INTRODUCTION TO THE STROKE PROGRAM

Objectives: Familiarize with the Stony Brook Stroke Program Discuss emergency assessment and expected time targets for acute stroke patient Verbalize location of Stroke Program’s guidelines, protocols and references Verbalize stroke core measures and quality measures per Joint Commission and New York State Department of Health

Stroke STATISTIC Stroke is a leading cause of serious long-term disability in the US. Approximately 3% of males and 2% of females reported that they were disabled because of stroke Stroke is the No.3 cause of death in the United States, >140,000 people die/year Each year, approximately 795,000 people suffer a stroke. About 600,000 of these are first attacks, and 185,000 are recurrent attacks. On average, every 40 seconds, someone in the United States has a stroke http://www.strokecenter.org/patients/about-stroke/stroke-statistics/ American Heart Association Heart Disease and Stroke Statistics - 2019 At-a-glance

Transient Ischemic Attack (TIA) TYPES of Cases reportable to Joint commission and New York STATE Transient Ischemic Attack (TIA) Brief episodes of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction

STROKE PROGRAM Certifications Awards Designated New York State Stroke Center Joint Commission Comprehensive Stroke Center Awards AHA/ASA Get-With-The-Guidelines Stroke Gold Plus and Target:Stroke Honor Roll award for administration of IV tPA in 60 minutes or less for at least 50% of eligible patients Healthgrades 2019 - one of America's 100 Best Hospitals for Stroke Care

STROKE PROGRAM Stroke interventions available: IV tPA administration – within 0-3 hours and 3-4.5 hours treatment window for eligible patients Mechanical Thrombectomy – up to 24 hours of last known normal for eligible patients Aneurysm and AVM treatment Carotid disease interventions Multiple on-going clinical trial for stroke including but not limited to: Minimally invasive evacuation of intracerebral hemorrhage (MIND Trial) Hydrogen and minocycline stroke study (H2M) Confidence trial for carotid stent

Stroke Program Accepts transfer of stroke patients from surrounding hospitals Cerebrovascular Center 2 Mobile Stroke Units Neuro Critical Care Unit Stroke Service Stroke Program Coordinator Stroke Program Navigator Stroke Quality/Data Specialist Physical Therapy Occupational Therapy Speech Therapy Social Work Case Manager Stroke Support Group – 2 meetings monthly Community outreach programs for stroke education/blood pressure screening

Stroke Practice Guidelines and Protocols Stroke Program Stroke Practice Guidelines and Protocols Accessible through the Stony Brook Medicine Intranet under Quick Links: Stroke – Code BAT Contains the Clinical Practice Guidelines and Protocols that the program follows in the assessment and management of stroke patients Contains stroke-related compliance data for core measures and quality measures Contains links to website for cerebrovascular-related CMEs and articles

NEW time target recommendations from AHA/ASA Target Stroke Initiative: Acute Stroke Assessment Current target response times: * Refer to IV tPA (Alteplase) Eligibility Criteria, Criteria for Endovascular Intervention NEW time target recommendations from AHA/ASA Target Stroke Initiative: Door to IV tPA administration: 45 minutes Door to Revascularization for Mechanical Thrombectomy: within 60 minutes for patients transferred from an outside hospital OR 90 minutes for patients presenting directly Patient needs to be evaluated immediately if with acute signs and symptoms of stroke and have CT Head completed faster than 25 minutes Door to revascularization for Mechanical Thrombectomy: <120 minutes

Stroke Program CODE BAT (Brain Attack Team) – mobilizes the Stroke Team to bedside for emergent assessment of a patient with acute stroke symptoms Code BAT is called for patients with last known well within 6 hours as per New York State recommendation “Code BAT CT Head” is ordered STAT to rule-out ICH If indicated, a STAT “Code BAT CT Angiogram Head/ Neck” is ordered to evaluate vessels. CT Perfusion study will be ordered if needed to evaluate perfusion mismatch for patients with large vessel occlusion Only the assessment of blood glucose level precede the administration of IV tPA (rt-PA) unless there is a suspicion of abnormal hematologic or coagulation test. Refer to PC0078 Code BAT Brain Attack Team for Acute Stroke Adult and Pediatric Refer to Code BAT Emergency Department Process Flow Refer to Code BAT Inpatient Units Process Flow Refer to ED Stroke Process Flow

