Improving Acute Stroke CareThe South Florida EMS Coalition

Brijesh P Mehta, M.D.NeuroInterventional SurgeonDirector, Stroke & Neurocritical CareMemorial Neuroscience Institute

New Era in Acute Stroke Care

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Mechanical Thrombectomy Landmark Trials

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MR CLEANP<0.05

REVASCATP<0.05

ESCAPEP<0.001

SWIFT PRIMEP<0.001

EXTEND-IAP<0.01

THERAPYNS

Endo-vascular

33% 44% 53% 60% 71% 38%

Control 19% 28% 29% 36% 40% 30%

0

25

50

75

Goo

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me

(%)

Ran

kin

0-2

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0 da

ys

Importance of Time to Treatment

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Relation Between In-Hospital Treatment Speeds and Functional Independence (mRS 0-2) at 3 Months Among Direct Arrival Patients in the Endovascular Thrombectomy Group Achieving Substantial Reperfusion (mTICI score, 2b or 3)

Saver et al. JAMA 2016.

Wake Up Strokes / Unknown Onset Time

5 Nogueira et al. ESOC 2017.

Wake Up Strokes / Unknown Onset Time

6 Nogueira et al. ESOC 2017.

Copyright © 2014 StrykerNV00011894.AA | Released: December 2014 | Page 7 of 28Copyright © 2014 StrykerNV00011894.AA | Released: December 2014 | Page 7 of 28

• Level 1 evidence study establishing a new option at approved study facilities for an underserved patient population who are currently only eligible for medical management

• 20-30% of AIS patients arrive to the ED more than 8 hours from symptom onset

The Importance of DAWN™ Trial

IV Lytic

Mechanical Clot

Retrieval

Medical Management

Growth Potential for Thrombectomy

• About 10k mechanical thrombectomy procedures in 2015– Three thrombectomies per 100k people

• Eliminating time and focusing on imaging selection– Fifteen thrombectomy-eligible patients per 100k

• Overall number of eligible patients– Potential for 30-60k thrombectomies per year

8Rai AT, et al. J NeuroIntervent Surg 2017

Are Florida Stroke Hospitals Ready?

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Considerations

• ASA & JNIS guidelines for LVO thrombectomy

• State-level attestation vs TJC certification

• Proliferation of CSCs – dilution of volume, not all submitting to GWTG

• EMS triage PSC vs CSC – delays in care

• Fragmented emergency neurology coverage – few stroke neurologists

• Variability in EMS protocols and Need for Education on LVO Scales

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Proposed Stroke Work Flow Metrics for LVO

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JNIS 2016

State-level Attestation vs TJC Certification

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• No onsite survey

• No recertification policies

• No core measures, metrics or outcomes tracking

• No minimum coiling/clipping requirement

• No submission of data to GWTG-Stroke database

• No requirement for research

Certification Matters

• Total of 477,297 acute ischemic stroke admissions • 977 certified PSCs

– 73.8% JC, 3.7% DNV, 1.2% HFAP, 21.3% state

• State-based centers underperformed JC hospitals– tPA administration rates– Door-to-needle times– In-hospital mortality

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Man et al. Hospital Certification, Measures, and Outcomes. Stroke 2017.

Certification Matters

Onsite Visit Requirement for State-level certification– Yes

• Massachusetts Department of Health• New York Department of Health

– No• Maryland Institute for Emergency Medical Services• Georgia Department of Public Health• Texas Department of State Health Services• Florida Agency for Health Care Administration• Oklahoma State Department of Health• Connecticut Department of Public Health

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Man et al. Hospital Certification, Measures, and Outcomes. Stroke 2017.

Proliferation of CSCs in Florida

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Higher Volume of CSC Matters

16 Rinaldo et al. Stroke 2017.

Information on Stroke Care Difficult to Find

• Get With The Guidelines

• Target Stroke Honor Roll

• Joint Commission

• State Certifying Organizations

• Mission Lifeline

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EMS Triage: PSC vs CSC vs which CSC?

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Froehler et al.; Interhospital Transfer Before Thrombectomy STRATIS. Circulation 2017.

PSC CSC Delays

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Froehler et al.; Interhospital Transfer Before Thrombectomy STRATIS. Circulation 2017.

Fragmented Stroke Neurology Coverage

20 Silva GS. Stroke. 2012;43:2078-2085.

Absence of Standardized EMS Protocols

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Palm BeachHollywoodPPinesBSOMiramarHallandaleDavieN Miami-Dade

Need for EMS Education

22Mehta BP et al. ISC 2017.

South Florida EMS Stroke Coalition

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EMS Stroke Triage in Thrombectomy Era

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Rural United States South Florida

EMS on Scene Groin Puncture

25 Mueller-Kronast et al. Stroke 2017.

EMS Nomogram for Triage to CSCs

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Field to ER Arrival Time (minutes)

Fiel

d to

Pun

ctur

e Ti

me

CSC #1 120 minCSC #2 100 minCSC #3 60 min

130m

10m 20m 30m

Median Door-to-Puncture Times

120m

90m

Triage Based on Distance + In-Hospital Process

What Can We Emulate?

• STEMI care

• Trauma care

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Recommendations for Systems of Care

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Smith and Schwamm. Stroke 2015. Endovascular Stroke Systems: North America

Development

• Presentation at EMS Chief’s Council in Fall 2015

• Founded in December 2015

• Working committee of EMS Medical Directors and NeuroInterventionalists

• Presentations to stakeholders

Supporters

• American Stroke Association

• Broward Stroke Council

• EMS Chiefs Council

• EMS Medical Director’s Association

• Fire Chief’s Association

Mission

• Improve the delivery of stroke care in tri-county region – Educate EMS and hospitals utilizing evidence-based

guidelines

– Standardize EMS and in-hospital care protocols

– Transparency among PSCs and CSCs to assist with EMS triage decisions

Participation in FL-PR Stroke Registry

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JFK Medical Center

Stroke Data Elements

Data Flow Chart

Regional Dashboard

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Regional Dashboard

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? Discharge mRS? 90d mRS

% rx patients mRS 0-2

Accountability

• Starting April 2018, EMS Medical Directors will request dashboards from individual hospitals in their territories on a quarterly basis

• For hospitals that decline to share data with EMS Medical Directors, actions based on group consensus

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Thank You

Contact Information

Brijesh P Mehta, MDNeuroInterventional Surgeon

Director, Stroke & Neurocritical CareMemorial Neuroscience Institute

617-775-5204neuroinx@icloud.com

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