(Florence Nightingale 1859) Our Journey “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”. (Florence Nightingale 1859)

Meet Teddy

Thrombolysis Each minute saved in delay to treatment with thrombolysis = 4.2 days health life days gained. Each 20 mins reduction in delay = an extra 3 months disability free life gained. Typical MCA infarct, 2 million nerve cells, 7.5 myelinated fibres and 14 billion synapses die every minute. (Does depend on collateral circulation, and neuron numbers lost can vary hugely). With thrombectomy we save brain/lives/money. Thrombectomy x1 (unofficially) 2014 x5 March-June 2017 x8 September alone 2017 - Teddy arrives! x 69 2018 (and 100 TK) ?? x100 2019

Steep learning curve post quake 2011 PMH (Just me - needing another stroke nurse as service split between sites) 2013 CPH? Stroke Unit disestablished as no room at CPH. So with the patient numbers (& tPA nos) increasing, I need more stroke nurses to cover tPA 24/7 and educate outliers. 2017 Teddy arrived back from Melbourne and livened up the service with speed, enthusiasm for research projects and making us the “Republic of Canterbury” changing to TK plus the advent of clot retrievals. 2018 100 tPA, 69 clot retrievals and the TK revolution 2019/2020 New facility with vascular surgery (on the 8th level !)

I needed minions!

6 neurologists share ward based roster or acute and clinics roster. ASU 4 rotating consultants do 4 months each All ‘code stroke’ patients come to Wd24 and compete with 3 medical teams for the 27 beds. Difficult to keep an empty bed for tPA calls.

Tenecteplase (TK) Is another modified human t-PA Prepared by recombinant technology Is more fibrin specific and longer duration than Alteplase/Actilyse Has a half–life of more than 30 mins (terminal phase takes 90-120 mins for the plasma concentration to fall by 50%). So can take 4-6 hours to eliminate. Excreted by the liver (Alteplase renally excreted). Can be administered as a single IV bolus

Clot retrieval One third of patients go home, often next day

Since the age of Teddy: We now average 48 ‘code strokes’ and 29 CTs per month (that’s 60% get an acute CT scan). (Nov 2018 we had 60 ‘code stroke’ calls). In 2018 135 ‘code strokes’ had an intervention tPA and clot retrieval, tPA alone or clot retrieval alone. That would be a 38% treatment rate of those undergoing acute CTs all hours. Frequently we get groups of tPA or ‘code stroke’ calls. If more than 3- 4, we have trouble accommodating them and resourcing them as ‘specials’. On 7/3/19 we had 5 calls: 2 clot retrievals, I ICB, 1 functional, and a mystery Ozzie man with L)hemi/reduced LOC and a clear perfusion scan (turned out to be Todd’s Paresis after all invests were done).

Data collection record Sticker and date with DOB and NHI Stroke onset time: Patient’s arrival time in E.D. (from ED front sheet not admission to ward green sheet): Pre notification to stroke RN: CT scan time: (as recorded on actual scan or CT stamp in notes): Tenecteplase given time: Any complications: If not for tenecteplase why not? On Dabigatran? (If so was it reversed with Idarucizumab/Praxbind?) Clot retrieval? Yes No NIHSS RN name

Teddy’s vision: Clot retrieval for most SI? – Only our DHB currently. Telestroke rolling out slowly. The expense! The problem: Getting patients back to their own areas for rehab. as soon as possible? Getting other DHBs to pay? NOT happening just yet!

Telestroke Video-conferencing with direction/responsibility from a neurologist. ‘Skype’ setting. Brings expertise to those less experienced clinicians, especially in regional hospitals or out of hours. Neurologists see the X-ray images on I-Pads, and the regional hospitals have mobile trolley units. 2016 successful pilot in Central Region for 6 months, with 164 patients assessed and 51 thrombolysed within the 4.5 hour window. Was supposedly rolling out in S.I. this year. Most units delivered after Teddy toured and checked capabilities in S.I. DHBs/hospitals. (it was very quiet in ASU for a week…) Now rug has been pulled.

New upcoming trials: 1 Having TK up til 4.5 hours after a ‘wake up stroke’. 2 Administration daily of an ‘insulin substitute’ and an inserted/carried device with constant, remote BSL monitoring. 3 Tranexamic acid in ICBs. ---------------------- Still involved with EXTEND IA and TASTE trials. --------------------------------- According to a reliable source, 40% increase in stroke is predicted in the baby boomer generation. Watch this space. -----------------------------------------------