Stroke Systems of Care

Sharon Webb, MD, FAANS,

FACS, FAHA

Disclosures

• No Disclosures

Objectives

• Describe Systems of Care

• Describe stroke levels of care

• Discuss SC stroke council state Initiatives

What is the systems of care?

• When it comes to stroke and heart disease, the systems of

care incorporates the coordination of care along the

following continuum:1. Primary prevention

2. Notification and response of emergency medical services (911

and EMS)

3. Acute treatment

4. Sub-acute care and secondary prevention

5. Recovery and rehabilitation

6. Continuous quality improvement initiatives

Why are systems of care

important?

To prevent the incidence and death of stroke, it is important to address the whole system from prevention to rehabilitation.

The health threats that the systems of care is designed to fight against are some of the leading causes of death in America. For example, stroke, heart attack, trauma.

If every state implemented a strong systems of care, we could help reduce heart disease and stroke deaths among Americans by 20 percent by the year 2020.

What specific improvements can

be made to the systems of care?

• States can officially recognize the best medical centers to treat stroke to ensure that the best care is delivered promptly

• States can develop a registry to track the response and outcome of each incident in order to discover and implement future improvements in the systems of care

• States can mandate the utilization of EMS transport protocols to ensure that all patients having signs or symptoms of stroke be transported to the nearest appropriate certified stroke center. Positive patient outcomes are reliant on specialized care and quick treatment that can be found in certified stroke hospitals

Stroke Systems of Care Study Committee Report (S*26)

(November 30, 2010)

Recommendation summary

(Primary Recommendations are listed in bold)

• 1. Support evidenced-based policy and systems changes which promote stroke prevention such as

increasing the number of hypertension specialists in SC. Support campaigns to enhance public

education and awareness of stroke. Provide resources to implement strategies to reduce stroke

treatment disparities.

• 2. Establish hospital designation based on level of stroke care through designation by DHEC so

that EMS can transport patients to the most appropriate, facility. Fund a full-time position, to

be managed through DHEC's EMS Division, to establish and monitor regulations relating to

hospital designation.

• 3. Ensure tele-health coverage through both public and private Insurance providers.

• 4. Ensure adequate coverage by private and public payers (including Medicaid) to provide stroke

rehabilitation in free-standing interdisciplinary rehabilitation hospitals and home health based

on need.

• 5. Offer tax credits, or limited state income tax, for stroke rehabilitation professionals in

underserved areas including physiatrists, physical therapists, occupational therapists, and

speech therapists.

• 6. Establish a statewide stroke registry, which will capture and link data on pre-hospital,

hospital, and rehabilitation services.

• 7. Establish a statewide stroke steering committee to evaluate Implementation, adherence, and

continuous improvement of the recommended changes.

• 8. Establish a full-time position, to be managed through DHEC's Heart Disease and Stroke

Prevention Division, to implement the state stroke plan.

Stroke Systems of Care

Act of 2011

• Establish hospital

designation

• Establish a statewide

stroke registry

• EMS triage tool

• EMS transport

protocols

• Establish a statewide

stroke steering

committee

Establish a Statewide Stroke

Steering Committee

Stroke Advisory Council

• Responsible for advising the department through the Bureau of EMS on all things related to stroke systems of care within the State. Like the EMS advisory Council, the members of the Stroke Advisory Council have the power to bring issues before the Council, make motions, and vote on matters that they see appropriate. Advisory Councils within the State have tremendous power and influence on system development and improvement.

Establish Hospital

Designation

Stroke Levels of Care

• Acute Stroke Ready Hospital

• Primary Stroke Center

• Comprehensive Stroke Center

Stroke Hospital Certification

CSC PSC ASRH

Role TreatAllStrokeTypesStabilizeAllStrokeTypes

TreatMostIschemicStrokes

Stabilize/TransferAllStrokeTypes

IVtPAforIschemicStrokes

ActueStrokeTeamAvailable24/7

Bedsidewithin15min

Available24/7

Bedsidewithin15min

Available24/7

Bedsidewithin15min

StrokeUnitNeuro-ICU

with24/7neuro-intensivistStrokebeds(notICU) nonerequired

RoutineImaging CT/MRI(24/7) CT/MRI(24/7) CT/MRI(24/7)

AdvancedImaging24/7CTA,MRA,angiogram,

CTP,TCdoppler,carotiddoppler,

TTE&TEE

notrequired

(except1cardiacimaging)notrequired

Neurologist24/7inperson,

abletohandlemultiplecomplexpts24/7inpersonortelemedicine 24/7inpersonortelemedicine

