1. Stroke Systems of Care A Regional Approach to Optimizing Patient Care and Outcomes

2. Agenda What and why? Regional system components Campaigns
Data Collection
QA/QI
Path forward

3. So Why a Stroke System of Care?

4. What is a Stroke System of Care?
“Stroke systems of care provide a comprehensive, diverse, longitudinal system that addresses all aspects of stroke care in an organized and coordinated manner. Characteristics of different stroke centers include, Acute Stroke Ready Hospitals, Primary Stroke Centers and Comprehensive Stroke Centers.”1
AHA/ASA Focus on: Stroke Systems of Care

5. What is a Stroke System of Care?
EMS plays a significant role in this system! Training and collaboration are imperative for success
Typically the first medical professionals with direct patient contact
Their initial assessments, actions, treatments and decisions have significant impact on patient’s subsequent care
Their role in patient triage, diversion and routing cannot be under-estimated
AHA/ASA Focus on: Stroke Systems of Care

6. Why do we need a system?
Systems minimize delays in the chain of survival
Deliver the right patient to the right place in the right amount of time
A coordinated response system for time critical conditions such as stroke and STEMI has shown to prevent mortality up to 10%1
1Source:
2Source: CDC -

7. Why do we need a system?

8. Complete systems should include all of the following components working consistently and cooperatively
Patients and the public need to be educated to recognize the signs and symptoms and to quickly call 911
Dispatch operators need to have quick procedures to recognize potential cardiac and stroke emergencies and dispatch appropriate personnel as quickly as possible
Prehospital personnel should have standard assessment, treatment, and triage procedures to appropriate hospitals
Emergency departments should also have standard assessment, treatment, and triage procedures for walk-in patients
Facilities should look for ways to reduce time to treatment by activating stroke teams based on prehospital or ER notification.
1Source:
2Source: CDC -

9. Why do we need a system?
Why integrate Stroke and STEMI? Arkansas compared to US Average (Age-adjusted death rates per 100,000), 2014
Arkansas
United States
Acute Myocardial Infarction (AMI)
rank #1
(Approx.2500 AMI deaths/year)
32.4
Stroke
rank #5
(Approx Stroke deaths/year)
36.2
Source: Centers for Disease Control and Prevention. CDC Wonder.

10. The Need for Speed Every second 32,000 brain cells die
Every minute 2 million brain cells die
For every hour, up to 200 million brain cells die and the brain ages 4 years!

11. The Need for Speed
Acute ischemic stroke accounts for 6.5 million deaths per year, and by will result in the annual loss of over 200 million disability- adjusted life years globally.
Ain A Neuhaus, Yvonne Couch, Gina Hadley, Alastair M Buchan; Neuroprotection in stroke: the importance of collaboration and reproducibility, Brain, Volume 140, Issue 8, 1 August 2017, Pages 2079–2092, 

12. The Right Patient The Right Place The Right Time The Right Care
Why do we need a system?
The Right Patient
The Right Place
The Right Time
The Right Care

13. 9-County Pilot Program (2016-2017)
Compared the pilot data to baseline data (N=222 confirmed stroke patients during August 2015 – July 2016)
Only 49.7% arrived via EMS, rest by private transport or other means.
EMS pre-notification of a suspected stroke increased from 38% to 69.2%
Time to treatment (IV t-PA by 2 hours, and treat by 3 hours) improved by 21%.
EMS pre-notification was nearly doubled in the pilot study and was associated with improved Door to t-PA time compared to private transports (p=0.026).

14. 9-County Pilot Program (2016-2017)

15. Regional Systems of Care
Ensure that all stroke patients are rapidly identified, transported, or transferred in a timely fashion to a hospital that provides the most appropriate level of care for the particular clinical situation
(1) Ensure effective collaboration
(2) Promote standardized approach
(3) Identify performance measures
(4) Identify potential Issues/Barriers
Southwest – 1st Region

16. Components of SW Regional Approach
Community Education
According to the American Heart Association and the American Stroke Association, 50 percent of people drive themselves or have someone drive them to the hospital when heart attack and stroke symptoms are present. Nationally and locally, the average time from arrival to treatment is significantly reduced by EMS.

17. Components of SW Regional Approach
EMS
Pre-hospital stroke screen
Pre-hospital notification
Blood glucose check
Stroke banding
Last known well time documentation
Minimum patient care guidelines
Hand-off form to ED

19. Hand Off / EMS Short Form

20. Components of SW Regional Approach
Hospitals
Tiered Levels of Stroke Care
Comprehensive Stroke Center (CSC)
Dedicated neuro ICU with 24/7 staffing
Catheter angio 24/7
Able to meet concurrent needs of multiple complex stroke patients
24/7 neurointerventionalist, neurosurgeon, neurologists
Aneurysm clipping/coiling, carotid stenting, endovascular care
Primary Stroke Center (PSC)
Additional capabilities vs. ArSRHs
Stroke unit or designated beds
Neurosurgical available within 2 hours
Arkansas Stroke Ready Hospital (ArSRH)
Standards similar to The Joint Commission Acute Stroke Ready
24/7 ED coverage
Dedicated stroke coordinator
Availability of standardized acute ischemic stroke protocol
Transfer and transport protocol in place
24/7 physician availability – either on-site neurologist or telestroke coverage
24/7 CT and 27/7 laboratory availability
Participate in AR Stroke Registry

21. AR Stroke Ready Hospitals

22. Components of SW Regional Approach
Data Collection and Performance Improvement
EMS Data Registry
Arkansas Stroke Registry
Future Linkage Projects
Telemedicine stroke assessment from the field

23. Key System Measures % of stroke patients that arrive by EMS
% of patients EMS provided early hospital pre-arrival notification
Time of symptom onset aka LKWT
PSAP call receipt
Time of dispatch
Time of EMS arrival at patient’s side
Time left scene
Time arrived at hospital
FAST, ECG or other clinical findings
(Resuscitation efforts and outcomes)
Medications administered

24. Key System Measures
Those elements are important for EMS to analyze internally, but they must also be shared with the receiving hospital in order to look at some of the measures that span from EMS to the patient outcome. According to Arkansas Rules and Regulations a written report must be given to the hospital within 24 hours of patient delivery, however the short form must be delivered at time of patient transfer. We also encourage hospitals to include EMS providers on stroke QI/QA initiatives.
The handoff of patient reports to the receiving hospital are critical for the immediate care of the patient, as well as overall system evaluation and quality improvement.

25. QUALITY IMPROVEMENT
Dispatch, pre-hospital and hospital partners should work together to set goals, a streamlined care process, communication processes and ensure they are being met

26. Components of SW Regional Approach
Continuing Provider Education
EMS, physicians and nurses
In-person such as Advanced Stroke Life Support
Online Education such as APEX stroke module
Quality Assurance Webinars

27. Conclusion
It’s all about collaboration with our partners
Expand care delivery team through facilitated communication.
Deliver highly specialized care at rural bedside.
Facilitate appropriate patient transfers.
Use data to drive meaningful interventions.
Engage at-risk patients to improve health.
Reduce costs through collaboration and sustainable models for access and treatment.

28. Conclusion
Questions
Questions
Questions
Questions