Rapid Reperfusion in Acute Stroke - Boca Raton Regional ...web.brrh.com/msl/South Florida Stroke...
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Rapid Reperfusion in Acute Stroke The Memorial Healthcare Experience Brijesh P Mehta, M.D. NeuroInterventional Surgeon Director, Comprehensive Stroke Centers Memorial Neuroscience Institute
Transcript of Rapid Reperfusion in Acute Stroke - Boca Raton Regional ...web.brrh.com/msl/South Florida Stroke...
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
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