Neurosurgery

Available24/7,

abletohandleaneurysmclipping,

AVMresection,carotidendartectomy

Accesswithin2hours

(atcenterortransfer)

Accesswithin3hours

(atcenterortransfer)

NeurosurgeryOR Available24/7Available24/7

onlyifNSGYatcenternotrequired

Endovascular Available24/7 notrequired notrequired

MinimumTreatmentIVtPA,openneurosurgery,

endovasculartreatmentsIVtPA IVtPA

TransferProtocols acceptsfromPSC/ASRHprotocolfortransfertoCSCforneurosurgery/endovascular

protocolfortransfertoCSC/PSC

MinimumYearly

Volume

20-25SAH

10-15aneurysmtreatments

25IVtPA(50/2years

carotidtreatmentvariable

nonerequired nonerequired

EducationPrehospitalpersonneleducation

Publicstrokeeducation(2/yr)Internaleducationalcourses(2/yr)

Prehospitalpersonneleducation

Publicstrokeeducation(2/yr)Prehospitalpersonneleducation

ResearchIRBapprovedpatient-centered

researchnonerequired nonerequired

Accreditation Organizations

Primary Stroke Center

• Mostly urban and suburban

• Typically 300+ stroke patient admissions per year

• Same level of care 24/7/365

• All attributes of acute stroke ready, plus….

Primary Stroke Center

• Collaboration with EMS providers.

• Access to stroke treatment & destination protocols.

• Provide support to remote area hospitals.

• Transfer protocols to primary or comprehensive stroke

center, when needed.

Primary Stroke Center

• Neuroimaging—24/7 basis:

– Able to obtain brain image within 25 minutes and interpretation within 20 minutes of completion.

• Advanced imaging:

– MRI with diffusion

– Vascular imaging (MRA, CTA, carotid doppler)

– Cardiac imaging (TTE, TEE, or cardiac MRI)

Primary Stroke Center

• Laboratory Services:

– Stroke labs within 45 minutes from order on 24/7 basis.

– ECG and chest x-ray within 45 minutes from order, when clinically indicated.

• Outcome and quality improvement activities.

• Community educational programs.

Primary Stroke Center

• Neurosurgeon available within 2 hours of need

identified. Or written transfer plan to facility with this

capability.

• Operating room capability 24/7.

Primary Stroke Center

• Stroke Units

– Does not require specific enclosed unit, but must be a unit where majority of patients are admitted where staff have annual education & specialized experience in caring for the stroke patient.

Primary Stroke Center

• Rehabilitation Services:

– Speech Language Therapy

– Physical Therapy

– Occupational Therapy

• Assessment and early initiation of a plan.

Primary Stroke Center,

Metrics

• Stroke Core Measures

• Volume of Ischemic, TIA, ICH & SAH admits

• Acute Stroke workup times:

– Door to CT

– Door to lab results

– Door to EKG & CXR

• IV tPA volume, door to needle times

Must show that you deliver care based on

these published guidelines.

Comprehensive Stroke Center

• Health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology.

• Advanced neuroimaging capabilities, such as MRI and various types of cerebral angiography, 24/7/365, most within 30 minutes of clinical need.

• Surgical and endovascular techniques, including clipping and coiling of intracranial aneurysm, carotid endarterectomy and stenting, and endovascular treatments for ischemic stroke.

• Infrastructure and programmatic elements such as a dedicated neuro intensive care unit staffed with neurointensivists.

• Post hospital care coordination.

• Extensive data collection and peer review process.

• Participation in stroke research.

Everything we’ve discussed so far, plus……

Comprehensive Stroke

Center

• Increased data collection requirements.

Examples:

• Ischemic stroke

– % of patients who received IV tPA in ≤ 60 minutes from arrival

– % who arrive in less than 6 hours of onset who were considered for endovascular tx

– 90 day modified Rankin scores

• Hemorrhagic stroke

– Initial severity scores documented (ICH & SAH)

– Procoagulant reversal times for ICH

– Median time from admit to surgical or endovascular tx for aneurysm

– % of patients who receive nimodipine within 24 hours of admit

• Serious complication and mortality rates for CEA, aneurysm coiling & clipping, carotid stents, thrombectomies, decompressive cranis, ventriculostomies, EVD’s & transduced lines, cerebral angiograms.

• Follow-up calls on complex stroke patients within 7 days of discharge.

Comprehensive Stroke

Center

• Enhances the ability to analyze and optimize how patients move through the system (EMS on through back into community).

– It allows for more team thinking of how we all work together to provide an efficient & optimal patient experience, rather than just thinking in silos about what occurs in and would work best for my own department.

