EiTESAL eHealth Conference 14&15 May 2017 Stroke systems of care between the past, present and future by Dr. Tamer Emara

1. Stroke Systems of Care
Between the past, present
and future
Tamer Emara MD MRCP
Assistant Professor of Neurology
Ain Shams University

2. Stroke: The challenge
• 20 years earlier
• 85% of stroke deaths occur in LMIC
• 100% inc rates vs 42% reduction
• x7 disability
• 3% MDT rehab

3. 05/21/17
Stroke units
• Impact
10 days mortality
one year mortality and institutionalization
SU effect: early mobilization, less complications, early aspirin and fluids, standard swallow therapy (chest infection 26% vs
47% on demand)
• PSC
Stroke unit or designated beds
CTA/MRA available 24/7
Neurologists 24/7 in person or via telemedicine
IV tpa treatment
Neurosurgavail within 2 hrs–if onsite neursurg–OR staffed 24/7
stroke team on site, not necessarily neurologists, stroke education

4. 05/21/17
Rtpa injection rate 5%
• CSC
Dedicated neuro ICU with 24/7 staffing
Catheter angio24/7
Able to meet concurrent needs of multiple complex stroke patients
24/7 neurointerventionalist, neurosurgeon, neurologists
Aneurysm clipping/coiling, carotid stenting/CEA, endovascular care
Patient centered stroke research
Additional volume requirements for IV tPAand SAH clip/coil volume
Neurorehab
Accept referrals from PSC

5. 05/21/17
How to improve rtpa injection rates?
1. Acute Stroke Ready Hospital
(ASRH)• 1000 stroke center; 10% CSC
• 50% of the population took more than an hour to reach a stroke
center
Neurologist –24/7 in person or via telemed
Telemed avail w/in 20 min
Transfer protocols with PSC or CSC
IV tPA available –anticipate transfer if treated
No stroke unit required
DIDO 1 hour

6. 05/21/17
ASRH-PSC-CSC
• Drip and Ship (DIDO time)
• Transferral policies, and agreements.
• Transferrals are inversely proportionate to cost effectiveness for the
patient and the spoke (1/3).
• Basic Hospital

7. 05/21/17
2. The important role of EMS

8. 05/21/17
EMS staff actually take the most
important decision

9. 05/21/17
RTPA injection rates moved up from 5% to
12%

10. 05/21/17
UHC
and
The Distribution Problem

11. 11
The Healthcare Delivery Bottleneck
Electronic Health Records $
Healthcare Information Exchange $
Personalized Medicine $
Remote Monitoring $
Big Data $

12. 05/21/17
TELE
MGH Telestroke Network
Mayo Clinic Telestroke and Teleneurology
network
UCLA TeleneuroICU service

13. 13
Balancing Resources w/ Remote Coverage
Tertiary Facility
Traditional Model
40 bed ICU
10 bed ICU
8 bed ICU
6 bed ICU
Affiliates
Affiliates census
below capacity
Tertiary facility
overloaded
Proactive Model
Tertiary Facility
40 bed ICU
10 bed ICU
8 bed ICU
6 bed ICU
Affiliates
Balance Bed Capacity
Across System
“Keep it within our system,
but do not overload the
tertiary care center”
Jeffrey Sadowski, MD
Dir Crit Care Med
Orlando Health

15. 05/21/17
MGH Telestroke Network
On Call vs TELE
• 2004-2009
• TS vs On Call rtpa injection rates
On call
414/3239
12.8%
TS
230/617
Success rate 37.3%
2/3 cases remained in ASRH/PSC
(Drip and Keep)
$ 120 M saved

16. 05/21/17
ASRH (+/- admissions)
PSC
• Neuro 24/7 onsite or tele (not on call)
• Stroke unit required in ASRH if they
will Drip and Keep
• Teleradiology
• CME
• Stroke teams
• Referral policies within the system
• EndoVascular Therapy
Accrediation requirements changed

