Maine Scientific Session 2009 Speaker Presentation: David ...
Transcript of Maine Scientific Session 2009 Speaker Presentation: David ...
The World is “Flat”: A Brief Future of Acute Stroke Care
David C. Hess M.D.Professor and Chairman
Co-Director, Brain and Behavior Discovery InstituteDepartment of Neurology
Medical College of Georgia
Disclosures
Genentech Speaker’s Bureau
Boehringer Ingelheim Speaker’s Bureau
Co-Founder REACH CALL, Inc, Board of Directors
The Geographic Penalty The quality of stroke care is dependent upon
the hospital you go to
If you live in a rural area or “underserved acute stroke care” area you will NEVER receive tPA
There is a GEOGRAPHIC penalty for stroke care
Rural Hospitals are Plentiful
5759 Hospitals in the United States 4919 Community Hospitals 2003 Rural Hospitals (AHA Hospital Statistics
2006) 1464 Community Hospitals in a network 2669 Hospitals in a system
The Limited Resource: the Willing Neurologist
40% of Emergency physicians reluctant to use tPA (want a Neurologist)
In 2006-7 only 32 Fellows in approved Vascular Neurology Fellowships in U.S
By comparison, during same period, 2300 Fellows in Cardiology Fellowships in U.S.
Many Neurologists abandoning Emergency Department call
Limited resources for tPA:Supply and Demand
Limited supply of “willing” Neurologists
Geographically clustered at urban academic medical centers
50% of US Hospitals <100 beds
High ED Staff turnover
IT infrastructure limited
Rural, “frontier” locations
Stroke System Models1. The COMMANDO model: stroke specialist drives to
urban/suburban hospitals
2. Telephone “drip and ship”
3. Helicopter “ship and drip”
4. Telestroke
5. Telestroke with helicopter
U.S. Stroke Belt
Source: US Census Bureau Postcensal Population Estimates (IDC9 430-438.9) (1991-1995)
Components of Decision making
Reliability of NIH Stroke Scale Scores Review of images (CT head) History-taking (time of onset) Lab results, BP “Eye in the ED”
Feasibility and Reliability of NIHSS via Telestroke
Shafqat S(Stroke,1999)
Wang S(Stroke, 2003)
Handschu R(Stroke, 2003)
Meyer BC(Neurology, 2005)
System Point-to-point ISDN lines
Web-based,Mobile consultant
Point-to-point* Web-based,Mobile consultant
Number of patients
20 20 41 (ED) 25
Reliability Kappa r=.97
Pearsonr=.95
Kappa r=.85 to .99
Kappa r=.94
Time 9.70 min vs 6.55 min
9.11 min vs 6.24 min
11.4 min vs 10.8 min
NR
Comments Remote vs on site NIH all <3
Remote vs on site NIH all <3
Facial paresisleast reliable
Modified NIHSS also reliable
Prospective, Randomized Trial of Telemedicine vs Telephone
(Meyer BC et al, Lancet Neurol 2008)
Acute Stroke Patients(4 Community Hospital
Emergency Rooms)
Telemedicine 28% (31/111) tPA
Correct Treatment Decision: 98%*
Telephone23% (25/111) tPA
Correct Treatment Decision: 82%
No difference in 90 day functional outcome
REACH Mobile Cart in ED
Remote evaluation cart is mobile and can be moved throughout Emergency Department
Georgia REACH Telestroke Network
Hospital Bed size
ED volumeVisits/yr
Jenkins 10 3,312
Morgan 20 4,888
McDuffie 47 11,255
Jefferson 65 6,252
Wills 50 6,134
Washington 56 8,777
Emanuel 72 10,104
Elbert 52 7,322
Cobb 71 12,500
Tift 191 28,000Hess DC, et al Stroke. 2005 ;36(9):2018-2
Rural Georgia REACH Network 152 patients treated with tPA
Mean age 66; 56% women; 40% African American
Mean NIHSS 13; median 11
Mean door to needle: 80 min
47% treated < 2 hrs; 16%< 90 min
sICH 3% (5/146) NINDS; 0% SITS MOST
System OTT <90 min(%)
< 2 hr(%)
REACH Telestroke(N=50)
128 24 50
MCG ED (n=26)
146 19 35
Published stroke systems
148 <5-10 28
Comparison of Onset to Treatment times (OTT) between systems
(Switzer et al J Emergency Medicine, 2008 )
IV tPA Plus
Bridging with IV tPA to IA tPA
Merci Device and other mechanical thrombolysis methods
Use of transcranial doppler to use ultrasound-enhanced thrombolysis
Telestroke
More than a “tPA treatment tool”
Only about 15-20% of consults at MCG result in a tPA treatment
Many other acute disorders are identified
ECASS III
Window extended safety to 4.5 hours
But TIME still CRITICAL!!!!
“Having more time does not mean we should take more time”
SITS MOST Study (Lancet 2007; 369:275)
European Union required a registry of tPA (Alteplase) treated patients
6483 patients from 285 European centers
ICH in 1.7% ; 7.3% vs 8.6% (randomized studies) using Cochrane definition
tPA can be given safety and effectively in MANY centers
Most urgent needs
Systems of stroke care organized by regional or state health departments
Every patient should have quality stroke care regardless of geography
This will best be achieved with telestroke systems
Georgia Coverdell-Murphy Bill Signed into law May 14, 2008
Establishes two tiers of stroke centers
Primary Stroke Centers (Joint Commission certified)
Remote Treatment Stroke Centers (new level of identification for hospitals utilizing stroke-specific telemedicine technology)
“Fixed” vs Web-based Telestroke Fixed uses dedicated
ISDN lines Consultant must
travel to dedicated sites
Tempis (Bavaria) Mass General, BST
Mobile uses the web (broadband access)
Consultant can be anywhere*
Fast access REACH, BF (USCD)
Telestroke Issues State licensure issues and credentialing
Reimbursement (NY State Medicaid solving problem in NY)
Medicolegal (advantages of recording, documentation)
Cost
Conclusions Telestroke can “flatten” stroke care and bring
a stroke specialist to ANY rural, community hospital
Web-based telestroke systems are “fast” with potentially very short onset to treatment times
Academic Medical Centers should become Hubs and support community hospitals as Spokes