Presentation on theme: "Formation and Certification of Acute Stroke Ready Hospitals in a Stroke System of Care Mark J. Alberts, MD Vice-Chair, Dept of Neurology Professor of Neurology."— Presentation transcript:
1Formation and Certification of Acute Stroke Ready Hospitals in a Stroke System of Care Mark J. Alberts, MD Vice-Chair, Dept of Neurology Professor of Neurology UT Southwestern Medical Center Dallas, TX
2Presenter Disclosure Information FINANCIAL DISCLOSURE:Speakers Bureau/Consultant: Genentech, Inc.Unpaid Consultant: The Joint Commission, HFAPUNLABELED/UNAPPROVED USES DISCLOSURE:None
3What is a Stroke System of Care? A comprehensive, diverse, longitudinal system that address all aspects of stroke care in an organized and coordinated mannerSpans the spectrum of stroke care from primary prevention, calling 9-1-1, acute care, secondary prevention, rehabilitation, return to the communityAs with any system, it is only as strong as its weakest linkThis talk will focus ASRHs, but all elements are important
4Pictorial Stroke System of Care Primary Prevention/Secondary PreventionPublic EducationCalling 911EMS elementsTransportation to hospitalStroke CentersAcute CareRehabilitationReturn to the community
5EMS Plays a Key Role in a Stroke System Is typically the first medical professionals with direct patient contactTheir initial assessments, actions, treatments, and decisions will have significant consequences in the patient’s subsequent careTheir role in patient triage, diversion, and routing cannot be under-estimated
6Medical Impact of Stroke Recent study of 91,134 patients admitted to 625 hospitals with acute stroke (all Medicare patients)Average age = 79 years58% female82% CaucasianOverall, 62% of these patients were dead or re-admitted after just 1 yearFonarow et al., Stroke, 2011
7Characteristics of Different Stroke Centers Academic Medical CenterTertiary Care facilityComprehensive Stroke CenterPrimary Stroke CenterWide range of hospitals;standard stroke care; stroke unit;use TPAAcute Stroke Ready HospitalRural hospitals; basic care;drip and ship;use tele-technologies
8Numbers of Various Types of Stroke Centers > 5000 total acute care hospitals in the U.S.Comprehensive Stroke CentertotalPrimary Stroke CenterFinal countAcute Stroke Ready HospitalPerhaps
9Acute Stroke Ready Hospitals “The New Kid on the Block” Typically small facilitiesLocated remotely away from a PSC or CSCTypically serve small cities or rural populationsStroke population small; likely 1 patient a week on averageLimited staffing and bed availabilityConcept: EMS would take patient to nearest ASRH for:1. initial diagnosis2. acute stabilization3. acute treatments4. then send patient to nearest PSC or CSC
10ASRH—State StatusMany states have developed or are developing their own definitions of ASRHThese vary greatly by state and regionTo date there is no central certifying body or organizationSome states have adopted a ‘postcard’ certification processThere is a need for uniform criteria and certification
11ASRHs and Other Hospitals ASRHs would have some type of relationship with one or more CSCs and PSCsProtocols for transfers and referralsTele-stroke link to another facilityEducational programsTransfer agreements (informal)Track transfers and outcomes
12Key Elements of a ASRH Element Comment Acute Stroke Team At least 2 members; staffed 24/7; at bedside within 15 minutesEMS and ED Care ProtocolsAnnual training and educationAble to do rapid brain imaging and lab testing45 minute turn around timeIV TPA protocol60 minute door to needle timeWritten transfer protocolsTo a CSC + PSCTelemedicine link within 20 minutesProcedures set up beforehand
13Examples of Acute Care at an ASRH Acute InterventionCommentIV TPA60 minute DTN timeReversal of coagulopathyICH and SAH patientsTreatment of increased ICPICH, SAH patientsTreatment of seizuresAll patientsBlood pressure controlVariable depending on clinical scenario
14Possible Performance Metrics at an ASRH Evaluation of stroke severityTime to first brain imagingDTN time for IV TPATime to initiation of anticoagulation reversal therapyTime to initiation of telemedicine linkTime to transfer of patient to PSC or CSCProtocol violations
15Certification Process for ASRH Formal certification is important to ensure requirements, standards, and performance are metCertification must be done by an outside, independent organizationSelf-certification is not acceptableMust include an assessment of facilities, personnel, protocols, and outcomesMust include a site visitSome information submitted on-line½ day visit every 2-3 years envisionedCosts = $5000-$7500 every 2-3 years
16Where to Locate these Hospitals?? Currently 12 PSCs in Iowa; total hospitals = 12012 PSCs cover 37% of the population31 PSCs could cover 75%if forced locationOr 54 could also cover 75%Who should direct PSC location??Need for dialogue and coordinationLeira et al., Stroke, 2012
17Stroke Care—A System (Network) Approach An increasing number of hospitals are forming care networksMaximizing the efficiency of care and resourcesCentralize some procedures and facilitiesImproving outcomes by increasing volumesSharing protocols and expertiseHave patient return to their community as soon as feasibleStroke is a particular challenge due to the emergent nature of the disease and time limitationsSimilar to trauma and trauma centers!!!
18By-passing Hospitals in a Stroke System of Care With multiple hospitals of various capabilities in a geographic area (or Stroke System), how can we properly triage and divert patients to the most appropriate facility?Guiding Principles # 1If all are close, go to the highest level Stroke Center initiallyWHY?Do not know the type of strokePatients can deteriorateUnclear what tests and treatments will be needed.
19By-passing Hospitals in a Stroke System of Care Besides the level of Stroke Center,what are other considerations for field triage?Guiding Principle # 2Time is more important than distance, because time is brainFactors to consider include:WeatherTrafficLocal geographyMode of transportation
20Other considerations—Know Your Hospitals By-passing HospitalsOther considerations—Know Your HospitalsGuiding Principle # 3To make the best decision, personnel must know theactual capabilities of their local hospitals as well as theEMS systemNot every hospital that claims to be a PSC or CSC will havethose capabilitiesEMS triage and routing skills may vary by city and regionBed availability and Who is on diversionAll politics are local!!!
21Challenges with Field Triage of Stroke Patients EMS personnel are correct with field Dx in about 50% of casesThere are assessment tools for stroke severityField Dx of ischemic vs hemorrhagic stroke still evolvingPilot studies of head CT in ambulancesPatients might still stop at local ASRH to be stabilized before going to CSC or PSCEMS is typically very fragmented and localizedChallenge to get uniform adoption of protocols
22ConclusionsASRHs offer rural access to acute Dx, Rx, and stabilization pending transfer to a PSC or CSCEMS must evolve to meet these challengesLooking to the future, the key challenges of a Stroke System of Care will relate more to EMS triage and diversionTHE GOOD NEWS……All of the problems are solvable!!!!!Good willHard workCommon sense