• Regular communication among stakeholders through an organized committee/advisory group structure helps to reinforce the team concept, helps to identify common goals, sets clear priorities, and builds positive working relationships.

Shannon Sternberg, RNGreenville Memorial Hospital

GHS Stroke Program Manager

Angel Rochester, MDGHS Emergency Medicine

Division Chief of Adult Emergency Medicine

Clinical Lead: Emergency Department

Sharon Webb, MDSoutheastern Neurosurgical &

Spine

Director Cerebrovascular, Endovascular, Neuro-

critical careCSC Surgical Stroke

Director

Clinical Lead: Endovascular, NICU

Mahmoud Rayes, MDNeuroscience Associates &

Southeastern Neurosurgical & Spine

System Stroke Medical Director

CSC Medical Stroke Director

Clinical Lead: Stroke , Research

GHS Stroke Team

Core Stroke team represents

Nursing, Neurology, Neurosurgery, Endovascular, Neurocritical Care & Emergency Medicine

CORE STROKE TEAM

STROKE ADVISORY TEAM

Physician: Neurology, Neurosurgery, Emergency, Radiology, Physiatry, HospitalistNursing: ED, IP, NeuroRadiology

Laboratory Pharmacy Radiology Rehab Therapy Nutrition Hospital Case Management Quality Management Referral Center EMS

Future of Hospital

Certification

JCAHO: Thrombectomy-Capable Stroke Center

4th designation

+ thrombectomy and ICU care

- neurosurgery/endovascular capabilities for other stroke types

12 thrombectomies/year, 2 operators

SNIS: Neuro-Endovascular Ready

Add on State designation (like Trauma)

+ thrombectomy capable

36 thrombectomies/year, 2 operators, proper training

EMS Triage Tool

EMS Transport Protocols

GC EMS

CVA

Protocol

Establish a Statewide Stroke

Registry

Statewide Stroke Registry

• Will use the GWTG data but will eventually also

include prehospital data from EMS and post

hospital stay data from rehab facilities

• ALL certified hospitals will be required to

participate in the state stroke registry and

submit data quarterly

Stroke Core Measures

STK-1 VTE Prophylaxis initiated by hospital day 2

STK-2 Discharged on Antithrombotics

STK-3 Anticoagulation for Afib

STK-4% who arrive in ED w/in 120 minutes of onset who received tPA w/in 3 hours of onset

STK-5 Antithrombotics started by hospital day 2

STK-6 LDL> 100 discharged on a statin

STK-8 Patient/family stroke education provided

STK-10 Assessed for rehab needs

PSC-7 Bedside swallow screen prior to any PO

PSC-9 Tobacco cessation provided during hospital stay

Power of Data

Public Comment

• Providing public comment to SC DHEC -

deadline October 23

• http://www.scdhec.gov/Agency/RegulationsAnd

Updates/PublicComments/

Stroke Systems of Care

• Does it make a difference?

– Compared to general hospitals, Primary Stroke

Centers have:

• Higher tPA treatment rates

• Lower death rates

• Improved outcomes

– Being certified by an independent licensing body

increases effectiveness of overall stroke care.

– The focus is on the entire continuum.

GHS – Leading the Way in

the Upstate

Cerebrovascular and

Stroke Center

Cerebrovascular and

Stroke Center

Cerebrovascular and

Stroke Center

Cerebrovascular and Stroke

Center

The Cerebrovascular and Stroke Service Line supports the

Neurosciences/Post-Acute Services with the following GHS

directives:

GHS Vision: Transform health care for the benefit of the people and communities we serve.

GHS Mission: Heal compassionately. Teach innovatively. Improve constantly.

GHS Values: Together we serve with integrity, respect, trust and openness.

CEREBROVASCULAR AND STROKE ADVISORY COUNCIL MISSION

-Support Cerebrovascular and Stroke strategy and provide feedback

-Improve effectiveness of patient experience

-Develop increased capabilities of Caregivers

-Advance awareness of Cerebrovascular and Stroke in the community

-Explore advocacy engagement of organizations, both internal and external

Cerebrovascular and Stroke

Fund

QUESTIONS?

Questions?

Office of Philanthropy and Partnership

Donations can be made:

1. Online: http://www.ghsgiving.org/2. Check payable to: Greenville Health System and mail to:

Greenville Health SystemOffice of Philanthropy and PartnershipGreenville Health System300 East McBee, Suite 503Greenville, SC 29601

3. Call the Office Of Philanthropy: 864-797-7757

If you want to discuss additional options contact: Dianne Dillon the Neuroscience and Post-Acute Philanthropy Representative at ddillon@ghs.org or 864-797-7733.