1. Broward EMS Stroke Coalition Brijesh P Mehta, M.D. NeuroInterventional Surgeon Director, Stroke & Neurocritical Care Memorial Neuroscience Institute

2. Positive Large Vessel Stroke Trials 2015 2 MR CLEAN P<0.05 REVASCAT P<0.05 ESCAPE P<0.001 SWIFT PRIME P<0.001 EXTEND-IA P<0.01 THERAPY NS Endo- vascular 33%44% 53%60%71%38% Control 19%28% 29%36%40%30% Good Outcome (%) Rankin 0-2 at 90 days

3. Better studies Faster times Careful selection Innovative devices Improved Outcome Renewed Focus on Work Flow

4. Stroke Care in Broward County 8 Comprehensive Stroke Centers (CSCs) Absence of a quality improvement oversight committee EMS triage criteria based soley on distance and not on quality of care at destination No transparency among CSCs for door-to-treatment times and clinical outcomes Lack of research or QI collaboration among CSCs 4

5. Broward CSCs Broward General Broward Health North Holycross Hospital Florida Medical Center Memorial Regional Memorial West Westside Medical Center Aventura Medical Center 5

6. Broward EMS Stroke Coalition 6

7. BESC Mission Improve the delivery of stroke care in Broward County – Standardized EMS and in-hospital protocols – Evidence-based medicine – Transparency among CSCs Achieve best outcomes possible for our patients 7

8. Support of Local and National Groups American Stroke Association Broward Stroke Council Fire Chief’s Association GBEMBDA 8

9. SNIS Workflow Metrics 9

10. Individual Time Points – ER arrival – CT start (scout image) – IV tPA – Groin puncture – Device deployment (first pass) – Final reperfusion Key Intervals Door-to-Reperfusion 90 min – Door-to-Picture <15 min – Picture-to-Puncture <45 min – Puncture-to-Reperfusion <30 min Outcomes – Initial NIHSS score – Discharge NIHSS score – 90-day mRS 10 BESC Proposed Metrics

11. CSC Survey Questions Workflow and evaluation Metrics, Data Collection Hospital Designation, Volume Personnel Resources Outcomes 11

12. Aggregate BESC Survey Results HCA not participating in survey Cleveland Clinic a PSC – impact on EMS triage criteria Only couple of hospitals have high volumes - i.e., >50 EMS stroke alerts per quarter Not all hospitals have pre-hospital EMS alert protocols 12

13. Aggregate BESC Survey Results IV tPA door-to-needle times are improving Significant variability/delays in door-to-puncture times for strokes with Large Vessel Occlusions Some hospitals have multiple NI cross covering Few hospitals have no policies for NI response time Most hospitals do not have a neurointensivist 13

14. Impact of EMS Alerts Pre-alerts reduce time to treatment RACE score 5 or higher has high probability for LVO Encourage all stroke centers to initiate RACE training 14

15. Next Steps Finalize data collection variables this month at next BESC meeting on June 8 Encourage all CSCs to participate in FL-PR stroke registry Initiate data collection via UM-Sacco collaboration July 1 Collect blinded data for 6 months and give hospitals opportunity to improve EMS and in-hospital stroke processes January 2017 – CSC data will be unblinded, allowing EMS to make informed triage decisions 15

16. Contact Information Brijesh P Mehta, MD NeuroInterventional Surgeon Director, Stroke & Neurocritical Care Memorial Neuroscience Institute 617-775-5204 brmehta@mhs.net 16

17. Thank You