1. Acute Stroke Redesign: Kaiser Telestroke Update
TRILOK S. PUNIANI, MD
May 6, 2017

2. Statement of Disclosure
I do not have affiliations that may constitute a conflict of interest with this program.

3. Objectives:
Briefly discuss types of strokes
Risk factors for stroke
Primary stroke center
Telestroke: Acute Stroke Redesign

6. Test Your Knowledge
Stroke is the leading cause of disability in the US
A. True
B. False

7. Answer: A

8. Strokes are not preventable.
True
False

9. Answer: B

10. Strokes mainly effect elderly
True
False

11. Answer: B

12. Stroke is the third leading cause of death in the US.
A. True
B. False

13. Answer: B

15. What Is a Stroke ?
Stroke is a sudden loss of neurologic function resulting from focal disturbance of cerebral blood flow due to ischemia or hemorrhage.

16. Stroke
Stroke was the third leading cause of death after heart disease and cancer. In 2008, it dropped to the fourth leading cause of death. Currently, stroke is the fifth leading cause of death.
Stroke is a leading cause of disability in the United States.
Improved care and stroke risk reduction measures by the primary care providers, public and health care professional education
Acute interventions and multi-disciplinary care, GWTG, substantially improved the outcome for stroke patients.

24. What are the risk factors for Stroke?
There are two types of risk factors:
Non-modifiable (factors you cannot control)
Modifiable (factors you can control)

25. Non-modifiable Risk Factors For Stroke
Age
Gender
Race / ethnicity
Heredity
Prior stroke / TIA
Effect on Stroke Incidence
Doubles per decade over age 55
24%-30% greater in men
2.4 fold increase in African-Americans
2 fold increase in Hispanics
Increased among Chinese
1.9 fold increase among first degree relatives
Increased risk

27. Modifiable Risk Factors
About 90% of stroke risk may be explained by TEN major risk factors:
Cardiac causes
Hypertension
Diabetes mellitus
Diet
Hyperlipidemia
Cigarette smoking
Abdominal obesity
Physical inactivity / sedentary behavior
Excess alcohol consumption
Psychosocial stress and depression

29. What is Stroke certification
Recognition (i.e. Certification) by Joint Commission as a facility which provides stroke care for patients across the continuum who have suffered from TIA or stroke.

30. Benefits of Primary Stroke Centers
Improved efficiency of patient care
Fewer peri-stroke complications
Increased use of acute stroke therapies
Reduced morbidity and mortality
Improved long-term outcomes
Reduced costs to healthcare system
Increased patient satisfaction

31. Major Elements of a Primary Stroke Center
Patient Care Areas 1. Acute stroke teams 2. Written care protocols (GWTG) 3. Emergency medical services 4. Emergency department 5. Stroke Unit 6. Neurosurgical services 7. Radiology services 8. Laboratory services

32. Stroke (STK) Core Measure Set
STK-1: VTE Prophylaxis
STK-2: Discharged on Antithrombotic Therapy
STK-3: Anticoagulation Therapy for Atrial Fibrillation / Flutter
STK-4: Thrombolytic Therapy
STK-5: Antithrombotic Therapy By End of Hospital Day 2
STK-6: Discharged on Statin Medication
STK-8: Stroke Education
STK-10: Assessment for Rehabilitation

33. Stroke Patient Work Flow
Stroke Alert Team
Radiology
Pharmacy
Call
Stroke Alert
Emergency
Department
In-Patient
Units
Operator
Activates
Laboratory
Processes Activated

34. Proven Strategies in Acute Ischemic Stroke Therapy
Reperfusion
Prevent Clot Propagation / Recanalization
Supportive Care
Early Implementation of Secondary Stroke Prevention

35. REPERFUSION THERAPY
Thrombolytic therapy is able to recanalize acute intracranial arterial occlusions.
A strong correlation has been shown between arterial recanalization and neurological improvement in acute cerebral ischemia.

36. The vision of thrombolysis for reversal of acute ischemic stroke (AIS) was launched in 1958, but it was not until 1995 that 2 landmark studies, one in Europe and the other in the United States, established IV administration of tissue plasminogen activator (tPA) as an effective treatment for AIS

37. Thrombolytic Therapy
In June 1996, the FDA approved the use of IV recombinant tissue type plasminogen activator (rtPA) for ischemic stroke within 3 hours of symptom onset.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group showed that treatment with IV tPA within 3 hours of onset of ischemic stroke improved clinical outcome.

