1. Provider Support System Development NINDS Stroke Symposium “Improving the Chain of Recovery for Acute Stroke in Your Community” December 10-11, 2002Arlington, VA PAS

2. NINDS Symposium 2002: Provider Support Systems Task Force Task Force Members Sidney Starkman, MD –Task Force Chair Phillip A. Scott, MD –Co-chair John Choi, MD Brian F. Connolly, MD Karen L. Furie, MD J. Stephen Huff, MD Walter N. Kernan, MD Marian LaMonte, MD Dennis Landis, MD Steven R. Levine, MD David B. Matchar, MD Brett C. Meyer, MD Debra G. Perina, MD Jeffrey L. Saver, MD Lee H. Schwamm, MD

3. NINDS Symposium 2002: Provider Support Systems Task Force Support Systems: Definition “The organization of human and material resources necessary to solve a clinical problem” Artificially imposed limits of first 24 hours of care

4. NINDS Symposium 2002: Provider Support Systems Task Force Why Develop Support Systems? Effective in improving medical care in other delivery systems –Trauma –AMI –Cancer Core Belief: Every health care delivery system providing care for patients with acute stroke has a responsibility to develop and implement plans for meeting the requirements of each phase of stroke care.

5. NINDS Symposium 2002: Provider Support Systems Task Force ACEP Policy Statement “There is insufficient evidence at this time to endorse the use of intravenous tPA in clinical practice when systems are not in place to ensure that … the NINDS guidelines for tPA use in acute stroke are followed. Therefore, the decision [for tPA use] should begin at the institutional level with commitments from administration, the ED, neurology, neurosurgery, radiology and laboratory services to ensure that the systems necessary for the safe use of tPA are in place ”

6. NINDS Symposium 2002: Provider Support Systems Task Force Specific Challenges for Support Systems Stroke is a clinical diagnosis Majority of patients present to ED without immediate access to “stroke expert” In-hospital barriers to stroke care Barriers exist for both fibrinolytic therapy and non-fibrinolytic stroke management

7. NINDS Symposium 2002: Provider Support Systems Task Force Areas for Support Systems Development Pre-hospital care Hospital-based care –Diagnosis Radiologic / Imaging Access & Expertise Stroke Diagnostic Expertise –Management Systems Implementation and Evaluation

8. NINDS Symposium 2002: Provider Support Systems Task Force EMS Training & Diagnostic Support Education on signs / symptoms of stroke EMS stroke identification instruments –Cincinnati Pre-hospital Stroke Scale –LAPSS –Consideration to others in development Guidelines / Policy and Procedures –Early contact with receiving hospital for patients with possible stroke

9. NINDS Symposium 2002: Provider Support Systems Task Force Pre-Hospital Management Support Guidelines / Policy and Procedures –IV access –Glucose assessment –BP management avoidance –Avoidance of unnecessary glucose –Early notification

10. NINDS Symposium 2002: Provider Support Systems Task Force EMS Transfer Support Systems Increased importance of early care –Transport without delay –To closest appropriate facility Pre-established EMS agreement –Hospitals –ED –EMS –Medical Director Aeromedical teams

11. NINDS Symposium 2002: Provider Support Systems Task Force Hospital Diagnostic Support ED triage stroke identification tools Pre-defined access to local expertise –Neurology –Neurosurgery –Radiology Remote Diagnostic Support

12. Hospital Diagnostic Support: Teleradiology and Teleconsultation Support Systems

13. Remote Image Review: Compressed DICOM images in a browser- based viewer on a PC ED Teleradiology ImagesSubacute Follow-up

14. NINDS Symposium 2002: Provider Support Systems Task Force Potential Teleconsultation Support Benefits: Improving diagnostic accuracy Facilitating delivery of t-PA in identified acute strokes Identifying patients for enrollment into acute treatment studies Improving non-thrombolytic acute stroke care

15. NINDS Symposium 2002: Provider Support Systems Task Force Technology Issues Bandwidth, Security, Reliability Image quality and transmission Data capture and review Multimedia integration Decision support Medical documentation Continuous quality assessment

16. . Tertiary Care Center Community Emergency Room PROVIDER SUPPORT NETWORK: Acute Stroke Location- Independent Stroke Consultant

17. Management Decision Support

18. NINDS Symposium 2002: Provider Support Systems Task Force Local Decision Support Options Protocol development –Paper-based, PDA, Web based tools –Thrombolytic treatment –Complications –Non-thrombolytic stroke management Access to responsive “in-house” specialty consultation –Standard consultation arrangements Development of “Code Stroke” teams

19. NINDS Symposium 2002: Provider Support Systems Task Force Remote Decision Support Options For sites without consistent specialty consultation Identified in advance Access to regional stroke centers –standard telephone consult –Telemedicine –“Commando” systems

20. NINDS Symposium 2002: Provider Support Systems Task Force Hospital Transfer Protocol Support Existence of clear transfer protocols Pre-established contact with referral centers Avoidance of EMTALA violations –transfer of medical records –Radiographic studies –Pre-packaged transfer forms

21. NINDS Symposium 2002: Provider Support Systems Task Force Clinical Trial Access Encourage participation in regional clinical trial networks Access to listing of active studies and their inclusion/exclusion criteria Ideally, clinical trial consideration should be integrated into clinical management algorithms

22. Implementation & System Evaluation

23. NINDS Symposium 2002: Provider Support Systems Task Force Delivery System Analysis/Implementation Focus groups with broad representation Checklists for resource availability Patient simulations “Mock Code Stroke” –Multiple stroke types –Variety of scenarios External review

24. NINDS Symposium 2002: Provider Support Systems Task Force Educational Programs CME Use of “code stroke” drills Email Academic Stroke detailing New-hire training Integration into Procedures and Policies

25. NINDS Symposium 2002: Provider Support Systems Task Force Credentialing as a Support Tool Staff –New-hire –Recurrent process Institutional –Demonstration of resources –External review –Stroke center level

26. NINDS Symposium 2002: Provider Support Systems Task Force Establishing Effectiveness Conformance to acute treatment guidelines, care pathways Performance evaluations –Door to CT –Door to tPA –Mock codes Registries

27. NINDS Symposium 2002: Provider Support Systems Task Force Summary Numerous support systems and tools exist Enhance the chain of survival Provided from resources at multiple levels to assist diagnosis, management and delivery system evaluation –Pre-hospital –Local hospital based –Remote based (hospital or elsewhere) Advance selection of needed elements is crucial

28. NINDS Symposium 2002: Provider Support Systems Task Force Comments and Questions