1 Improving Stroke Care in NEBRASKA Improving Stroke Care in NEBRASKA Nebraska Department of Health and Human Services Nebraska Cardiovascular Health Program and Nebraska Department of Health and Human Services Nebraska Cardiovascular Health Program and

2 The mission of the Nebraska Stroke Advisory Council (NSAC) is to raise awareness of stroke, promote stroke prevention, and improve systems of stroke care throughout Nebraska

3 Continually assess the needs and assets of stroke care in Nebraska and create action plans to improve systems based on evidence. Identify barriers and issues related to stroke care in Nebraska, especially among priority populations. Promote and advocate health policy recommendations regarding stroke care in Nebraska. Purpose of the NSAC

Advantages of Developing Stroke Readiness Best stroke care made available to community Improved stroke expert support available Plan for transfers in place if appropriate/needed Improved reimbursement for stroke patients 4

5 Stroke Chain of Survival and Recovery FASTFAST

6 Treatment of Acute stroke with tPA Intravenous recombinant tissue plasminogen activator (rtPA) Patients who are eligible for treatment with rtPA within 3 hours of onset of stroke should be treated as recommended in the 2007 ASA/AHA guidelines 1. A recent prospective study, the European Cooperative Acute Stroke study (ECASS)-3, has provided new data on rtPA (alteplase) treatment in the 3-to-4.5– hour window. rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). Intravenous recombinant tissue plasminogen activator (rtPA) Patients who are eligible for treatment with rtPA within 3 hours of onset of stroke should be treated as recommended in the 2007 ASA/AHA guidelines 1. A recent prospective study, the European Cooperative Acute Stroke study (ECASS)-3, has provided new data on rtPA (alteplase) treatment in the 3-to-4.5– hour window. rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). Expansion of Time Window for Treatment of Acute Ischemic Stroke. Stroke. 2009;40: Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655–1711.

Adjusted Odds of a Favorable 3 Month Outcome by Time From Stroke Onset to Start of Treatment (OTT) N=3670 Lees et al, Lancet :9727: ECASS, ATLANTIS, NINDS, EPITHET OR 2.55 OR 1.64 OR 1.34 OR 1.22

IV TPA Symptomatic Hemorrhage Rate = 6% NINDS t-PA Stroke Study Group, Stroke 1997 NIHSS Symptomatic Hemorrhage

9 NINDS Time Goals for Stroke

Barriers to tPA Use Medical and Fiscal Lack of experience in tPA use Hemorrhagic complications associated with tPA Use Treatment of stroke mimics with tPA Expiration of tPA resulting in financial loss to hospital due to low volume Stroke neurology expertise available Net benefit of tPA in spite of hemorrhage risk Very low risk of hemorrhage in non stroke Expired tPA replaced by Manufacturer 10

Barriers to tPA Use Medical-Legal Fear of litigation Concerns that tPA is not of net benefit Likelihood of litigation much higher with non- treatment Treatment with tPA for acute ischemic stroke is the standard of care in patients who meet inclusion and exclusion criteria 11

Risk / Benefit and Medicolegal Issues Medicolegal issues are reported as a barrier to administration of tPA Administration of tPA is the standard of care for treatment of acute ischemic stroke in patients meeting inclusion and exclusion criteria The primary claim relevant to tPA use was the failure to provide tPA rather than the adverse events associated with its use A good estimate is that IV - tPA for stroke will cause meaningful clinical deterioration in ~1% of patients Neurology (11)

Hospital Medicare Reimbursement Stroke Acute Ischemic Stroke –with tPA and Major Complications and $17,100 Co-Morbidities –Complications and Co-Morbidities $11,300 –Without Complications or Co-Morbidities $8,900 Intracranial Hemorrhage –Major Complications or Co-Morbidities $10,700 –Complications or Co-Morbidities $6,800 –Without Complications $4,800 13

14 Stroke Levels of Care Stroke Level Designation by the NSAC Working Group

15 All Nebraska hospitals should have a written plan for treatment and/or triage of stroke patients available to health care providers, EMS and the public. All hospitals should have a plan for access to expertise at a Primary Stroke Center or a Comprehensive Stroke Center Proposal for Stroke Centers Designation by the NSAC Working Group

16 Level 1 Comprehensive Stroke Center Level 2 Primary Stroke Center Level 3 Advanced Stroke Capable Hospital Level 4 Basic Stroke Capable Hospital Proposal for Stroke Centers Designation by the NSAC Working Group

17 All Criteria for Primary Stroke Center Plus: Personnel with Expertise in Vascular Neurology, Neurosurgery, Neuro-radiology, Critical Care Specialists, Advanced Practice Nurses, Rehabilitation Specialists including Physical, Occupational, and Speech Therapy Advanced Diagnostic Techniques including MRI, MRA, MRP, CT/CTA/CTP, Cerebral Angiography, and TEE Capability to Administer Intravenous and Intra-arterial Alteplase Level 1 Comprehensive Stroke Center

18 All Criteria for Primary Stroke Center Plus: Capability to Perform Carotid Endarterectomy/Stenting, Intracranial Angioplasty/Stenting, Aneurysm Clipping/Coiling, Endovascular Ablation of AVM’s Supporting Infrastructure including 24/7 Operating Room, Interventional Neuro-radiology, and Neuro-Critical Care Support Stroke Registry Educational and Research Programs Utilize telemedicine network Level 1 Comprehensive Stroke Center

