The Mid America Brain and Stroke Institute Kansas City, Missouri M A B S I

Self-Organization and Emergence: A Complexity Science Foundation for the Saint Luke’s Hospital Stroke Center Marilyn M. Rymer, MD Plexus Institute Conference December 7, 8, 2004

SAINT LUKES HOSPITAL of KANSAS CITY Stroke Center opened 1993

Stroke Facts Third leading cause of death 750,000 new strokes per year-one every 47 seconds in the U.S. African Americans are twice as likely to experience or die from a stroke as white Americans Leading cause of adult disability Leading cause for admission to nursing homes $50 billion/year in direct and indirect costs

Eight years after FDA approval of tPA (clot buster) for acute stroke, only 2-3% of stroke victims in the US are receiving treatment. WHY??

… an EXtremely short amount of time to achieve the best outcome for victims of stroke Stroke 0 hour 3 hours National Stroke Reversal Treatment Rate = 2% Clinton Mo. Emergency Department Doc One Transfer Team

CASE STUDY 28 year old female developed abrupt onset of complete right sided weakness and inability to speak at 0730 in St. Joseph, Mo - 90 miles from Kansas City. No significant past medical history. Husband called 911 Transport to local hospital by 0800

Case History (continued) Patient is triaged as an emergency ED physician makes the diagnosis of stroke even though the patient’s age is atypical. Neurologist called in MRI/MRA showed no hemorrhage, early injury and L MCA occlusion (90 minutes after onset).

MRI HeadMRA Head Baseline Imaging L MCA occlusion

Case History (continued) Neurologist calls Saint Luke’s Hospital Stroke Team (available 24/7) Patient receives initial dose of IV tPA (0.6 mgm/kgm 15% bolus, the rest over 30 min.) Helicopter transfer to Kansas City is arranged (IV tPA completed in flight)

The Life Flight Helicopter??

Case History (continued) Patient arrives in Kansas City at 1030 (3 hours after onset of stroke) Neurologist meets the helicopter Neuro-interventional radiology team ready in the angiography suite (bi-plane digital angiography equipment available).

Cerebral Arteriography Before treatment L MCA occlusion still present

The Merci Clot Retriever (MERCI) Trial US Sites: Phase I (April ’02) –Saint Luke’s, Kansas City –UCLA –UCSan Francisco –Columbia/Cornell –Emory

Cerebral Arteriography After treatment Complete recanalization of L MCA

Patient is moving and speaking normally 8 hours after completion of the intra-arterial thrombolysis Note: Patient had large PFO/ASA - paradoxical embolus was the likely mechanism

Working as a Regional Network 73.2% (268/366) of MABSI interventional stroke cases were referred from outlying hospitals 51.9% of the cases received IV tPA in the hospital before transfer to Saint Luke’s Secrets of success –Accept all transfers with one call –Speak directly to family to confirm time of onset and outline treatment options. Get cell phone # if available. –Get to know the ED physicians and nurses and share protocols, paths, orders, etc. –Provide outcome information

Map of some of the hospitals referring patients for acute stroke intervention within 150 miles of Saint Luke’s: 47 in 2004.

Arrived at SLH first Trans- ferred in

Acute Stroke Intervention Rate 18% 19% 28% 21% 31% 52/28861/31679/30880/38769/222 YTDN= IV tPA IV –IA tPA IAtPA Device alone Device + tPA 28% National Average = 2-3%

John Kelly’s story in Newsweek

Six weeks post procedure with Dr.Grobelny – interventional neuro- radiologist

SAINT LUKES HOSPITAL of KANSAS CITY How does a community hospital without a neurology teaching program do this?

The Lens of Complexity

A “Good Enough” Vision The goal of the Saint Luke’s Hospital Stroke Program is to decrease the incidence of and morbidity from stroke in Kansas City and the surrounding region. Clinicians buy in when it is REALLY about patients and not about competition or market share.

Our Complex Adaptive Systems The Stroke Team The Regional Network Public Relations for the Stroke Center All of these are constantly changing and self- organizing. They are very dependent on generative relationships and are always listening for “noise.”

Whose in the Regional Network? S G (Shotgun) Jackson Deepwater, MO Norman Sapp, Fireman Andrew McMahon, EMT Sal Simone, EMT Life Flight Crew SLH Stroke Team

47 hospitals referred patients for stroke intervention so far in are in the KC metro area, 34 are in the surrounding 150 mile radius. They range in size from 30 beds to 460 beds. There has been no formal effort to organize this network.

Who’s on the Stroke Team?

Listening to “noise” CHUNKING

Strokes that occur in the hospitals are often difficult to recognize and treat quickly.

Stroke Watch Action Team SWAT Program Stroke team will provide timely consultation and evaluation for all patients within the institution who demonstrate a change in neurological status.

Heirarchy is gone! A culture has changed for good