1. Edward P. Sloan, MD, MPH, FACEP Stroke Patient Care in the Prehospital and ED Settings: Should EMS Triage & Inter-hospital Transfer Occur?

2. Edward P. Sloan, MD, MPH FACEP 4 th EuSEM Congress Crete, Greece October 5-7, 2006

3. Edward P. Sloan, MD, MPH FACEP Edward P. Sloan, MD, MPH FACEP Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

4. Edward P. Sloan, MD, MPH FACEP Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL

5. Edward P. Sloan, MD, MPH FACEP Disclosures NovoNordisk, King Pharmaceuticals, UCB Pharma Advisory Boards NovoNordisk, King Pharmaceuticals, UCB Pharma Advisory Boards Eisai Speakers’ Bureau Eisai Speakers’ Bureau ACEP Clinical Policies Committee ACEP Clinical Policies Committee ACEP Scientific Review Committee ACEP Scientific Review Committee Executive Board, Foundation for Education and Research in Neurologic Emergencies Executive Board, Foundation for Education and Research in Neurologic Emergencies

6. Edward P. Sloan, MD, MPH FACEP Session Objectives Discuss if and when direct EMS triage to specialized stroke centers should take place. Discuss if and when direct EMS triage to specialized stroke centers should take place. Determine under what circumstances the inter-hospital transfer of ED ischemic stroke patients should take place when specialized stroke patient care is desired. Determine under what circumstances the inter-hospital transfer of ED ischemic stroke patients should take place when specialized stroke patient care is desired.

7. Edward P. Sloan, MD, MPH, FACEP Key Clinical Questions Should pre-hospital stroke patients be directly triaged by EMS to specialty stroke centers? When should the ED inter-hospital transfer of stroke patients to specialty stroke centers occur?

8. Edward P. Sloan, MD, MPH FACEP Case Presentation… 62 yo male brought in by paramedics 62 yo male brought in by paramedics Paramedics called due to left face, arm and leg “going dead” and slurred speech while eating breakfast Paramedics called due to left face, arm and leg “going dead” and slurred speech while eating breakfast On paramedic arrival, he has a facial droop, slurred speech and L hemiparesis On paramedic arrival, he has a facial droop, slurred speech and L hemiparesis Should this patient go to the closest hospital or a specialized stroke center? Should this patient go to the closest hospital or a specialized stroke center?

9. Edward P. Sloan, MD, MPH FACEP Case Presentation… This patient is taken to the closest hospital for immediate ED evaluation. This patient is taken to the closest hospital for immediate ED evaluation. The patient is stabilized and a head CT is obtained. Should he go to a stroke center for continued care? The patient is stabilized and a head CT is obtained. Should he go to a stroke center for continued care? Does this decision depend on whether or not IV tPA is administered? Does this decision depend on whether or not IV tPA is administered?

10. Edward P. Sloan, MD, MPH FACEP Direct Stroke Pt Triage What are “specialized stroke centers”? What are “specialized stroke centers”? Why do these special stroke centers impart improved patient outcome? Why do these special stroke centers impart improved patient outcome? Will direct EMS triage to these centers improve patient outcome? Will direct EMS triage to these centers improve patient outcome? Can these same clinical competencies be made in all hospital comprehensive EDs? Can these same clinical competencies be made in all hospital comprehensive EDs? Which is the preferred approach? Why? Which is the preferred approach? Why?

11. Edward P. Sloan, MD, MPH FACEP Stroke Centers US Model via JCAHO US Model via JCAHO Joint Commission for the Accreditation of Healthcare Organizations Joint Commission for the Accreditation of Healthcare Organizations Designated as a Primary Stroke Center Designated as a Primary Stroke Center Institutional commitment to the delivery of the highest quality care to stroke patients, including that provided in ED Institutional commitment to the delivery of the highest quality care to stroke patients, including that provided in ED As of October, 2006, there are 260 in US As of October, 2006, there are 260 in US 3 States designate separately 3 States designate separately

12. Edward P. Sloan, MD, MPH FACEP Tertiary Centers Provide specialized care Provide specialized care Often are university-affiliated Often are university-affiliated Treat the most complex medical cases Treat the most complex medical cases Most are primary stroke centers or are in the planning process Most are primary stroke centers or are in the planning process These tertiary centers often have capabilities beyond some hospitals that are primary stroke centers These tertiary centers often have capabilities beyond some hospitals that are primary stroke centers

13. Edward P. Sloan, MD, MPH FACEP Comprehensive Stroke Centers Highest level stroke patient care Highest level stroke patient care Expected to be university-affiliated and/or tertiary centers Expected to be university-affiliated and/or tertiary centers Will provide 24/7 interventional radiology, advanced diagnostics such as MRI, MRA, CTA and conduct extensive research Will provide 24/7 interventional radiology, advanced diagnostics such as MRI, MRA, CTA and conduct extensive research Limited number, as with Level I trauma Limited number, as with Level I trauma Unknown if direct EMS triage planned Unknown if direct EMS triage planned

