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

Agenda What and why? Regional system components Path forward

What is a Stroke System of Care? A comprehensive, diverse, longitudinal system that addresses all aspects of stroke care in an organized and coordinated manner. 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

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: http://www.heart.org/HEARTORG/Professional/MissionLifelineHomePage/EMS/Recommendations-for-Criteria-for-STEMI-Systems-of-Care_UCM_312070_Article.jsp#.WkyygsKWx9A 2Source: CDC - https://www.cdc.gov/dhdsp/programs/about_pcnasp.htm

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) 75.4 rank #1 (Approx.2500 AMI deaths/year) 32.4 Stroke 47.6 rank #5 (Approx. 1500 Stroke deaths/year) 36.2 Source: Centers for Disease Control and Prevention. CDC Wonder. http://wonder.cdc.gov/controller/datarequest/D76

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

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!

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).

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

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.

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

Hand Off / EMS Short Form

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

AR Stroke Ready Hospitals

Components of SW Regional Approach Data Collection and Performance Improvement EMS Data Registry Arkansas Stroke Registry Future Linkage Projects

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

Path Forward Opening Stroke Designation Statewide – If not yet applied, go to ADH website https://www.healthy.arkansas.gov/programs-services/topics/stroke and email completed application to Dr. Tammie Marshall (Tammie.Marshall@arkansas.gov) and David Vrudny (David.Vrudny@Arkansas.gov) Stroke Registry Participation – If not yet participating in AR Stroke Registry, contact David Vrudny for details on possible grant support to cover cost of Get With The Guidelines-Stroke Patient Management Tool license

AR Time Critical Diagnosis System Trauma Trauma Stroke Community EMS Hospitals STEMI Questions?