Stroke Systems of Care

1
Stroke Systems of Care

• Patricia Santos
• September 20, 2007

2
Progression of Stroke Care

• Treatment NINDS
• Development Stroke Centers
• Ability to administer treatment
• Stroke Systems of Care
• - Ability to consistently administer treatment

3
Development of Current Acute Stroke Treatment

• 3 hours
• IV tissue plasminogen activator (t-PA)
• 6 hours
• Intra-arterial tissue plasminogen activator
• 8 hours and beyond
• Clot retrieval devices

4
Development of Stroke Centers

• Brain Attack Coalition - Included the American
  College of Emergency Physicians
• Primary Stroke Centers The Joint Commission/EMS
  requirement
• Comprehensive Stroke Centers

5
NINDS Recommended Stroke Evaluation Targets for
Potential Fibrinolytic Candidates
6
Components of a Stroke Neurovascular
ProgramPrimary Stroke CentersBrain Attack
Coalition (BAC) Guidelines 2002

• Administrative Commitment Support
• Acute Stroke Team
• Written Care Protocols
• Emergency Medical Services
• Emergency Dept Specialization
• Designated Stroke Care Units
• Neurosurgical Services
• Neuroimaging Services
• Laboratory Services
• Outcome and Quality Improvement
• Continuing Medical Education

7
Comprehensive Stroke Centers

• Capability of offering endovascular treatment
  options for stroke
• Certification not available yet will most
  likely also include element of research protocols

8
Stroke Systems of Care

• Links in the chain of successful stroke
  intervention
• Public Education (directed at ALL populations,
  not just those at risk)
• ASA, NSA, other organizations
• Local Providers
• Hospitals
• Rehab
• Industry
• EMS Agencies

9
EMSEmergency medical services and emergency
department personnel can play a critical role by
altering the behavior of patients and
hospital-based health care providers.4

• Crucial to Time Dependent Care
• Assessment
• Pre-notification
• Transport

10
Time Dependent Care

• Data is clear that patients who arrive via EMS
  receive t-PA more frequently than those who
  arrive by private auto
• Cincinnati Stroke Scale/Los Angeles Prehospital
  Stroke Screen increase the sensitivity to
  identification of stroke in the field4
• Time of onset is often miscalculated and can be
  difficult to assess, EMS assessment is critical
  in this arena
• Pre-notification of possible stroke increases
  time to diagnosis and treatment.

11

Recommendations for the Establishment of Stroke
Systems of Care American Stroke Association1

• The trauma care system is guided by principles
  that are applicable to improving stroke care,
  including
• enhanced communication among hospitals and
  emergency medical services (EMS)
• clear transport protocols to ensure that
  patients are taken only to facilities with
  appropriate resources
• strategies for treating and transporting
  patients who live in rural and remote areas
• integration of rehabilitation services
• the use of evidence-based treatment protocols.

12
Like trauma? Not quite..

• Despite being based on similar principles, a
  number of important differences exist between the
  organization of trauma care and that of stroke
  care.
• The medical personnel involved in the evaluation
  and treatment of stroke and trauma differ.
• Primary stroke centers are less resource
  intensive to establish than are level I trauma
  centers.
• Because of the nature of stroke, virtually all
  facilities will continue to evaluate and treat
  stroke patients, and the identification of
  hospitals that function as primary stroke centers
  within stroke systems should be as inclusive as
  possible.
• Primary stroke centers certainly should be more
  numerous than level I trauma centers. 1

13
City-wide systems of stroke care

• Birmingham, AL (with direct EMS Triage)
• Cincinnati, OH
• Dallas, TX
• Houston, TX
• New York, NY (with direct EMS Triage)
• Ann Arbor, MI

14
Kansas City Proactive Approach2

• Saint Lukes Hospital
• - grew from 5 to 47 hospitals in the network,
  14 urban and 33 rural facilities ranging in size
  from 15 to 586 beds
• - spanning a 150 mile circumference
• - education of EMS and hospital emergency
  personnel
• - ease of transport
• - ongoing community education

Outcomes of hospital-transferred patients were
equal to those originally brought into the stroke
center
15
State-wide systems of stroke care
From Lily Chaput, MD, California Dept of Health
Services
16
Common Barriers to Developing Effective Stroke
Systems of Care

• Multiple providers within a geographical area
• Variable policies and procedures
• Urban vs. Rural
• Closest facility vs Stroke ready facility

17
Future Directions?

• Telemedicine
• Video conferencing
• Solutions for the Neurology shortage

18
More important

• Building stroke systems throughout the United
  States is the critical next step in improving
  patient outcomes in the prevention, treatment,
  and rehabilitation of stroke. The current
  fragmented approach to stroke care in most
  regions of the United States provides inadequate
  linkages and coordination among the fundamental
  components of stroke care. Providers and
  policymakers at the local, state, and national
  levels can make significant contributions to
  reducing the devastating effects of stroke by
  working to promote coordinated systems that
  improve patient care. 1

19

• 1Recommendations for the Establishment of Stroke
  Systems of Care, Circulation. 20051111078-1091,
  2005 American Heart Association, Inc
• 2Organizing regional networks to increase acute
  stroke intervention, Neurologicl Research 2005
  Volume 27 June, The Mid America Brain and Stroke
  Institute
• 3Improving the Chain of Recovery in Your
  Community, A Task Force Report, 2002, National
  Institute of Neurological Disorders and Stroke
  (NINDS)
• 4The Role of EMS in the Management of Acute
  Stroke Triage, Treatment, and Stroke Symptoms,
  NAEMSP Position Statement, Prehospital Emergency
  Care, 2007