Stroke Program Future Plan- Implementation of Code CSI (Complex Stroke Intervention) to expedite assessment and treatment of complex stroke patients presenting to the Emergency Department

PRIMARY STROKE CoRE MEASURES STK-1 VTE prophylaxis on the day of or the day after hospital admission. STK-2 Antithrombotic therapy at hospital discharge. STK-3 Anticoagulation for Atrial fibrillation/flutter at hospital discharge. LIPs must be mindful of the specific time period of the core measures for compliance. Reason(s) must be documented in the medical record why elements of the core measures were not implemented for the patient. STK-4 IV t-PA initiated at this hospital within 3 hours of time last known well. STK-5 Antithrombotic therapy by the end of hospital day 2. STK-6 Statin medication at hospital discharge. STK-8 Patient and/or caregiver stroke education: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, personal risk factors for stroke, and warning signs and symptoms of stroke. STK-10 Rehabilitation services assessment

Comprehensive Stroke Core measures CSTK 01 – NIH Stroke Scale score performed for Ischemic Stroke patients CSTK 02 - Modified Rankin Score at 90 Days CSTK 03a - Severity Measurement Performed : Hunt and Hess Scale performed for SAH CSTK 03b – Severity Measurement Performed: ICH Score performed for ICH patients CSTK 04 - Procoagulant Reversal Agent Initiation for ICH patients CSTK 05a - Hemorrhagic Transformation for IV t-PA patients CSTK 05b - Hemorrhagic Transformation for IA t-PA and/or Mechanical Endovascular Reperfusion Therapy patients CSTK 06 - Nimodipine Treatment Administered CSTK 07 - Median Time to Revascularization CSTK 08 - Thrombolysis in Cerebral Infarction (TICI) post-treatment reperfusion grade CSTK 09 - Arrival Time to Skin Puncture CSTK 10 - Modified Rankin Score at 90 Days: Favorable Outcome CSTK 11 - Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher CSTK 12 - Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

Quality Measures AHA/ASA Quality Measures - Dysphagia Screen before being given any food, fluids, or medication by mouth RN or LIP completes bedside swallow evaluation using the Yale Swallow Protocol If indicated, formal swallow evaluation by Speech Therapist For patients who failed swallow evaluation: Order Aspirin per rectum or place NGT for patients who need Plavix or Brilinta - Documented Lipid profile - Intensive Statin Therapy Use (Lipitor ≥ 40mg, Crestor ≥ 20mg) Additional New York State requirements - Documentation of NIH Stroke Scale on discharge - Annual 8 hours of cerebrovascular-related continuing education for Physicians, NP/PAs and RNs taking care of stroke patients

Stroke Program Stroke Quality/Oversight Meetings: Cerebrovascular Conference – every 1st and 2nd Wednesday of the month, case-based discussion. Offers 1.0 CME credit. Stroke QA/Peer Review – every 3rd Wednesday of the month, stroke case reviews and discussion. Offers 1.0 CME credit. Code BAT meeting – every second Tuesday of the month at 3PM. Attended by EMS, ED, Stroke/Neurology, CVC/Neurosurgery, Radiology, Pharmacy, Neuroscience Administration.

For questions, contact: THANK YOU ! For questions, contact: Anne Froehlich, Stroke Program Coordinator: anne.froehlich@stonybrookmedicine.edu Marret Anderson, Stroke Program Navigator: marret.anderson@stonybrookmedicine.edu Josephine George, Stroke Data Specialist: josephine.george@stonybrookmedicine.edu Antonieta Rosenberg, Stroke Service NP: antonieta.rosenberg@stonybrookmedicine.edu