Minnesota Acute Stroke System Council WebEx/Teleconference Meeting April 27, 2011

Agenda 12:00 – Welcome and Introduction 12:10 – Model: Washington 12:30 – Model: Utah 12:50 – Discussion and Next Steps

Stroke Systems of Care Implementation In Development

Why Washington and Utah?

Similar in demographics and land area MinnesotaWashingtonUtah Population, 20095,266,2146,664,1952,784,572 % 65 and older % White % Bachelors degree Land area79,61066,54482,143 Persons/square mile Source: US Census Bureau, State & County QuickFacts, 2009 estimates.

Kim Kelley, Cardiac/Stroke Systems Coordinator Heart Disease and Stroke Prevention Program Washington State Department of Health Washington’s Emergency Cardiac and Stroke System

Emergency Cardiac and Stroke Care in Washington Problem: effective treatments are available--but too many people don’t get them at all or in time Only 4% strokes get t-PA Only 35 of 95 hospitals administered t-PA Estimated 39% of heart attacks get PCI Only 55% of hospitals give lytics under 30 min OHCA survival rates very low

30/60 Minute Drive Times for Primary Stroke Centers

Emergency Cardiac and Stroke Care in Washington Solution: establish statewide emergency cardiac and stroke system similar to trauma (right patient/right place/right time) to reduce time to treatment.

Emergency Cardiac and Stroke Technical Advisory Committee Hospitals Dispatch and EMS Clinicians (ED MDs, Cardiologists, Neurologists, RNs, MPDs) DOH, AHA, WSHA/RHQN, COAP, ACC

Basic System Components Public education Standardized prehospital (dispatch and EMS) procedures and protocols: rapid dispatch, FAST, 12- lead ECG, CPR, defibrillation, triage and transport, pre-arrival notification Hospital categorization/designation program System goals Data collection and QI

SSHB 2396 signed by Governor Gregoire

SSHB 2396 and the State ECS System in a Nutshell… Requires EMS to take stroke, heart attack, and CPA-ROSC patients to specified hospitals based on transport times. Built into EMS and Trauma System

Working together to make it happen Evidence/data Shared vision Patient-centered Broad stakeholder participation Champions Administrative support Strategic plans and legislation

Kim Kelley,

The Utah Stroke System Peter Taillac, MD Bureau of EMS and Preparedness Robert F. Jex, RN, MHA, FACHE Bureau of EMS and Preparedness

Objectives Describe the need for a stroke system Describe objectives of the Utah Stroke System Plan Describe the role of EMS and Emergency Departments in the plan Describe the importance of rapid recognition, triage, transport to dedicated stroke facility and intervention for stroke patients

45.7 Stroke Deaths per 100,000 population Third leading cause of death in Utah 3,256 visits/yr to hospitals with Dx Stroke Stroke care is time sensitive There is a golden 3 – 4.5 hour window for Rx Potential benefits if eligible for treatment The Utah Stroke System--Need

Utah is very rural, all primary stroke centers clustered in the urban center of the state Impossible to transport all stroke patients to urban centers Utah is the first state to adopt an inclusive approach; other systems based on by-pass Goal: improve the level of stroke care at all community EDs

Brief History of Stroke in Utah 2007-Acute Care Subcommittee of the Utah Stroke Task Force Plan for Stroke Receiving Facility Presented Criteria Developed-Stroke Tool Kit created Invitation to all Utah hospitals sent

The Hub and Spoke System  Hubs: Primary Stroke Centers  Act as referral and consultation centers to the SRFs  Joint Commission Certified  Spokes: Stroke Receiving Facilities  Utilize PSCs for consultation  Phone / Telestroke  May transfer patient, if desired  UDOH Verified

Spoke and Hub Hub Hospitals (JC Designated PSCs) – U of U – IMC – McKay-Dee – Utah Valley Regional – Ogden Regional Spoke Hospitals (State Verified SRFs) – St. Marks – Park City – Jordan Valley – Pioneer Valley – Lakeview – Timpanogos – San Juan – Dixie Regional – Alta View – American Fork – Cache Valley – Mountain View Total: 17 of 45 Utah Hospitals voluntarily participating so far

Stroke Tool Kit Stroke Receiving Facility Toolkit Utah State Stroke System

Stroke Receiving Facility Standards Voluntary system Hospitals and EMS agencies work together EMS preferentially delivers suspected stroke patients to PSCs or SRFs

Stroke Receiving Facility Standards Stroke Team available 24/7 Phone or Telestroke consultation with Primary Stroke Center available 24 hr MD and RN in ED authorized to begin stroke protocol using standard forms and protocol CT and Lab available 24/7: results in 45 minutes Thrombolytic (rt-PA) available in/to ED Stroke Coordinator and administrative support Ad

Stroke Receiving Facility Standards Site visit by UDOH team Verifies: – Stroke protocols, resources, equipment – Stroke Team organization – Physician and administration support – Process improvement, data collection, stroke education (including EMS education) If verified, local EMS agencies notified that the hospital is “stroke ready” to receive stroke patients via EMS

EMS Stroke Guidelines Goals: Ensure rapid identification of strokes and transport to appropriate Stroke Center or Stroke Receiving Facility Utilize standardized stroke scale (e.g. Cincinnati) and specific stroke treatment protocol Blood sugar determination critical Early notification of receiving hospital to allow time for Stroke Team to prepare

EMS Stroke Guidelines (con’t) EMS must determine the exact time of onset as accurately as possible (or the time the patient was last seen well) Preferentially transport to Stroke Center or Stroke Receiving Facility Time = Brain Tissue

Continuity of Stroke Care Team Approach Detection – Importance of early recognition by lay public Dispatch (9-1-1) – Obtains pertinent info; identifies urgency Delivery (EMS) – Evaluates, obtains symptom onset, minimizes on scene time; immediate transport and pre-notification to PSS or SRF as soon as possible!

Continuity of Stroke Care Team Approach Door (ED) – Pre-alerts stroke team, performs patient exam & assessment (NIH Stroke Scale), rapid CT scan Data – Reviews all pertinent patient information Decision – determines if thrombolytic therapy candidate – may utilize PSC neurologist (phone/telestroke) to assist Drug – administers treatment <60 min of arrival

The Utah Stroke System Measurement Length of stay Cost/charge per stroke patient Diagnostics/bed utilization Clinical outcomes (improvement in stroke scales after treatment) Percent of eligible patients treated with TPA Time data (door-to-needle time, door-to-CT time Complications (intracranial hemorrhage, other hemorrhage, etc.) Customer satisfaction

The Utah Stroke System Data Submission Total number of “stroke” admissions to ED – Both EMS and walk-ins Total number with Dx ischemic stroke Percent of eligible patients treated with TPA – If not treated, why not? Time data (door-to-needle time)

The Utah Stroke System Outcome Goals Provide nationally-accepted, evidence- based best practice emergency stroke care at as many community level EDs as possible Increase systematic approach to stroke care Reduce morbidity and mortality due to acute ischemic stroke Increase quality of life for stroke survivors

Questions? Thanks to: Utah Stroke Task Force Utah Hospital Association American Stroke Association Utah Stroke Advisory Committee Utah Bureau of Stroke and Heart Disease Prevention

Discussion Questions, Comments Next: Subcommittees – Around what topics should we organize? – Suggestions for process going forward?

Next Steps Comment at Respond to evaluation (to be ed) Next Meeting: May 25, 2011 Noon Contact: (651)