Rapid Reperfusion in Acute Stroke The Memorial Healthcare Experience

Brijesh P Mehta, M.D. NeuroInterventional Surgeon

Director, Comprehensive Stroke Centers

Memorial Neuroscience Institute

Disclosures

None

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Background

Dr. Brijesh P Mehta

– Acute strokes, carotid stenosis, intracranial stenosis

– Aneurysms, AVMs, tumors

• Massachusetts General / Brigham

– Internal Medicine

– Neurology

– Stroke & Neurocritical Care

– Endovascular Neurosurgery

Stroke Systems of Care

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Code Stroke

5 Teleb MS, et al. J NeuroIntervent Surg 2016

Sequential process

Significant

Delay!!!

Sequential Stroke Work Flow

Sequential Process

Sources of Delays – LEAN Analysis

Delay in

arrival to

angio suite

4) Decision

to treat

3) MRI scan

• Discussion of benefit from IAT

• Patient transferred back to ED bay instead of

directly to angio suite

• Elective intubation in ED

• Consent for clinical trial only after MRI completed

• Difficulty in contacting healthcare proxy for consent

• Patient not transferred until nursing pass off

1) ED arrival

• No advance ED2CT page

• Lack of transport

equipment when patient

ready for scanner

• Patient unstable, requiring

intubation

2) CT scan

• Scanner occupied by different

patient

• No scan order in system

• Awaiting labs before giving

contrast or treating with IV tPA

• Difficult IV access

• Neuroradiology fellow not

available for rapid scan

interpretation

• Late notifcation to neuroIR team

despite high clinical suspicion

for vessel occlusion

• Scanner occupied by different patient

• No scan order in system

• MRI checklist not completed

• Lack of MRI-compatible EKG leads

• Needed to change equipment for

MRI scan

• Research fellow not present for

clinical trial consideration

• Awaiting renal function labs

• Patient movement during scan

• Neuroradiology fellow not available

for rapid scan interpretation

Parallel Work Flow in Acute Stroke

8 Mehta BP, et al. JAHA 2014.

Memorial Stroke Redesign

Major Goals

• Redesign IV tPA Work Flow

– Goal DTN consistently < 30 minutes

– Adopt ASA Target Stroke guidelines

• Revamp Endovascular Stroke Work Flow

– Goal Door-to-Reperfusion time < 90 minutes

– Run it as a Code Heart

– Parallel Activation of NeuroInterventional team

– Process map posted in ED, angio suite, inpatient units

– Track core metrics for continuous process improvement

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Reduce IV tPA Door‐to‐Needle Times

– Pre-hospital notification

– Stroke alert system - StatLinx

– Bypass ED bay, go straight to CT scanner

– Keep IV tPA in ER

– Pre-mix IV tPA

– Rapid CT interpretation

– Await labs only if concern for coagulopathy

– Administer tPA while in CT scanner

Xian et al. Stroke 2014.

EMS Pre-Hospital Alert

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Actionable information

for IV tPA and/or

early cath lab activation

FaceTime for EMS Stroke Alerts

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Updated October 17, 2014

Call Dr. Brijesh Mehta NeuroInterventional Surgeon

Stroke Alerts RACE Score >5

Phone Number 617-775-5204

Available 24/7 for any Stroke Questions

Ambulance Magnets

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NITRO Stroke Parallel Process

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NITRO Parallel Workflow Neuro Interventional Thrombectomy Recanalize Occlusion

• Any patient with disabling deficits = Possible ELVO

• Goal Picture-to-Puncture <60 minutes

EMS stroke alert call NeuroInterventionlist BEFORE imaging

Dial *61 for ‘Brain Attack’ cath lab if gaze preference or global aphasia

Get brain attack CT/CTA head & neck (scan first, labs later)

Keep patient in holding area near scanner; do not return to ER

Rads will provide prelim read <5 min; call Dr Mehta if any delays

Update Neurologist / NeuroInterventionlist of scan results

Administer IV tPA bolus if patient eligible

Take patient immediately to cath lab neuro room #12

Goal to cath lab <10 min after scan completion

Do not wait for consent; thrombectomy a standard of care

Updated 7.1.15 by Dr Brijesh P Mehta

CT/CTA MRI

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All of the below must be metClinical

