1 Implementing pathway for Neuro-intervention in Hyper acute Stroke for Clinical and Research Dr. Indira NatarajanConsultant Stroke PhysicianClinical Lead for Acute Stroke TIA ServicesUniversity Hospital of North StaffordshireClinical Lead for Stroke – Heart and Stroke NetworkShrosphire and Staffordshire1
2 UK National Stroke Strategy DH National Stroke Strategy 2007, page 32.There may be a role for interventional neuroradiology in the management of basilar thrombosis.Patients should have access to a stroke service with neuro-interventional capacity.A network approach may be required to develop an agreed protocol, so that each stroke unit is linked to a regional neurosciences centre for emergency review of local brain imaging- for example by electronic link- and emergency transport (and then repatriation) of appropriate patients.Strategic Health Authorities, through specialised commissioningarrangements, to support the co-ordination of the availability of specialist neuro-intensivist care including interventional neuroradiology and neurosurgery expertise….
3 BASP CS viewsThere is a need for RCTs of endovascular treatments and UK stroke services should recruit patients to such trials once they are open.Endovascular treatments should not be offered routinely until evidence from RCTs is availableUntil such evidence is available treatment should be on a case by case basis guided by agreed treatment and referral pathwaysEVT should only be given in centres with agreed pathways and protocols including A&E, the stroke service, neuro-interventionalist, ITU and speciality nursesParticipation in national register/ International registersCentres participating in RCTs will have to have experience in the procedure before enrolling patients.
4 UHNS Acute Stroke Unit (ASU) 2001 to 2010 Outcome/Results Integrated working 32 Beds24 Beds39 Beds
5 Where are we?LocationIn relation to neighbours, borders and other Network areas. Type of population and size5
9 Until 2010 No clear Neuro- interventional pathway
10 First encounter…….. December 2009 75 year old gentleman Recent cervical spine surgery 4 months agoAdmitted with collapse and found unconsciousGCS 4/15Intubated and ventilatedNo reversible pathologyAtrial fibrillationCT brain Normal study
12 Basilar occlusion on CTA Discussion with Orthopaedic Surgeon/ Neuro- radiologistAgreed for Intravenous and intra-arterialAnaesthetist arrangedWhole episode was chaoticSince no clear pathway - theatre team difficult to co- ordinateODA had to be pulled off from Neuro-surgical theatreSignificant amount of time lost from arrival of patient to A and E and before procedure commenced
16 The Team Interventional Neurorradiologist 1 Radigrapher 1 Nurse Stroke PhysicianAnaesthetist / ODA
17 Agreed patient group… Age<75 Previously fit and well Working hours (out of hours if interventional neuroradiologist available)
18 Teams that we engaged Radiology / Neuroradiology Anaesthetics/ ITU NeurosurgeryEmergency Medicine
19 Radiology protocol Yellow sheet for Stroke patients CT brain and CT angiogram as agreed protocolCT head scan£ Order a non-contrast CT head immediately after arrival (urgent e.g. within 1 hour) for all strokes.[label form ACUTE STROKE call 4042 (daytime) or on call radiologist (nights, weekends and holidays)].Thrombolysis candidates and patients on warfarin must be scanned immediately (within 15 min)£ Order a CT angiogram (arch to Circle of Willis) if <75 y and no contraindications to contrast andwithin < 8 h of onset and no haemorrhage and no signs of established infarction on the CT head scan.
20 Neuro-radiologist / Stroke Physician alerted when CT angiogram findings which suggests need for IA interventionCarotid T occlusion (intracranial carotid bifurcation occlusion with involvement of A1 and M1 segments)M1 (trunk of the MCA) or M2 (MCA branch in Sylvian fissure) occlusionVertebro- basilar thrombosis
21 To get a Standard Operation Pathway agreed for Stroke as E 1 Emergency theatres prioritisation codesE1 Immediate transfer to theatreE2 Within 6 hoursE3 Within 12 hoursE4 Urgent, but timing not critical
22 Potential indications for EVT Primary intra-arterial thrombolysisSevere disabling neurological deficit andContraindications to iv thrombolysis (e.g. recent surgery), 3-6 h from symptom onsetIntravenous/ Intra-arterial /EVTLarge vessel occlusion in MCABrain stem strokeTreatment can be delivered within 9 h of symptom onset andOcclusion of basilar artery documented on 4-vessel angiographyEligible even if consciousness impaired and or patient ventilated
23 Key paperworks…… Consent Sheets form 1 / form 4 Patient information sheetTheatre check listIA logNursing pathway for Intervention
24 Time CT angioIV alteplase givenY / NTime of IV alteplase bolusConsent/assent signedTime of last micturition (offer bottle & conveen)Arrival time in cathlabAnaesthesiaGA / LAStart time of GA/LATime of femoral puncture = start of procedureStart time catheter angioCatheter used for angioIA lysis doneCatheter used for IA lysisTime of IA catheter at clotTime first dose of IA tPATime last dose of IA tPATotal dose of IA tPATotal dose of IV & IA tPAMechanical ThrombectomyDevice used for MTStat time of MTNo of attempts of MTTime of clot captureTime of final catheter angio = end of procedureTime of post procedure CT (after final angio)Time out of cathlabArrival time in stroke unit
25 Suitable patient Potential patient for IAT/MT identified Fit for GA/ thrombectomyPreviously independentNIHSS>=10 or basilar artery thrombusNo bleed or sub acute infarct on CT headCTA shows large vessel occlusion (ICA/M1/M2/ VA/BA/ PCA)
26 Lysis ProtocolStart iv lysis while waiting for theatre. Give 0.6 mg /kg alteplase (bolus and infusion) iv unless iv lysis is contraindicated (recent surgery, post-partum). Leave 0.3mg/kg (max 30 mg) for i.a. lysis.Do CT head immediately post procedure and after 24 h.Stay with patient until awake and settled on stroke unit.Ensure patients is monitored according to the IAT nurse pathway.
