Acute Stroke Redesign: Kaiser Telestroke Update TRILOK S. PUNIANI, MD May 6, 2017

Statement of Disclosure I do not have affiliations that may constitute a conflict of interest with this program.

Objectives: Briefly discuss types of strokes Risk factors for stroke Primary stroke center Telestroke: Acute Stroke Redesign

Test Your Knowledge Stroke is the leading cause of disability in the US A. True B. False

Answer: A

Strokes are not preventable. True False

Answer: B

Strokes mainly effect elderly True False

Answer: B

Stroke is the third leading cause of death in the US. A. True B. False

Answer: B

What Is a Stroke ? Stroke is a sudden loss of neurologic function resulting from focal disturbance of cerebral blood flow due to ischemia or hemorrhage.

Stroke Stroke was the third leading cause of death after heart disease and cancer. In 2008, it dropped to the fourth leading cause of death. Currently, stroke is the fifth leading cause of death. Stroke is a leading cause of disability in the United States. Improved care and stroke risk reduction measures by the primary care providers, public and health care professional education Acute interventions and multi-disciplinary care, GWTG, substantially improved the outcome for stroke patients.

What are the risk factors for Stroke? There are two types of risk factors: Non-modifiable (factors you cannot control) Modifiable (factors you can control)

Non-modifiable Risk Factors For Stroke Age Gender Race / ethnicity Heredity Prior stroke / TIA Effect on Stroke Incidence Doubles per decade over age 55 24%-30% greater in men 2.4 fold increase in African-Americans 2 fold increase in Hispanics Increased among Chinese 1.9 fold increase among first degree relatives Increased risk

Modifiable Risk Factors About 90% of stroke risk may be explained by TEN major risk factors: Cardiac causes Hypertension Diabetes mellitus Diet Hyperlipidemia Cigarette smoking Abdominal obesity Physical inactivity / sedentary behavior Excess alcohol consumption Psychosocial stress and depression

What is Stroke certification Recognition (i.e. Certification) by Joint Commission as a facility which provides stroke care for patients across the continuum who have suffered from TIA or stroke.

Benefits of Primary Stroke Centers Improved efficiency of patient care Fewer peri-stroke complications Increased use of acute stroke therapies Reduced morbidity and mortality Improved long-term outcomes Reduced costs to healthcare system Increased patient satisfaction

Major Elements of a Primary Stroke Center Patient Care Areas 1. Acute stroke teams 2. Written care protocols (GWTG) 3. Emergency medical services 4. Emergency department 5. Stroke Unit 6. Neurosurgical services 7. Radiology services 8. Laboratory services

Stroke (STK) Core Measure Set STK-1: VTE Prophylaxis STK-2: Discharged on Antithrombotic Therapy STK-3: Anticoagulation Therapy for Atrial Fibrillation / Flutter STK-4: Thrombolytic Therapy STK-5: Antithrombotic Therapy By End of Hospital Day 2 STK-6: Discharged on Statin Medication STK-8: Stroke Education STK-10: Assessment for Rehabilitation

Stroke Patient Work Flow Stroke Alert Team Radiology Pharmacy Call Stroke Alert Emergency Department In-Patient Units Operator Activates Laboratory Processes Activated

Proven Strategies in Acute Ischemic Stroke Therapy Reperfusion Prevent Clot Propagation / Recanalization Supportive Care Early Implementation of Secondary Stroke Prevention

REPERFUSION THERAPY Thrombolytic therapy is able to recanalize acute intracranial arterial occlusions. A strong correlation has been shown between arterial recanalization and neurological improvement in acute cerebral ischemia.

The vision of thrombolysis for reversal of acute ischemic stroke (AIS) was launched in 1958, but it was not until 1995 that 2 landmark studies, one in Europe and the other in the United States, established IV administration of tissue plasminogen activator (tPA) as an effective treatment for AIS

Thrombolytic Therapy In June 1996, the FDA approved the use of IV recombinant tissue type plasminogen activator (rtPA) for ischemic stroke within 3 hours of symptom onset. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group showed that treatment with IV tPA within 3 hours of onset of ischemic stroke improved clinical outcome.

