Update from education committee

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Presentation transcript:

Update from education committee Train the trainer—content reviewed from Strategies to Improve Door In/Door Out During Acute Stroke Transfer “First Tuesdays” Lecture Series

Introduction and Goal of “First Tuesdays” Sabreena Slavin MD – Vascular Neurologist and Neurohospitalist at KU School of Medicine Craig Bloom RN, BSN, MBA – Senior Clinical Specialist Lytics, Genentech, Inc. Didactic lecture series as part of the Kansas Initiative for Stroke Survival Updates in Practice and FAQ’s on Acute Stroke Care 20 minute didactic, 10 minutes for questions/discussion

Review of Acute Stroke Interventions IV alteplase (tPA) for all patients who have disabling symptoms of acute stroke Mechanical thrombectomy: only for large vessel occlusions (LVO). Only hospitals with capabilities (eg: comprehensive stroke center) can perform thrombectomy. A higher NIHSS (10 or more) can be indicative of a large vessel occlusion. Diagnosed with CTA head/neck

Prabhakaran et al, Stroke, 2011

Prabhakaran et al, Stroke, 2011 In a hub-and-spoke system in Chicago, transfer delay between referring hospital and CSC excluded 18 (13.6%) of 79 patients initially eligible for interventional therapy. Prabhakaran et al, Stroke, 2011

EMS Prenotification Large retrospective study on over 370,000 patients from April 2003 – March 2011: EMS prenotification occurred in 67% of total cases. Prenotification was associated with better door-to-imaging time (26 minutes vs 31 minutes) and door-to-needle time (78 minutes vs 80 minutes). Will help direct EMS to CT scanner Lin et al, Circulation 2012.

Cutoff Score for possible LVO: ≥4 Lima et al, Stroke, 2016

Sun et al, Stroke 2013

CT vs CTA vs CTP at non-CSC? Immediate door to CT scanner for suspected acute stroke. CT/CTA can often be obtained on initial arrival as long as IV tPA is not delayed. For patients with severe acute stroke with last well within 24 hours, (NIHSS ≥ 10 or cortical signs such as weakness + aphasia/gaze/neglect), consider not obtaining CTA/P at your site and calling CSC for transfer immediately.

Wait for Creatinine before CTA? One study on acute stroke patients receiving CTA/P without waiting for serum Cr. All patients received IVF afterwards. Out of 623 cases, only 16 (2.6%) had contrast induced nephropathy (CIN), however with 15/16 cases also with dehydration, UTI, or medication induced-nephropathy 0 cases progressed to CKD or required dialysis! There was no negative impact of CIN on 90-day mRS outcomes. Ang et al, Int J Stroke 2015

Other strategies Have EMS stay nearby if suspecting LVO ED staff training to call/notify CSC early in process, do not wait for neurology consult/assessment. In vast majority of cases, MRI brain is not needed and only delays care. On CSC end, we will use air transport if faster and notify our interventional team early. If patient being transferred for intervention, we will ask for 2 large bore IV’s and Foley placed; but do not delay transfer to get these!

Questions? Call for help anytime! KU BAT phone: 913-588-3727 http://www.kissnetwork.us/ sslavin2@kumc.edu