1. Telestroke & the Management of the Acute Stroke Patient: What you need to know. Alexandra Marine and General Hospital, Goderich Ontario October 19 and October 28, 2010

2. Welcome Introductions Housekeeping Participant Pkgs Flipchart and sticky notes ACKNOWLEDGEMENTs Thank you Kelly Lumley Leger, Regional Education Coordinator, Champlain

3. Learning Objectives for the day At the end of this program you, the nurse will be: Able to recognize S&S of a stroke Able to manage the hyper-acute and stroke patient using best practices in stroke care Able to successfully perform and communicate the findings of the NIHSS Understand the overall intent of the policy and procedures for a “acute stroke code” in AMGH Community Hospital Knowledgeable about the benefits of telestroke

4. In order to do this you will be utilizing the Hyper acute Learning Plan

5. Agenda Morning: Overview of Telestroke Management of Acute Stroke Basic Neuroanatomy Stroke management Telestroke at AMGH, protocols, orders Afternoon: Concurrent Sessions: NIHSS/ Practice tPA Skills practice Scenarios Wrap Up: Additional Questions, Follow-up, Resources

6. Overview of Telestroke

7. The Burden of Stroke 3 rd leading cause of mortality Major cause of disability Goal of acute stroke therapy: Reduce disability

8. Ontario Stroke System Vision “Fewer strokes. Better outcomes.”

9. Health Promotion Risk Factor Management Pre-hospital Acute care Rehabilitation Community Re-integration Ontario Stroke System Secondary Prevention TELESTROKE THE STROKE SURVIVOR

10. Background Telestroke began in North Bay in 2002 Between July 2002 and October 2010, 1581 consults were provided to Ontario stroke patients by telestroke physicians. Over 479 patients have received tPA (~30%) as a result of a telestroke consult Average 40 telestroke calls/month over 13 sites Update stats

11. What is telestroke? Telestroke is an emergency telemedicine application It allows for the assessment & treatment of patients experiencing acute ischemic stroke via a consult with a remote neurologist. Referring telestroke sites are those that don’t have an on-site neurologist but do have a CT scanner, telemedicine network infrastructure, telemedicine equipment and protocols. Consulting sites are where participating neurologists can review the results of a patient’s CT scan electronically & “see” a patient at a remote site using live video.

12. Who is currently involved? 13 referring sites Brantford, Dryden, Fort Frances, Kenora, New Liskeard, Niagara, North Bay, Oshawa, Pembroke, Peterborough, Sault Ste. Marie, Sudbury, Timmins 10 provincial consulting neurologists Toronto, Thunder Bay, Barrie, Hamilton, Niagara Update

13. Who is joining the program? 6 new referring sites in 2010/11: Ajax Belleville Cornwall Goderich Hawkesbury Scarborough Update

14. The telestroke program… Provides a 24/7 emergency service that receives 24/7 technical support from OTN for telemedicine equipment; Uses CritiCall to contact a telestroke neurologist using a single on-call system; Provides equipment and supports neurologists in their homes for 24/7 coverage; Supports discussions between referring and consulting physicians the regarding delivery of tPA; Makes CT imaging available to the neurologist; and provides access to neurologists for 24-hour follow-up, if required.

15. Technology & Support Videoconferencing units – in ER depts (Tandberg Interns), desk top home based units for neurologists CT image access eFilm workstations at referring hospitals (CT scanner configured to push images to eFilm), eFilm accessed from home PCs 24/7 OTN service desk to support videoconferencing & eFilm access

17. Brainsave video Insert video clip (short segment)

18. Time is Brain THETREATMENTWINDOW for thrombolytic therapy is 4.5 hours 4.5 hours

19. Time is Brain: Diminishing Returns over Time TIMENNT <1.5 hrs3-4 3 hrs10 4.5 hrs15 ECASS study N Eng J Med 2008;359:1317-29 Benefit for tPA No Benefit for tPA

20. Telestroke & Acute Ischemic Stroke Management  Make an accurate and rapid diagnosis  Reduce the size of the infarct  Avoid secondary complications  Prevent recurrent strokes  Educate and Rehabilitate

21. OcclusionRecanalization

22. Telestroke in Ontario New provincial system 1000 th patient through telestroke in Ontario between July 2002 and August 2009, over 1100 consults were provided to Ontario stroke patients over 300 patients have received tPA (approx. 30%) as a result of a Telestroke consult currently averaging 40 Telestroke calls/month Update stats

23. Provincial Program 8 Referring Sites Lake of the Woods (Kenora) North Bay General Pembroke Regional Hospital Peterborough Regional Health Centre Sault Area Hospital Sudbury Regional Hospital Timmins District Hospital Lakeridge Health Corporation (Oshawa,) 7 Consulting Sites Baycrest Geriatric HCS Sunnybrook HSC University Health Network Thunder Bay Regional HSC Huntsville District Memorial Hamilton HSC The Ottawa Hospital Update

24. Who is joining? 7 additional referring sites by Dec 31, 2009: Cornwall Community Hospital Dryden Regional Health Centre Laverendrye Hospital (Fort Frances) Rouge Valley Health System o Ajax-Pickering site o Scarborough Centenary site Quinte Health Care Corporation o Belleville General site Temiskaming (New Liskeard) Update

25. Telestroke in AMGH: An Overview ED physicians lead the process in the ED (referring site) Neurologist will link in by videoconferencing and make the decision for tPA (consulting site) Nurse facilitates the process, assesses & manages the patient on an ongoing basis Internist/MRP will manage the patient post ED

26. Local Benefits of Telestroke ED is able to provide the community with the potential for thrombolysis where they would otherwise not make the time window. Earlier treatment = increased potential for saving more brain tissue and function… Opportunity to implement stroke best practices for all stroke patients.

27. That is where you come in! Success is based on rapid and accurate implementation of the whole process!

28. So let’s say a person has a stroke at McDonalds …. Let’s discuss what you think would happen based on what you know right now…. o …without telestroke program in Goderich (status quo) o …with telestroke program in Goderich (a couple months from now)

29. Roadmap: Scenario A Jim arrives through emerg, within 4.5hr window Receives CT Scan and is eligible for tPA Transferred to ICU post tPA (2 days) Dec 6 th 0200hrs Dec 6 th 0230 Dec 6 th 0500Dec 8th Transferred to the medical floor, full recovery, no deficits

30. Roadmap: Scenario B Jim admitted to Emerg, last seen normal time was at bedtime, not a candidate for tPA Receives CT scan, NIHSS: Admitted to ICU, concerns re neurological and respiratory status monitoring Transferred to medicine Dec 6 th 0200 Dec 6 th 0300Dec 6 th 0230Dec 7th

31. Roadmap: Scenario C Nurse makes her rounds at 0200hrs and Jim is awake playing solitaire. He engages in a conversation with the nurse and suddenly his speech becomes garbled. RN calls a Code Stroke Patient assessed NIHSS. Patient routed to CT scanner. CT shows no hemorrhage. Pt is a candidate for tPA Patient admitted to Emerg, assessed and receives tPA Patient transferred to ICU Dec 3 rd 0200hrs Dec 3 rd 0230 Dec 3 rd : 0240 Dec 3 rd 0340 Transferred to medicine. Speech improved Dec 4 th 1600hrs

32. Importance of Communication to Success Between EMS and the ED Nurses within the ED Nursing and Physician within the ED Referring site and consulting site CritiCall, referring site and consulting site ED, Lab, CT, Portering, Critical Care, Patient Registration Health Care Professionals, Patient and Family ED Physician and Internist Using Videoconferencing, telephone, face to face, written

33. Questions so far?