27 Pathway in action….Keep next of kin on site for consent /queries or establish contact route Clinician (stroke physician / A&E doctor) to get an anaesthetist STAT: neuro-anaesthetist, if possible, otherwise on call: contact via switch Clinician (Stroke physician / A&E doctor) to inform ODA Out of hours Arrange for an anaesthetist – go to online services / rota watch / on call anaesthetist – bleep 3rd on call Radiologist to get radiographer and scrub nurse for the procedure. Set up operating trolley and equipment immediately.Inform Stroke Unit for arranging a bed – Stroke team
28 Prepare the patient (A&E staff/ stroke team/ neurointerventionalist) Discuss procedureComplete consent formComplete theatre checklist (inside the consent form)Put patient into a theatre gownOffer bottle or catheterizePut in IA line (in A&E or theatre)Transfer to neuro-interventnional theatre
29 Prepare for intervention Start the intra-arterial intervention logTheatre team to move patient onto the intervention tableTheatre team to cover patient with sterile sheetsAnaesthetist and ODA to commence local/ general anaesthesiaNeuroradiologist or scrub nurse to clean/ disinfect groin.
30 During / After Intervention Complete intra-arterial intervention logRemove catheter/ intra-arterial lineLiaise with ASU to alert team about patient transferGet a bed tracked to the intervention suite to transfer patient to ASUPatients who were ventilated before the procedure may need ITU/MIU.
31 Regional referral protocols…. Devised protocols through our Heart and Stroke Network for regional DGH’sClear pathway for in hours and out of hoursDrip and Ship with escortWe have accepted patients outside our region on occasions
32 Barriers…..TrustCommissioningCostingGetting all the teams together
33 Media – Not a good idea Pioneering stroke drugs saved Patient Tuesday, February 09, 2010Pioneering stroke drugs saved PatientThis is StaffordshireFATHER-OF-FOUR owes his life to being at the right place atthe right time after suffering a massive stroke.The attack was severe enough to give him just a 20 per cent chance of surviving.
34 Costings…… Consumables overall £ 1600 Device cost ranges roughly around £ 4000( prices can be negotiated depending upon trusts)Average use of devices is around 1.5 (from our experience of 50 cases)Out of hours theatre staff cost £ 500Overall rough cost estimate is around £ 6100
35 Cost for Post Stroke Care Hospital CareBasic bed day in Stroke unit: £ 170 /dayWith added costs : £ 350/ dayPatients with mRs 4 and 5 average LoS: 90 daysCost for 90 days: £ 31,500Social / Residential care:mRS 5 : £550 / week ( £ 28,600/ year)mRS 4: £ £ 450 /week ( £ 20,800 - £ 23,400/year)mRs 3: ( if care required) : £ 300/week ( £ 15,600/year)
36 Funding Primary Care Trust 2 NHS 2 Stroke Network 1 Stroke Fund 1 Intervention Fund 1Neuroscience Department 1Geriatric Medicine 1Under discussion 1
37 HRG CodingPercutaneous trans-luminal embolectomy / thrombectomy of artery:L 712HRG - QZ15 A - Major complication with co- morbidities £ 9554HRG – Q Z15B – Minor complications £ 5098HRG – QZ15 C – No complications £3731On top for Alteplase: you get another 800£
38 Challenges 24/ 7 Sustainability Reliant on key individuals Job Plan Integrated pathway agreement with other centresNeed to demonstrate quality before taking part in Research trials
39 Centres in the UK> 1 per month5 – 10 / 10 months
40 Frequency of endovascular treatments for acute ischaemic stroke in active centres in 2010 Number of centres41-4(1 every 3 mo or less)85-9(one every other month)5>=106
41 Capacity, organisation, and quality control ( Nationally) 23 active centres71 interventional Neuroradiologists in the UK in 201046% of centres not providing EVT had no procedures for referral to centres providing such treatments.56% of centres providing EVT entered patients into the SITS register56% of centres providing EVT entered patients into the SINAP
42 Type of ApproachThrombolysis pathwayNeuro-interventional pathway
43 In Summary Newer interventions needs newer pathway Part of expansion of Neurosciences UnitsPart of the Clinical Research activityOne needs to start somewhere………………..
44 Resources http://www.stroke-in-stoke.info/ You can look at our: PathwayPatient Information leafletProcedure logNurse pathwayProtocolsData entry file – We are happy to support data
45 Acknowledgements…. Prof Christine Roffe Dr. Sanjeev Nayak All the Neuro-interventional team / Anaesthetic team/ ITU team / Stroke team/ Exec Board