Victorian Stroke Telemedicine A Regional Perspective Janet May Victorian Stroke Telemedicine Site Coordinator Latrobe Regional Hospital 25th November 2016

Overview LRH background Stroke Telemedicine Pathway Case study with tissue Plasminogen Activator (tPA) and Endovascular Clot Retrieval (ECR) Key factors for success/sustainability in a regional setting

Importance of Time 1.9 million neurons, 14 billion synapses and 12 kms myelinated fibres are lost each minute during an untreated Stroke*- equates to brain aging 3.6 years each hour Impact delayed tx has on pt is huge at the other end of their Stroke journey. Time and cost in hospital and rehab, but more importantly effect of pt’s outcome and quality of life. Treat Strokes like a STEMI. *Source: Jeffery Saver; ‘Time is Brain – Quantified’, 2014 http://stroke.ahajournals.org/content/37/1/263

LRH Emergency Department (ED) ED annual presentations approximately 30,000 Stroke/TIA admitted inpatients = 227 in 2015 Stroke Telemedicine commenced in Nov ’15 112 VST calls (YTD) 61 Ischaemic Strokes, 10 TIA, 4 ICH, 7 Migraines, 30-other 27 pt’s thrombolysed, 7 transferred for ECR 15 pt’s thrombolysed July 2014 – June 2015 Increase of 80% of patient’s thrombolysed since comm VST Aim of the program to Improve access to reperfusion therapies and reduce delays in diagnosis and treatment is working

How the VST program works… Phone 1300 TELEMED (1300 835 363) Regional Hospital Stroke symptom onset < 4.5 hours Paramedics notify hospital Rapid triage and assessment CT brain and CTA Acute stroke therapies – tPA/ECR delivered within acceptable timeframe Video consultation with family and regional clinician Rapid review of brain imaging remotely Assessment by VST stroke specialist Acknowledge the principles to Stroke Mg is much more than during hyper-acute stage. Initial time frame impacts on care that other health professionals deliver in Stroke Unit and Rehab.

Case Study Mr N, 78 year old man. Independent, home with wife, MRS=0 PHx of IHD (stable), smoker 30 years ago Witnessed onset aphasia + right hemiparesis while working in his shed Stroke onset 12:30pm NOTE: Remember stroke onset is last time seen well Stroke discovery can be different to stroke onset Modified Rankin Score – scale from 0-6 measures degree of disability or dependence in their daily activities. 0-2 independent, 3-6 – dependent to death. Be aware of ‘Wake Up Strokes’ – have to take the onset time from last time seen well. If unknown – can’t thrombolyse.

VST Pathway AV pre-notification. Pre-order CT scan Taken directly to CT from AV trolley-18G IVC Med Reg -R/V pt and attends CT Med Reg Initiates VST call when baseline diagnosis is established, exclude ICH. +/- CTA Neurologist R/V’s CT images, timely diagnosis and management Pt returns to ED for further Assessment + urgent pathology Neurologist dials into Teledoc for audio-visual consult. NIHSS 23 (severe stroke) In conjunction with CT results, patient’s pre-MRS, NIHSS score – Neurologist provides Med Reg with management suggestion Timing of call to VST varies at each site. Some call prior to pt’s arrival. LRH – call after we exclude ICH.

National Institute of Health Stroke Scale (NIHSS) Internationally recognized tool to determine severity of stroke Consists of 11 items, scores a specific ability, ranges 0-4 Score Stroke severity No stroke symptoms 1-4 Minor stroke 5-15 Moderate stroke 16-20 Moderate to severe stroke 21-42 Severe stroke

Background of Thrombolysis In 2007 the stroke care strategy for Victoria supported the use of thrombolysis for appropriately identified patients, who met the criteria Radically changed approach to acute stroke management LRH introduced the use of tPA (thrombolysis) in June 2010 2015 large clinical trials demonstrated clot retrieval intervention almost double benefits in pt outcome than thrombolysis for large artery obstruction Stroke can be Ischaemic or from haemorrhage. Thrombolysis is used for ischaemic strokes only – been around now for nearly a decade

tPA The aim of thrombolysis is to recruit as much of the penumbra as we can by breaking down the clot.