NIHSS ≥ 6 for anterior circulation (variable for posterior circulation)Age < 90LKW ≤ 24 hours anterior circulation/≤ 48 hours posterior circulationPremorbid condition

-Normal baseline functional status (mRS < 2)-Life expectancy > 6 months-Reperfusion reasonably expected to prevent infarction of tissue at risk

RadiologicalAnterior circulation

ASPECTS > 6 (NCCT) or Infarct core < 70 cc (DWI)Proximal arterial occlusion (ICA, M1 or proximal M2 )

Posterior circulationMinimal brainstem or thalamic infarct coreProximal arterial occlusion (basilar artery or dominant vertebral artery)L

ike

ly t

o B

en

efit IAT Selection Criteria

Created by: BP Mehta, MD Phone: 617-775-5204

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One of the below needs to be metClinical

NIHSS < 6Age > 90LKW > 24 hours Anterior circulation/> 48 hours Posterior circulationUnknown Last Known WellPremorbid condition

-Moderate-severe dementia (leading to loss of independence)-Significantly impaired baseline functional status (mRS ≥4; inability to walk and attend to activities of daily living) -Life expectancy of < 6 months

RadiologicalAnterior

ASPECTS ≤ 6 (NCCT) or infarct core > 100 cc (DWI) Distal arterial occlusion (Mid-M2, A2 or distal)

PosteriorPontine, midbrain or thalamic infarcts > 50% of the territoryProximal vertebral arterial occlusion Distal arterial occlusion (isolated PCA )

Uncert

ain

to B

enefit IAT Selection Criteria

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Cath Lab = Nascar Pit Stop

NeuroInterventional Suite

• NeuroInterventionalist will be the leader of the team

• Suite arrival to groin puncture goal time < 10 minutes

• Everyone should know their roles/responsibilities

• Focus on BP management

• IV sedation vs general anesthesia

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BRISK Kit for Rapid Prep

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Standardized Cath Lab Process

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Cath Lab Teamwork

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Inviting EMS Crew to Observe Cases

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Procedure Time Log

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EMS Stroke Alert Utilization

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EMS Tour of CSC Stroke Process

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EMS Seeing Good Outcomes Firsthand

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Annual Stroke Survivors & EMS Recognition Dinner

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Annual Stroke Survivors & EMS Recognition Dinner

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Community Events to Increase Awareness

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EMS Group on WhatsApp

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Annual EMS Stroke Update

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Impact of EMS Alert on Door-to-tPA Times

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Faster tPA Process = Rapid Time to Cath Lab

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Impact of Early Cath Lab Activation

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South Florida Stroke Coalition

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EMS Landscape in South Florida

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Palm Beach

Coral Springs

Margate

Hollywood

PPines

BSO

Miramar

Hallandale

Davie

Seminole

Miami-Dade

ASA Certified Stroke Centers

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hospitalmaps.heart.org

EMS Stroke Triage in Thrombectomy Era

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Rural United States South Florida

EMS Nomogram for Triage to CSCs

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Field to ER Arrival Time (minutes)

Fie

ld t

o P

un

ctu

re T

ime

CSC #1 120 min

CSC #2 100 min

CSC #3 60 min

130m

10m 20m 30m

Median Door-to-Puncture Times

120m

90m

Triage Based on Distance + In-Hospital Process

SFSC Mission

• Improve quality of stroke care in tri-county region

– Educate EMS and hospitals utilizing evidence-based

guidelines

– Standardize EMS and in-hospital care protocols

– Data transparency among PSCs and CSCs to assist

with EMS triage decisions

– Move beyond AHCA self-attestation to TJC certification

Supporters

• Tri-county NeuroInterventionalists

• American Stroke Association

• EMS Chiefs Council

• EMS Medical Director’s Association

• Fire Chief’s Association

Updated February 2019

Tri-County Hospital Participation TJC CSC, TJC TCSC, *AHCA CSC, PSC

*BOCA RATON REGIONAL HOSPITAL *DELRAY MC

GOOD SAMARITAN MC *JFK MC

*JFK MC – N. CAMPUS

*JUPITER MC PALM BEACH GARDENS MC

*SAINT MARY’S MC WEST BOCA MC

Palm Beach County (9/12 FSR Hospitals)