The Basic Concept TIME IS BRAIN

Time is brain 2 million nerve cells die per minute For every 15 minutes faster time: More patients go home Fewer die Fewer bleed More are independent at discharge JAMA. 2013;309(23):2480-2488. doi:10.1001/jama.2013.6959. Stroke.2006; 37: 263-266

The two most important concepts for recovery - Penumbra Stroke Recovery The two most important concepts for recovery - Penumbra - Time is Brain Concept

Ischemic Penumbra Penumbra: Latin pene “almost” + umbra “shadow” Zone of tissue around an infarct (ischemic core) which receives some collateral circulation Potentially salvageable if blood flow is restored

We know that Time is Brain, Time lost is Brain lost…… The challenge is…. How to reduce door to needle (DTN) time < 60 minutes Obtain very rapid CTH with interpretation Treat and evaluate

Telestroke This is one of the most rapidly expanding and successful application of telemedicine, delivery much needed stroke expertise to hospitals and patients The number of telestroke networks continue to grow in the US and throughout the world. Quality measures, operational protocols, order sets, policies and procedures are established by an agreement between the hub and spoke

February 2015 (ISC) Prior to ISC 2015 Acute Stroke Redesign TODAY No proven role for endovascular therapy (it was a rare treatment option) February 2015 (ISC) 4 studies with proof of superiority of endovascular therapy for large vessel occlusions post IV tPA TODAY Endovascular therapy is the standard of care! Rapid evaluation – CTA for most if not all strokes Rapid treatment with IV t-PA then rapid transfer for endovascular therapy

Comparison of RCTs for EST vs. Standard of Care Now there is a 5th trial REVASCAT (206 patients. Similar outcomes. NNT= 6.3) showing effectiveness of EST 6 Hours Anterior Circ alteplase vs. alteplase+EST Small Core (Perfusion → ASPECTS) 100% alteplase Standard vs. Standard + EST No core or collateral assessment 87% alteplase 12 Hours Anterior Circ Standard vs. Standard + EST Small Core (ASPECTS) Good collaterals 73% alteplase 6 Hours Alteplase vs. alteplase+EST Small Core (CTP) 100% alteplase

Achieve 20-30 minutes door to needle (DTN) times? What would it take to… Achieve 20-30 minutes door to needle (DTN) times? Obtain very rapid CTH / CTA performance and interpretation Treat, evaluate, and transfer for endovascular therapy in less than 45 minutes?

The world has changed

KP STROKE EXPRESS (EXpediting the PRocess of Evaluating and Stopping Stroke)

The key to speed… Key components = early involvement of stroke neurologist Don’t room – straight to CT Order TPA before CT TPA in CT Problem: small volumes cannot justify in house stroke neurologist Solution: video consultation + redesigned process

KP Stroke EXPRESS EXpediting the PRocess of Evaluating & Stopping Stroke

Acute Stroke Redesign: Stroke Neurologists involved early in the workflow via video (7AM – MIDNIGHT)

Neurology Telestroke Hub Centralized hub of specialized stroke neurologists working remotely 7AM to Midnight to examine all potential stroke patients early in the workflow via CISCO video carts

Call to Neurologist via central 800 number - neurologist activates tele-presence unit Clinical assessment and exam by stroke neurologist by video Clinical assessment by ED physician IV access Lab Blood sugar testing INR if on warfarin or unknown

Step One: Rapid assessment on arrival with video

Inclusion Criteria for IV alteplase Diagnosis of acute ischemic stroke LKWT (last known well time) is < 3 hours and in some cases < 4.5 hours from start of IV alteplase Over 18 years of age 7 .

Discussion of t-PA / CTA risks, benefits, alternatives IV t-PA ordered as soon as possible (allows time for mixing) Call on / off stroke alert based on clinical assessment Checklist / time out before leaving for CT

Direct to CT scanner - Once tPA is determined appropriate in the ambulance bay or triage area the patient will go directly to the CT scanner

tPA in CT scanner - IV tPA will be delivered and pushed in the CT suite directly after the CT is completed

CTA completed directly after CT or tPA - CTA completed on nearly all stroke patients

KP STROKE EXPRESS Telestroke neurologist plays an active role in establishing diagnosis of stroke, ensuring inclusion/exclusion criteria for alteplase /endovascular Rx, obtaining consent, ordering alteplase, initiating administration of alteplase, and discussing with the neurointerventional radiologist whether endovascular Rx is appropriate.

All Facilities First two weeks 2015 Median = 54 minutes, 36 cases per month First two weeks 2016 Median = 35 minutes, 42% < 30 minutes 76 cases per month

t-PA Cases: Jan –Dec 2012: 13 Jan – Dec 2013 6 Jan- Dec 2014 8 Jan- Dec 2015 21 Jan- Dec 2016 36

STROKES ARE PREVENTABLE