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. Crucial to �Time Dependent Care� Assessment Pre-notification Transport 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

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.  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 Luke�s 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

15. State-wide systems of stroke care

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. 2005;111:1078-1091, 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