What is tPA Most effective, evidence-based acute stroke therapy is thrombolysis with recombinant tissue Plasminogen Activator (tPA) Converts plasminogen to plasmin, the major enzyme responsible for clot breakdown Thrombolysis can only be used for ischaemic strokes Alteplase is the drug used in thrombolysing strokes who meet the criteria Other thrombolytic drug trials (e.g Streptokinase) halted due to high rates of ICH

Giving Alteplase Point of care INR check for pt’s on warfarin/New Oral Anticoagulants (NOACs) Meet eligibility criteria >18 years - not absolute Expensive 0.9mg/kg, max. dose 90mg. Don’t shake. Administration: 10% as bolus (IV push over 1 min), remaining 90% as infusion over 1 hr. Short half-life - 5 minutes NIHSS score 2 hrs, 24 hrs post Alteplase and day 7/discharge Avoid IVC, art line insertion, NGT for 24hrs, CCU for 24hrs Post tPA obs in protocols –talk for another day Thus > 50% of t-PA is cleared from plasma within 5 minutes after discontinuance of an IV infusion and approximately 80% is cleared within 10 minutes. Older clots have more fibrin cross-linking and are more compacted or in plain English older clots are more difficult to dissolve. Beyond that time, the efficacy diminishes and higher doses are generally required to achieve desired lysis and the great the risk of unwanted complications. Reteplase is less fibrin selective and has longer half life IF BP >180/110 should be treated prior to commencing t-PA 7% of pts with ischaemic Stroke receive t-PA Mortality rate =21% not tx t-PA, 17% for pts tx with t-PA –Stroke Foundation Time frame: Studies done <6 hrs of symptoms. Mortality rate wasn’t increased

Cautions Signs of angioedema, anaphylaxis, bleeding ICH – 6.4% of pts receiving Alteplase – 50% occurs in first 24hrs and half are fatal Minor bleeding is common – look at gums, IVC site Poorer outcomes: Severe impairment (NIHSS >22) >85 years age Hypertensive Hyperglycaemia

Aim - 60mins Door to Needle time Pre-VST VST LIVE Pre-VST DNT = 90 minutes Pre-VST CT time = 17 minutes Reasons for delays pre-VST Different process CT not initial priority Time for CT interpretation Due to multiple delays in time pt’s could exceed 4.5hour time frame and >6hours for ECR VST DNT = best 40 minutes VST CT time = best 1 minute Mr N’s Door to CT time = 12mins Mr N’s DNT = 40mins Door to ED exit time = 1hour 15mins (transfer RMH for ECR)

ECR Decision to pursue ECR –large vessel occlusion-best patient outcome VST Stroke Physician contacts receiving ECR Physician (RMH) – determine suitability for ECR. Urgent interhospital transfer – 000 – request <15 minute response. AV Code 1 Adult Retrieval Victoria only required for patients with airway compromise, coma or haemodynamically instability Angioedema kit to go with patient Can be transferred with tPA infusion insitu ECR – highly effective tx reduces disability and death after ischaemic stroke du to lg vessel artery occlusion Requires specialist skills – avail RMH, soon to be avail at MMC Majority are transported by ALS crew on Code 1

Mr N’s Outcome Endovascular clot retrieval <6hours ECR procedure took 30mins Patient was responding yes/no & moving R)side post ECR & improved daily Returned LRH Rehab 7 days post ECR D/C home one month later Post mRS (on discharge) = 2 Slight speech delay & slight R)sided deficit. Independent with ADLs (Remembering that he had aphasia + right hemiparesis and NIHSS of 24)

Key Factors to Success Mr N’s wife remembered the FAST acronym and dialled 000 immediately AV pre-notified LRH AUM Immediate CT, CTA and CTP Called VST as early as possible Neurologist received images within 2minutes Rapid CT interpretation & diagnosis Med Reg was proficient with NIHSS Administration of timely tPA (aiming for DNT 30-40minutes. KPI<60 mins) Patient considered for ECR <6hours Teamwork!

Challenges Differentiating TIA/other diagnosis Wake up Strokes – determining time Stroke mimics – migraines, functional, seizures, syncope, hypoglycaemia, sepsis, etc Consult with VST/Neurologist ASAP

Key Factors to Success- Telemedicine Close collaboration with the Florey Active input from supportive executive and influential key stakeholders Close working relationships with local ambulance crew  consistent pre notification Ongoing education to rotating medical staff Everyone involved can contribute to timely outcome: - Paramedics, Clerks, Orderlies, Drs, Nurses, Radiographers Shaving minutes off delays - saves millions of neurons Save a Minute, Save a Day

Acknowledgements The Florey Institute. Particular thankyou to Prof Chris Bladin, Dominique Cadilhac, Michelle Vu, Dr Katie Bagot VST Site Coordinator colleagues, particular Lauren Arthurson Site Coordinator Echuca Regional Health and Emma Marino (predecessor at LRH) Nerylee Morris- Stroke Coordinator, LRH Carolyn Beltrame- CNS ED LRH https://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_465029.pdf Inform Me, 2016: https://informme.org.au/learning-modules/take?id=89c034cf-eb43-4df5-b6e1-c53d3360bcd0 Stroke Foundation, 2016: https://informme.org.au

Questions