17. 05/21/17
EMS
The call to needle
timeBased on your estimated stroke severity,
real-time traffic updates, publicly
reported door to needle times and
rates of thrombectomy in all hospitals
reachable within 4.5 or 6 hours from
your time last known well:
EMS recommends:
• Immediate transport to Tiny Hospital
• TeleStroke for IV tPA with DIDO <60
• Transfer to Giant Medical Center for
further specialized care if needed
• Activating EMS Dispatch now
• Performing pre-arrival notification and
requesting tPA dispensing based on
high predicted likelihood of eligibility

18. 05/21/17
• establish a working group
• entry requirements
• assessment visits
• written protocols; standardized nationally,
customized locally
• sign contracts
• communication
• integrate education
• Pick the right team. Local champs.
• Bear the pain of change
How can we start?
National Stroke System of Care

19. 05/21/17
ems -stroke centers- people -opc-community-
network-auditing, revisions and expansion
(EVT)-positioning (public eye, regional,
private)-research• invest in HR. They are the future leaders
• Mutual visits. One onsite round per week. One virtual grand round between centers.
• short term fellowships in ASU for residents and master degree students
• CME
• fast track MSc and Online Diploma via elearning and onsite training
• Specialized one year diplomas in stroke, neurointernvention
• Nurses training, role in community awareness (stroke awareness study)
• EMS: call-dispatch-CT-Needle- decision keep or ship
• GPS stroke centers
• Outcome measures upon discharge
• national certification protocol for stroke treatment centers in Egypt

20. 05/21/17
EMS
GPS map for stroke centers

21. 05/21/17

22. 05/21/17
• Incentivize the whole team
education
leadership
Job opprtunities
decrease the brain drain
leadership board
renewal of licensing
Accreditation system of this network

23. 05/21/17
• Impact of evidence
• International conferences
• International accreditation
• Going regional

24. Acute Stroke Triage: Speed and Coordination
Notify Stroke Team Perform CT
Stroke center
IV tPA
ED physician initial
eval
10 5 10
Interpret CT
20
15
Saver. Stroke. 2010;41:1431-1439. Fonarow Circulation. 2011;123:750–758
Lansberg et al, Stroke 2009

25. Acute stroke triage to improve access to IV tPA
Site of
stroke
Patient history,
vitals, CT scan
Triage decision:
ED physician/
neurologist confirms
stroke diagnosis
Negative CT Positive CT ICH
EMS transfer
Prehospital
triage
Self-present
Stroke center
Hospital

26. 05/21/17
All what is takes is to support a dedicated
team
• Hospital team
• Home care
• SNF
• Community team
• Integrated EMR
• Outcome measure analysis

27. 27
Spoke
ASU
Hub
Spoke
Spoke Spoke
Spoke
Spoke
Spoke
Spoke
MOH
CSC
Spoke
Spoke
Spoke
S/H
Chain Reaction of Knowledge Teach
Treat&

28. Vision
• fewer strokes, better outcomes

29. Strategy
1. Establish a working group
2. Situation analysis
3. Create a timeline
4. Obtain support
5. Draft the policy
6. Consultation and communication
7. Provide training and supervision
8. Finalize and implement the policy
9. Periodic review and evaluation

30. Establish a working group
(Select key members of the working group)
Example:
•Human resources consultant
•Facilities directors
•Senior clinical and/or medical consultants
•Key employee groups
•Key client groups
•Security representative
•Pharmacy representative
•Health education representative
•Public affairs representative

31. Situation analysis
Defining goals and expected outcomes
Review of existing stroke policies
Evaluation of personnel and facilities before implementation
Assessment visits
•Checklist of prerequisites and type of center applied for
•Application form
•Available assessment form
Define eligibility criteria
•Competency of personnel
•Presence of CT and labs
•Presence of trained stroke team with adequate number of personnel in the facility
•Large catchment area
•Intermediate care beds or stroke units available
•Presence of internet access
•Measurement of: Complication rate, door-to-needle time, mortality rate

