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Provider Support System Development

NINDS Stroke Symposium“Improving the Chain of Recovery for Acute Stroke in Your Community”

December 10-11, 2002 Arlington, VA PAS

NINDS Symposium 2002: Provider Support Systems Task Force

Task Force Members

• Sidney Starkman, MD – Task Force Chair

• Phillip A. Scott, MD– Co-chair

• John Choi, MD• Brian F. Connolly, MD• Karen L. Furie, MD• J. Stephen Huff, MD• Walter N. Kernan, MD

• Marian LaMonte, MD• Dennis Landis, MD• Steven R. Levine, MD• David B. Matchar, MD• Brett C. Meyer, MD• Debra G. Perina, MD• Jeffrey L. Saver, MD• Lee H. Schwamm, MD


Support Systems: Definition

• “The organization of human and material resources necessary to solve a clinical problem”

• Artificially imposed limits of first 24 hours of care


Why Develop Support Systems? • Effective in improving medical care in other

delivery systems– Trauma– AMI– Cancer

• Core Belief: Every health care delivery system providing care for patients with acute stroke has a responsibility to develop and implement plans for meeting the requirements of each phase of stroke care.


ACEP Policy Statement• “There is insufficient evidence at this time to endorse the

use of intravenous tPA in clinical practice when systems are not in place to ensure that … the NINDS guidelines for tPA use in acute stroke are followed.

• Therefore, the decision [for tPA use] should begin at the institutional level with commitments from administration, the ED, neurology, neurosurgery, radiology and laboratory services to ensure that the systems necessary for the safe use of tPA are in place”


Specific Challenges for Support Systems

• Stroke is a clinical diagnosis• Majority of patients present to ED without

immediate access to “stroke expert”• In-hospital barriers to stroke care

• Barriers exist for both fibrinolytic therapy and non-fibrinolytic stroke management


Areas for Support Systems Development

• Pre-hospital care• Hospital-based care

– Diagnosis• Radiologic / Imaging Access & Expertise• Stroke Diagnostic Expertise

– Management• Systems Implementation and Evaluation


EMS Training & Diagnostic Support

• Education on signs / symptoms of stroke• EMS stroke identification instruments

– Cincinnati Pre-hospital Stroke Scale– LAPSS– Consideration to others in development

• Guidelines / Policy and Procedures– Early contact with receiving hospital for

patients with possible stroke


Pre-Hospital Management Support

• Guidelines / Policy and Procedures– IV access– Glucose assessment– BP management avoidance– Avoidance of unnecessary glucose– Early notification


EMS Transfer Support Systems

• Increased importance of early care – Transport without delay– To closest appropriate facility

• Pre-established EMS agreement– Hospitals – ED– EMS– Medical Director

• Aeromedical teams


Hospital Diagnostic Support

• ED triage stroke identification tools• Pre-defined access to local expertise

– Neurology– Neurosurgery– Radiology

• Remote Diagnostic Support

Hospital Diagnostic Support: Teleradiology and Teleconsultation

Support Systems

Remote Image Review:Compressed DICOM images in a browser-

based viewer on a PC

ED Teleradiology Images Subacute Follow-up


Potential Teleconsultation Support Benefits:

• Improving diagnostic accuracy • Facilitating delivery of t-PA in identified

acute strokes• Identifying patients for enrollment into

acute treatment studies• Improving non-thrombolytic acute stroke

care


Technology Issues

• Bandwidth, Security, Reliability• Image quality and transmission• Data capture and review• Multimedia integration• Decision support• Medical documentation• Continuous quality assessment

.

Tertiary Care Center

CommunityEmergencyRoomPROVIDER

SUPPORT NETWORK:Acute Stroke

Location-IndependentStroke Consultant

Management Decision Support


Local Decision Support Options

• Protocol development – Paper-based, PDA, Web based tools– Thrombolytic treatment – Complications– Non-thrombolytic stroke management

• Access to responsive “in-house” specialty consultation– Standard consultation arrangements

• Development of “Code Stroke” teams


Remote Decision Support Options

• For sites without consistent specialty consultation• Identified in advance• Access to regional stroke centers

– standard telephone consult– Telemedicine– “Commando” systems


Hospital Transfer Protocol Support

• Existence of clear transfer protocols• Pre-established contact with referral centers• Avoidance of EMTALA violations

– transfer of medical records– Radiographic studies– Pre-packaged transfer forms


Clinical Trial Access

• Encourage participation in regional clinical trial networks

• Access to listing of active studies and their inclusion/exclusion criteria

• Ideally, clinical trial consideration should be integrated into clinical management algorithms

Implementation & System Evaluation


Delivery System Analysis/Implementation

• Focus groups with broad representation• Checklists for resource availability• Patient simulations “Mock Code Stroke”

– Multiple stroke types– Variety of scenarios

• External review


Educational Programs

• CME• Use of “code stroke” drills• Email • Academic Stroke detailing• New-hire training• Integration into Procedures and Policies


Credentialing as a Support Tool

• Staff– New-hire– Recurrent process

• Institutional– Demonstration of resources– External review– Stroke center level


Establishing Effectiveness

• Conformance to acute treatment guidelines, care pathways

• Performance evaluations– Door to CT– Door to tPA– Mock codes

• Registries


Summary

• Numerous support systems and tools exist • Enhance the chain of survival• Provided from resources at multiple levels to

assist diagnosis, management and delivery system evaluation– Pre-hospital– Local hospital based– Remote based (hospital or elsewhere)

• Advance selection of needed elements is crucial


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