39. The Basic Concept
TIME IS BRAIN

41. Time is brain 2 million nerve cells die per minute
For every 15 minutes faster time:
More patients go home
Fewer die
Fewer bleed
More are independent at discharge
JAMA. 2013;309(23): doi: /jama
Stroke.2006; 37: 

43. The two most important concepts for recovery - Penumbra
Stroke Recovery
The two most important concepts for recovery
- Penumbra
- Time is Brain Concept

44. Ischemic Penumbra Penumbra: Latin pene “almost” + umbra “shadow”
Zone of tissue around an infarct (ischemic core) which receives some collateral circulation
Potentially salvageable if blood flow is restored

46. We know that Time is Brain, Time lost is Brain lost……
The challenge is….
How to reduce door to needle (DTN) time < 60 minutes
Obtain very rapid CTH with interpretation
Treat and evaluate

50. Telestroke
This is one of the most rapidly expanding and successful application of telemedicine, delivery much needed stroke expertise to hospitals and patients
The number of telestroke networks continue to grow in the US and throughout the world.
Quality measures, operational protocols, order sets, policies and procedures are established by an agreement between the hub and spoke

51. February 2015 (ISC) Prior to ISC 2015 Acute Stroke Redesign TODAY
No proven role for endovascular therapy (it was a rare treatment option)
February 2015 (ISC)
4 studies with proof of superiority of endovascular therapy for large vessel occlusions post IV tPA
TODAY
Endovascular therapy is the standard of care!
Rapid evaluation – CTA for most if not all strokes
Rapid treatment with IV t-PA then rapid transfer for endovascular therapy

53. Comparison of RCTs for EST vs. Standard of Care
Now there is a 5th trial REVASCAT (206 patients. Similar outcomes. NNT= 6.3) showing effectiveness of EST
6 Hours
Anterior Circ
alteplase vs. alteplase+EST
Small Core (Perfusion → ASPECTS)
100% alteplase
Standard vs. Standard + EST
No core or collateral assessment
87% alteplase
12 Hours
Anterior Circ
Standard vs. Standard + EST
Small Core (ASPECTS)
Good collaterals
73% alteplase
6 Hours
Alteplase vs. alteplase+EST
Small Core (CTP)
100% alteplase

55. Achieve 20-30 minutes door to needle (DTN) times?
What would it take to…
Achieve minutes door to needle (DTN) times?
Obtain very rapid CTH / CTA performance and interpretation
Treat, evaluate, and transfer for endovascular therapy in less than 45 minutes?

56. The world has changed

57. KP STROKE EXPRESS
(EXpediting the PRocess of
Evaluating and Stopping
Stroke)

58. The key to speed…
Key components = early involvement of stroke neurologist
Don’t room – straight to CT
Order TPA before CT
TPA in CT
Problem: small volumes cannot justify in house stroke neurologist
Solution: video consultation + redesigned process

59. KP Stroke EXPRESS EXpediting the PRocess of Evaluating & Stopping Stroke

60. Acute Stroke Redesign:
Stroke Neurologists involved early in the workflow via video (7AM – MIDNIGHT)

62. Neurology Telestroke Hub
Centralized hub of specialized stroke neurologists working remotely 7AM to Midnight to examine all potential stroke patients early in the workflow via CISCO video carts

63. Call to Neurologist via central 800 number - neurologist activates tele-presence unit
Clinical assessment and exam by stroke neurologist by video
Clinical assessment by ED physician
IV access
Lab
Blood sugar testing
INR if on warfarin or unknown

64. Step One:
Rapid assessment
on arrival with video

67. Inclusion Criteria for IV alteplase
Diagnosis of acute ischemic stroke
LKWT (last known well time) is < 3 hours and in some cases < 4.5 hours from start of IV alteplase
Over 18 years of age
7 .

68. Discussion of t-PA / CTA risks, benefits, alternatives
IV t-PA ordered as soon as possible (allows time for mixing)
Call on / off stroke alert based on clinical assessment
Checklist / time out before leaving for CT

69. Direct to CT scanner - Once tPA is determined appropriate in the ambulance bay or triage area the patient will go directly to the CT scanner

71. tPA in CT scanner - IV tPA will be delivered and pushed in the CT suite directly after the CT is completed

72. CTA completed directly after CT or tPA - CTA completed on nearly all stroke patients

73. KP STROKE EXPRESS
Telestroke neurologist plays an active role in establishing diagnosis of stroke, ensuring inclusion/exclusion criteria for alteplase /endovascular Rx, obtaining consent, ordering alteplase, initiating administration of alteplase, and discussing with the neurointerventional radiologist whether endovascular Rx is appropriate.

77. All Facilities First two weeks 2015 Median = 54 minutes,
36 cases per month
First two weeks 2016
Median = 35 minutes,
42% < 30 minutes
76 cases per month

78. t-PA Cases:
Jan –Dec 2012: 13 Jan – Dec Jan- Dec Jan- Dec Jan- Dec

81. STROKES ARE PREVENTABLE