Creating and Sustaining the Greater Cincinnati / Northern Kentucky Stroke Team Edward C. Jauch, MD MS FACEP Assistant Professor Department of Emergency Medicine and Faculty, Greater Cincinnati / Northern Kentucky Stroke Team

GC/NK Stroke Team History Originated in 1982 as a collaboration between the Departments of Neurology and Emergency Medicine Original goal was to “Maximize stroke patient outcome by delivering evidenced-based effective, efficient and safe stroke care throughout pre-hospital and acute hospitalization to all stroke patients in the Tri-state region.” (Judy Spilker)

Greater Cincinnati / Northern Kentucky Stroke Team A Community Resource = From the very beginning it was designed not to be solely a University based system, rather involve all Tri-state hospitals as a regional resource.

GC/NK Hospital Network Research Network 15 Hospitals 1 University 3 Teaching 11 Community Also provides acute stroke phone consultation and referral for 20 regional hospitals

GC/NK Stroke Team Elements Acute treatment physicians Nurse coordinators Neurosurgeons and neuroradiologists Clinical fellows in neurology and emergency medicine Biostatistics / Grant support staff Basic science researchers EMS personnel Because the team was also founded founded to facilitate research and training, members of the team not only include the expected acute treatment elements but also key personnel who support the research efforts.

GC/NK Stroke Team Personnel Roles Physicians Provide acute stroke care Develop clinical research Interface with hospital medical staff Nurse coordinators Treatment infrastructure at each hospital Site study coordination Data collection / patient follow-up Stroke care delivery quality assurance MD – Local MD staff includes discussions with PMD in individual cases, establishing practice guidelines (TNI), CME programs, etc RN – Infrastructure includes local stroke pathways and study materials/drug at each hospital. Local RN’s often hired for research, facilitating investment by hospital into system and developing local champion.

GC/NK Stroke Team Physicians Neurology Joe Broderick, MD (Director) Daniel Woo, MD Brett Kissela, MD Dawn Kleindorfer, MD Alex Schneider, MD Dan Kanter, MD Emergency Medicine Art Pancioli, MD Edward Jauch, MD MS Interventional Neuroradiology Tom Tomsick, MD Mary Gaskill-Shipley, MD Neurosurgery Mario Zuccarello, MD Andrew Ringer, MD Current Fellows Peter Panagos, MD Additional interventional neuroradiology also available at two other hospitals to provide backup

GC/NK Nurse Coordinators Judy Spilker, RN Laura Sauerbeck, RN Rosie Miller, RN Janice Carrozzella, RN Kathy Alwell, RN Irene Ewing, RN Ann Geers, RN Diane Oberschmidt, RN Colleen Reynolds, RN Pam Schmit, RN Theo Nodler, RN Diana Goins, RN

GC/NK Stroke Team Mechanics Single pager number for entire team Stroke Team members respond to the local hospital Stroke Team physician responsible for initial treatment decisions Treated patients admitted to local hospital in conjunction with primary care physician Patient care assumed by PCP after first 24 hours Redundancy in the system Backup available and helpful in training setting with decentralized system

GC/NK Communication Tools Call 844-7686 TIME IS BRAIN ACUTE STROKE TEAM CONTACTS Joseph Broderick, MD Office: 558-2957 Pager: 691-0764 Cell: 919-5404 Home: 891-3532 Daniel Kanter, MD Office: 558-5043 Pager: 249-8738 Cell: 919-5403 Home: 792-0051 Art Pancioli, MD (Emer Med) Office: 558-8103 Pager: 577-0994 Cell: 604-4436 Home: 754-1064 Tom Tomsick, MD (Neurorad) Office: 584-0607 Pager: 269-4478 Cell: 520-0139 Home: 561-2115 Janice Carrozzella, RN Office: 558-4789 Pager: 589-5502 Cell: 604-3561 Home: 352-0847 Brett Kissela, MD Office: 558-5445 Pager: 249-7168 Cell: 678-8180 Home: 793-6553 Andy Ringer, MD (NeuroSurg) Office: 558-1290 Pager/Cell: 256-7444 Admin Asst: 475-8662 (Karen) Daniel Woo, MD Office: 558-2705 Pager: 249-3112 Cell: 509 2214 Home: 794-1822 Mary Gaskill-Shipley, MD (Neurorad) Office: 584-0605 Pager: 269-4354 Cell: none Dawn Kleindorfer, MD Office: 558-5328 Pager: 691-1002 Cell: 919-5407 Home: 793-4362 Alex Schneider, MD Office: 558-1480 Pager: 554-5315 Cell: 859-322-1742 Home: 731-0360 Mario Zuccarello, MD (Neurosurg) Office: 558-5387 Pager: 269-2344 Cell: Admin Asst: 475-8624 (Janine) Ed Jauch, MD (Emer Med) Office: 558-0474 Pager: 590-3191 Cell: 604-4434 Home: 936-9332 Pete Panagos, MD (Emer Med) Office: 558-0106 Pager: 230-9465 Cell: 503-3743 Home: 871-9047 Judy Spilker, RN (Emer Med) Office: 558-5430 Pager: 249-0517 Cell: 604-4438 Home: 385-6652   Similar for RN’s and interventional neuroradiology

GC/NK Tenets Follow the 3 A’s Provide feedback to entire “Chain” Affable Available Able Provide feedback to entire “Chain” Feedback is through two systems – Weekly stroke team meetings with entire team and open to all Letters, calls, CME with regional EMS, ER staff, and PCP

Regional Hospital Responsibilities Maintain “Chain of Recovery”, pathways Emergency Nursing Identification of stroke symptoms Emergent triage Assess patient, coordinate care, administer drugs Emergency Physicians Assess and verify onset time Initial medical management Contact Stroke Team early Example of hospital role: tPA not RPA in PIXUS, CT availability, floor care

Additional GC/NK Roles Education: Public and EMS stroke education Community physician education Patient Care: Care pathways and protocols for hospitals National promotion of improved stroke care Research: Clinical trials Epidemiology Basic science

Benefits of GC/NK System Clinical The patient gets expertise in stroke care and exposure to latest stroke therapies The local E.D. physician gets help The local hospital gets to keep the patient, unless they cannot provide necessary service Local neurologists get a consult without taking call in the middle of the night

Benefits of GC/NK System Research Patient population of 1.5 million people Multiple sites for multiple projects Representative population for epidemiologic research Integrated system for both ischemic and hemorrhagic stroke Training Large system allows for excellent fellow training

Limitations of GC/NK System Clinical Variability in post-stroke treatment Labor intensive and not supported by reimbursement Unique due to competition in health care systems Removes community physicians (emergency medicine and neurology) and residents from initial treatment process

Limitations of GC/NK System Research In-servicing multiple sites Duplication of paperwork (IRB, informed consents, pharmacy, etc) Need for larger amounts of study drug or additional medical devices Transportation of clinical specimens Expanding treatment window confuse hospitals

“When the end of the world comes, I want to be in Cincinnati because it's always twenty years behind the times." Functional neurologic deficit influenced as much by location as by infarct size.