BROWARD HEALTH CORAL SPRINGS *BROWARD HEALTH MC

*BROWARD HEALTH NORTH *CLEVELAND CLINIC FLORIDA

*FMC - CAMPUS OF NORTH SHORE *HOLY CROSS HOSPITAL

MEMORIAL HOSPITAL PEMBROKE *MEMORIAL HOSPITAL WEST

*MEMORIAL REGIONAL HOSPITAL NORTHWEST MEDICAL CENTER

*WESTSIDE REGIONAL MC

Broward County (11/14 FSR Hospitals)

*BAPTIST HOSPITAL Coral Gables Hospital

Hialeah Hospital *JACKSON MEMORIAL HOSPITAL

Jackson North MC Jackson South Hospital

*MOUNT SINAI MC *NORTH SHORTE MC

*PALMETTO GENERAL HOSPITAL South Miami Hospital

University of Miami Hospital West Kendall Baptist Hospital

Miami-Dade County (12/16 FSR Hospitals)

UM Florida Stroke Registry

6) EMS Medical

Directors request copies from Hospitals

Palm Beach EMS Medical Director

Broward Hospitals Palm Beach Hospitals

A, B, C, D, E, F, G, H, I J A, B, C, D, E, F, G H

Broward EMS Medical Director

5) Hospitals

download their Regional Dashboards

7) Hospitals provide

copies to EMS Medical Director

Steps 5-7 are at the hospitals

discretion and timeline

1) Download and clean data- (up to 3 weeks)

2) Develop Dashboard graphs (1 week)

3) Upload to secured website (2 days)

4) Notify hospitals to visit secured website (1 day)

Regional Dashboards- Dissemination Process

UM FSR team Florida Stroke Registry Secure Website

FSR Hospital

UM Florida Stroke Registry

Dashboards

• Ischemic stroke volume

• IV tPA treatment rates

• IV tPA door to needle times

• Thrombectomy treatment rates

• Thrombectomy door to puncture times

• Outcomes

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Median Door to Needle Time among those receiving IV tPA

2018 Q1

UM Florida Stroke Registry

Median Door to Groin Time among those receiving EVT

2018 Q1

UM Florida Stroke Registry

Percent mRS 0-2 at Discharge among those receiving EVT

2018 Q1

Included: • Ischemic Stroke patients who

received EVT at this hospital with modified Rankin score 0 to 6 at discharge

Excluded: • Age<18 • clinical trial • Stroke occurred after hospital arrival

note: The UM FSR metrics are NOT available in IQVIA

UM Florida Stroke Registry

Strategy for Data Transparency & Utilization

• Three-pronged strategy to promote data transparency

– Inform EMS medical directors of dashboards being

available starting end of q1 2019

– Letter from behalf of EMS Medical Directors to all

thrombectomy stroke centers requesting dashboards to

be shared with EMS

– Proactive stroke centers in each county to lead the way

with sharing of dashboards with EMS

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Letter to Hospitals

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Meeting with senators in Tallahassee April 2019

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Meeting with senators in Tallahassee April 2019

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Florida Stroke Legislation 2019

• Require all stroke centers in Florida to be certified by nationally

recognized organizations such as the Joint Commission by

2021

• List all nationally certified thrombectomy stroke centers on

AHCA website for improved EMS and public understanding

• Require all stroke centers to submit data to statewide stroke

registry

• Develop EMS pre-hospital stroke protocols with appropriate

scales and triage pathways PSC vs CSC

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Thank You

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Contact Information

Brijesh P Mehta, MD

NeuroInterventional Surgeon

Director, Comprehensive Stroke Centers

Memorial Neuroscience Institute

617-775-5204

neuroinx@gmail.com

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