Telestroke Network Program Implementation and improved Stroke Care Delivery in an Urban Healthcare System Katja G. Bryant Neuroscience Clinical Specialist, Northside Healthcare System, Atlanta, GA

Objectives Demonstrate critical success factor for improved utilization and outcomes for stroke patient population Discussing real time, high quality video conferencing using a formalized organizational network Understanding multidisciplinary and multidepartment approach to Telestroke program implementation

Outcome Goals Telemedicine Increases the effective management of stroke patients, efficient utilization of Alteplase, evaluation for endovascular therapy and transfer to CSC (Comprehensive Stroke Center) Support with difficult to manage patients through the ability to visualize the patient using telemedicine technology Improved 60 and 45 minute Door-To-Needle (DTN) times, increase in Alteplase utilization Improved patient retention using telemedicine technology and advanced imaging Establishment of telestroke quality indicator to monitor program performance and outcomes Increase regional influence for advanced stroke care and enhanced regional reputation

Outcome Data Northside Hospital Year tPA use % increase Telestroke Implementation Year Atlanta 2014 6% 2018 18% 12% 2017 Cherokee 3% 21% 2011 Forsyth 5% 16% 11% Source : GWTG-S Target Stroke. National Registry 2019

Telemedicine Specialty Support Available at point of care 24/7/365 Provider to provider feedback at point of care Simultaneous team approach to emergency patient situation Team decision making on patient treatment plan and care delivery

Protocols and Criteria Northside Healthcare uses EBM for the treatment of acute stroke patients 2018 AHA AIS CPG adapted for evaluation and treatment B.E.F.A.S.T. criteria for triage of stroke patients 24 hour Stroke Alert Window ED and Inpatient 4.5 hour for initiation of Alteplase for eligible patients Protocols for emergent advanced Imaging: CT-Angiography, CT- Perfusion, MR-imaging, MR-Angiography Capability of receiving RAPID images through CSC collaboration Transfer of eligible patient to CSC (Comprehensive Stroke Centers)

B.E.F.A.S.T.

Process Improvement 2017 Process design and Re-design for Telestroke process, 24 hour Stroke Alert and Alteplase in CT, combined multidisciplinary team approach Telemedicine identified as evidence-based, save, effective patient management strategy for stroke emergency Rapid patient evaluation and utilization of neurology expertise when needed Implementation of stroke protocols include telemedicine technology Establishment of Telestroke quality indicator to monitor program performance and outcomes 2019

Telestroke Program Elements Key Stakeholder & Provider Buy In Gap Analysis Timeline Testing! Testing! Testing! Training Mock Tele-Stroke Alerts Go-Live Maintenance – Monitor – Outcome Reporting

Quality Management A telestroke note is documented in the patient record with every telestroke consult Initial competencies are completed for all providers include in the telestroke process Updated and annual review of the stroke alert document includes the telestroke process Quality Measure (MOS) Primary Goal: ED: Door to Telestroke: 25 min IP: RRT call to telestroke: 25 min Secondary Goals Call back time from time of initiation of contact in 10 minutes Door/Call to Needle 45 min or less Door/Call to transfer 120 min or less

Outcome Data ED 2018 Median Times (min) Onset to Arrival at NSH Door To MD Goal 10 Door To CT/Results Goal 20/35 Door to Telestroke Goal 25 Door to Needle Goal 45 Door IN Door OUT Transfers Goal 120 NSA 50 4 5/21 28 47 (51) 171 (15) NSC 94 6 12/33 27 40 (50) 170 (14) NSF 60 12/26 No data* 44 (28) 119 (23) * Started October 2018

Outcome Data IP 2018 Median Times (min) Call to RRT Arrival Goal 10 Call To MD Call to Telestroke Goal 25 Call to CT Goal 20 Call to CT results Goal 35 Call to tPA Goal 45 NSA (69) 4 44 (11)* 23 38 58(2) NSC (46) 2 37 (16) 11 27 64(3) NSF (31) 3 5(1)** 34 none *nights and WE coverage** Started October 2018 2019 new Goal: Call to Transfer 120 min

If I had a dream for telemedicine technology & stroke? Urgent Care Triage OP Follow up at home

Questions? Thank you!