32. Create a timeline
Establishment of a time-line for nationwide implementation:
•Establish national stroke working group
•Create buy-in with top-level administrators and clinical staff
•Develop and secure budget
•Evaluate personnel and facilities
•Draft policy and garner feedback from involved parties
•Review current stroke management protocols
•Announce plans for implementation of new protocol
•Start countdown
•Educate involved parties
•Train personnel on new protocol
•Launch policy
•Review and re-evaluate policy

33. Obtain support
Presentations highlighting cost-benefit of implementation of new
protocol
Offering privileges for best participating facilities:
•Fast tracking MSc and M.D.
•Offering training opportunities in a comprehensive stroke center
•For hospitals: Infection control and complication rate, best door-to-
needle
•Ranking among local hospitals

34. Draft policy
• Establishment of a detailed written protocol on which personnel are trained
• Stroke team: Presence of at least 1 trained physician 24/7
• EMS training: Recognition and management of acute stroke
• Emergency room personnel and activation of a stroke code for accelerated management
• Access to a stroke unit: Continued availability of beds
• Rapid transport of patients from ED to stroke unit
• Neurosurgical and neuro-interventional liaison service
• Lab services (Which labs to order, acceleration of results)
• Neuroimaging (NECT brain, CT cerebral angiography, MRI brain)
• Continued training (Rounds on stroke patients)
• Tools for tracking of patient outcomes

35. Consultation and communication
Communicate drafted policy to implementing parties and review
feedback
Obtain feedback on:
•Call-to-needle time
•Door-to-needle time
•Complication management
•Standardized nationwide tools for assessment and database

36. Consultation and communication
(cont’d)
Possible simulations held for the feasibility of the policy:
•Quick assessment and NIHSS
•On-call specialist consultation
•Door-to-needle simulation (Assessment, consultation, labs, imaging,
preparation, acquisition of meds, IV bolus, infusion and monitoring)
•Information to give family to obtain consent
•Systems-based practice in individual hospitals

37. Provide training and supervision
•Training on policy and procedures
•Online CME
•Regular on-site visits
On development of training materials, the following should be
acknowledged:
•Target trainees
•Content of training
•Knowledge and skills-based competencies to be developed

38. Provide training and supervision
(cont’d)
Training in the medical and systems-based issues in individual
secondary health care centers in cities:
•Physicians
•Nurses
•Porters
•Security
•Lab and imaging technicians
•Administrators for provision of meds and acceleration of management

39. Provide training and supervision
(cont’d)
Anticipate challenges:
Technical challenges:
•Stroke mimics and stroke chameleons
•Imaging interpretation
•Changing vital signs: The patient whose BP rises just before injecting and available
anti-hypertensives
•Preparing the patient (IV access, need for additional tubing, stabilization of vital
signs, which signs to monitor)
•Dose calculation
•Using alteplase
•What to do in case of bleeding
•Patients with acute stroke and other acute co-morbidities (polytrauma, acute
MI…)

40. Provide training and supervision
(cont’d)
Anticipate challenges:
Administrative challenges:
•Lab delays
•Paperwork and administrative delays in obtaining alteplase
•Running costs
•Sustainability

41. Finalize and implement policy
• Select the date to launch the policy for all staff, patients, and visitors.
• Focus the education campaign (key messages: stroke symptoms and
risk factor management) initially on staff, extending to the broader
community.
• Extend the staff education campaign to target patients, visitors and
the broader community.
• Provide clear information on the details of the policy. Effective
communication will ensure broad support for the policy, which will in
turn ensure a high level of compliance with the policy.

42. Periodic review and evaluation
• Define outcomes to be reviewed as per policy
• Develop an implementation review checklist with individual
objectives
• Reassess policy

43. Of use
• List of certified stroke centers communication to EMS and emergency
telemedicine services for transport and management of acute stroke
patients
• GPS applications for availability of stroke care beds
• Translated FAST posters

44. The role of telemedicine
• Training
• 24/7 back-up network of neurology consultants