSI is committed to improving acute stroke care
  in Montana

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Seven Step Stroke Chain of Survival and Recovery

• Pre-arrival Post-arrival
• Detection 4. Door
• Dispatch 5. Data
• Delivery 6. Decision
• 7. Drug

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4. Door Emergency Department Triage

• Even if a potential stroke victim arrives in the
  emergency department in a timely fashion, too
  often hours may elapse before appropriate
  neurological consultation and diagnostic studies
  are performed.

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5. Data Emergency Evaluation and Management

• ABCs should be reassessed and rechecked
  frequently.

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5. Data Emergency Evaluation and Management

• An emergency neurological stroke assessment
  should be done quickly focusing on four key
  issues
• Level of consciousness
• Type of stroke (hemorrhagic versus
  nonhemorrhagic)
• Location of stroke (carotid versus
  vertebrobasilar)
• Severity of stroke

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5. Data Emergency Evaluation and Management

• Obtaining the exact time of stroke or onset of
  symptoms from family or people at the scene is
  critical.

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Emergency Diagnostic Studies

• Currently, CT is the single most important
  diagnostic test.
• Goal CT scan obtained and read within 45
  minutes of the stroke victim's arrival at the
  emergency department.

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Emergency Diagnostic Studies

• Anticoagulants and fibrinolytic agents should be
  withheld until CT has ruled out a brain
  hemorrhage.

Hemorrhagic Stroke
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Differential Diagnosis

• Unrecognized seizures
• Confusional states
• Syncope
• Toxic or metabolic disorders
• Hypoglycemia
• Brain tumors
• Subdural hematoma

Adams et al. Stroke. 2003341056
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6. Decision Specific Stroke Therapies

• General care includes, but is not limited to
• Prevention of aspiration
• Management of hypertension
• Management of hyper/hypo-glycemia
• Management of seizures
• Management of intra-cranial pressure (ICP)

Acute Stroke, 2003 American Heart Association
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7. Drugs Fibrinolytic Therapy for Ischemic Stroke

• Because of the time criteria and risk associated
  with fibrinolytic therapy, it is important for
  hospitals to develop specific strategies and
  protocols that will achieve rapid initiation of
  therapy.

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NINDS-Recommended Stroke Evaluation Targets for
Potential Fibrinolytic Candidates
Time Target
Target times will not be achieved in all cases,
but they represent a reasonable goal.CT
indicates computed tomography.By phone or in
person.
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Management of Hemorrhagic Stroke

• Optimal management
• Prevention of continued bleeding.
• Appropriate management of ICP.
• Timely neurosurgical decompression when
  warranted.
• Large intracerebral or cerebellar hematomas often
  require surgical intervention.

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Summary Pre-hospital Critical Actions and
Management

• This is what should happen
• Recognize the signs of stroke and TIA
• Rapid neuro exam (Cincinnati Stroke Scale or
  similar).
• Determine time of symptom onset (if possible).
• Provide rapid transport to an ED capable of
  caring for acute stroke (pre-notify).
• Perform finger-stick to assess serum glucose
  levels.

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Conclusion

• Now, fibrinolytic and other emerging therapies
  offer practitioners the opportunity to limit
  neurological insult and improve outcome in stroke
  patients.

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Conclusion

• The challenge with these therapies is that they
  require administration within hours of stroke
  onset, making the following measures imperative
• Education of at-risk patients
• Early recognition of stroke signs
• Prompt transport to the hospital
• Rapid hospital triage and evaluation

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PIN Baseline Study

• 11 facilities 66 cases
• CIS Panel concerns related to hospital care
• Quality of documentation of neuro exam
• Documentation of patient monitoring throughout
  the ED stay
• Lab test evaluation of patients presenting with
  stroke symptoms
• Limited use of neurologists consult
• Treatment congruent with recommendations from
  AHA, ASA and the Montana Stroke Initiative

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Additional Issues

• Extreme delays in recognizing S S of stroke
• PIN over 7 hours delay in seeking treatment
• Range 30 minutes to 35 hours
• Alliance 3.8 hours
• Range 25 minutes to 16 hours

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• The Montana Stroke Initiative is a collaboration
  between the Montana Department of Public Health,
  Cardiovascular Health Program, American Stroke
  Association and physicians, nurses, EMS personnel
  and hospital administrators thoughout the State.
  Our mission is to develop a state-wide stroke
  system of care that allows patients access to the
  best stroke care regardless of where they live in
  Montana.
• www.montanastroke.org

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The Alliance Project

• Baseline measurement for all members
• Priorities
• Educational materials EMS, hospital community
• Treatment protocols
• Staff training