19 24/7 Stroke Team Availability Written Care Protocols Transfer Agreement with a hospital capable providing a higher level of care ED Personnel Trained in Stroke Care Capability to Administer Intravenous Alteplase Dedicated Stroke Unit Neurosurgery Available within 2 Hours Physician Medical Director with Expertise in the Treatment of Stroke Level 2 Primary Stroke Center (JC Certified)

20 Hospital Administration Commitment and Support for Excellence in Stroke Care Neuro-imaging and Lab Services Available 24/7 Outcomes and Quality Improvement Process Continuing Stroke Medical Education for ED and Team Members Provide Public and Professional Educational Programs in the Community and EMS Written protocol for receiving stroke patients transferred from other facilities Utilize telemedicine network Level 2 Primary Stroke Center (JC Certified)

21 Acute stroke team available 24/7 Written care protocols Emergency medical services integration Staffed Emergency department 24/7 Commitment and support of medical organization including a medical director Neuro-imaging and Laboratory services available 24/7 Level 3 Advanced Stroke Capable Hospital

22 Outcome and quality improvement activities that includes tracking of all patients seen with acute stroke and appropriate use of thrombolytic therapy with collection of relevant verifiable performance measures May not have all the non-acute care capabilities required of Primary Stroke Centers Encouraged to pursue formal PSC certification Must have a transfer plan to a Comprehensive/Primary Stroke Center as deemed appropriate. Utilize telemedicine Level 3 Advanced Stroke Capable Hospital

23 Defined Plan for Immediate Transfer to a Level 1, 2 or 3 Stroke Center May Admit Non-Alteplase Eligible and Non-Acute Stroke Patients Immediate consultation with Neurologist for possible transfer to a higher level stroke center recommended Defined plan for immediate transfer EMS Agreements for Services Hospital Administration Support ED Personnel with Training in Acute Stroke Care, NIHSS Employed in Initial Acute Stroke Evaluation, Promote Professional and Public Stroke Education in the Community, Level 4 Basic Stroke Capable Hospital

24 Outcomes and Quality Improvement Process Continuing education hours defined for stroke team members. 6 hours of stroke continuing education on a bi- annual basis for stroke team members. Definition of stroke team: must include a Director (physician or mid-level provider) and a Stroke Coordinator (RN or LPN). The Director and Coordinator can be the same person, but it is recommended the stroke team consist of at least 2 people. Utilize Telemedicine network Level 4 Basic Stroke Capable Hospital

25 Any facility that is unable to provide the appropriate level of care should initiate immediate rapid ground or air transport to an appropriate hospital for suspected acute stroke patients. These rules apply to patients who arrive by private car or by EMS when acute stroke was not suspected at dispatch or in the field. Treatment with tPA is the Standard of Care in patients who meet inclusion and exclusion criteria Non-Acute Stroke Care Capable Hospital

26 Stroke Network Transfer to Most Appropriate Facility Level 1 CSC Level 3 or 4Level 2 PSC

27 Improving Stroke Care in NEBRASKA Improving Stroke Care in NEBRASKA Thank You for your interest in

References Adams HP et. al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655–1711. Liang, B., Lew, R., & Zivin, J. Review of tissue plasminogen acitvator, ischemic stroke, and potential legal issues. Neurology (11) Lees et al, Lancet :9727: Nebraska Vital Records 2008 Nebraska BRFSS 2008 Nebraska Hospital Discharge Data 2008 Taylor et al, Stroke 1996 Roger et al, Circulation 2011 Jones et al, Assessment of Acute Stroke Treatment in Nebraska Hospitals Study, NHHS 2006 Stroke-Unit Care for Acute Stroke Patients Lancet 2007:369: Schwamm et al, Recommendations for the Establishment of Stroke Systems of Care Stroke. 2005;36: Del Zeppo et al. Expansion of Time Window for Treatment of Acute Ischemic Stroke with Intravenous Tissue Plasminogen Activator, Stroke Alberts et al., Recommendations for Establishment of Primary Stroke Centers, JAMA 2000: 283 (23)

NSAC Membership Committee Members 2012 NSAC Chair Denise Gorski, The Nebraska Medical Center 2012 NSAC Steering Committee James Bobenhouse, M.D. - Neurology Associates PC Karen Bowlin - NE EMS Association Cherie Boxberger - American Heart Association Jose Cardenas, MD, Neurology Associates of Great Plains Tam Christen - Bryan LGH – StarCare Teresa Cochran - Nebraska PT Association Dean Cole - NDHHS – EMS Scott Crawford - Omaha Fire and Rescue Janet Dooley - CIMRO of Nebraska Jill Duis - Jefferson Comm. Health Center & Stroke Survivor Pierre Fayad, M.D. - UNMC Dale Gibbs - Nebraska Telehealth Network/Good Samaritan Hospital Maria Hines - Minority Health Mary Ellen Hook – Bryan LGH Katherine Jones – UNMC Brian Krannawitter - American Heart Association Beth Malina - St. Elizabeth Regional Medical Center Mitch Marsh – St. Elizabeth Regional Medical Center Marcia Matthies – NE State Stroke Association Rita Parris - Public Health Association of Nebraska Joann Schaefer, M.D. - NDHHS – Chief Medical Officer Francis Sparby, St. Francis Medical Center Bill Thorell, M.D. – UNMC Thaddeus Woods, M.D. - Critical Care Associates 2012 NSAC Ad Hoc Members P.J. Richards - Genentech, Inc. NSAC Staff Support: NDHHS – Cardiovascular Health Program Staff Jamie Hahn - Program Manager - (402) Kari Majors - Heart Disease & Stroke Prevention Coordinator - (402) David DeVries - Health Surveillance Specialist - (402) Verify Members