14. Edward P. Sloan, MD, MPH FACEP Improved Outcome Basis Related to stroke care systems Often due to advanced nursing care and decreased stroke-related complications Reduced aspiration, DVT, infections May be related to increased rate of tPA use and/or fewer tPA complications, or from advanced therapeutics use The latter has not been demonstrated

15. Edward P. Sloan, MD, MPH FACEP Direct EMS Triage Trauma triage established in US Some cities now require EMS triage to stroke centers Will get stroke patients to stroke centers May negatively impact non-stroke centers Could lead to most hospitals becoming primary stroke centers, which is what is desired by the JCAHO & stroke advocates

16. Edward P. Sloan, MD, MPH FACEP Acute ED Competencies Rapid diagnosis and systems use Head CT interpretation quick, correct IV tPA use often assessed, used NINDS protocol successfully followed Comparable tPA effects and outcomes In other words, clinical effectiveness in the acute treatment of ED stroke pts Ability to transfer complex cases

17. Edward P. Sloan, MD, MPH FACEP The Preferred Approach Majority of hospitals become stroke centers by any means possible Institutional buy-in to stroke patient care IV tPA use often assessed, used Clinical effectiveness in the acute treatment of ED stroke pts Limited need for transfer out of hospital Increased capacity for optimal care

18. Edward P. Sloan, MD, MPH FACEP Key Clinical Questions stroke patients be directly triaged by EMS to specialty stroke centers Should pre-hospital stroke patients be directly triaged by EMS to specialty stroke centers? No. Not if it is possible to increased competencies and capacity for excellence in stroke patient care, including acute ED care

19. Edward P. Sloan, MD, MPH FACEP Inter-hospital Transfer When help is needed, it is provided When help is needed, it is provided What can happen after IV tPA is provided? What can happen after IV tPA is provided? What can happen if IV tPA is not used? What can happen if IV tPA is not used? Should IV tPA be deferred for another Rx? Should IV tPA be deferred for another Rx? Do long-term indications support transfer? Do long-term indications support transfer? Which is the preferred approach? Why? Which is the preferred approach? Why?

20. Edward P. Sloan, MD, MPH FACEP Providing Higher Level of Care US standard: provide help when asked US standard: provide help when asked If you can’t provide care, another will If you can’t provide care, another will Some problems with “financial triage” Some problems with “financial triage” Some problems with “wallet biopsy” Some problems with “wallet biopsy” Raises question of why not direct triage Raises question of why not direct triage Interhospital transfer agreements common Interhospital transfer agreements common AMI & PCI: Poorer outcomes not seen AMI & PCI: Poorer outcomes not seen

21. Edward P. Sloan, MD, MPH FACEP Providing Higher Level of Care One example in Reno, Nevada in US One example in Reno, Nevada in US Central tertiary hospital (Hub) with 27 outlying hospitals that transfer (Spokes) Central tertiary hospital (Hub) with 27 outlying hospitals that transfer (Spokes) Annual review of acute care and transfers Annual review of acute care and transfers Four man neurology group takes calls from all referring EDs, with teleradiology Four man neurology group takes calls from all referring EDs, with teleradiology Telemedicine the next step, now in Boston area out of Harvard hospitals? Telemedicine the next step, now in Boston area out of Harvard hospitals?

22. Edward P. Sloan, MD, MPH FACEP Stroke Care After IV tPA The following have not been demonstrated to improve stroke patient outcome after IV tPA: The following have not been demonstrated to improve stroke patient outcome after IV tPA: Combination thrombolytic therapy Combination thrombolytic therapy Mechanical interventions after IV tPA Mechanical interventions after IV tPA It is likely that systematic care after acute care is superior, but this should be able to be provided in most hospitals It is likely that systematic care after acute care is superior, but this should be able to be provided in most hospitals

23. Edward P. Sloan, MD, MPH FACEP Therapies Other Than IV tPA Merci device is FDA approved for clot retrieval, but not standard of care Merci device is FDA approved for clot retrieval, but not standard of care Why? It is surgical device, not a therapeutic Why? It is surgical device, not a therapeutic It therefore is approved for use but not able to be used by all operators, hospitals It therefore is approved for use but not able to be used by all operators, hospitals All other additional therapies experimental All other additional therapies experimental Are advanced diagnostics therapeutic in that they lead to other therapies? This is unknown. Are advanced diagnostics therapeutic in that they lead to other therapies? This is unknown.

24. Edward P. Sloan, MD, MPH FACEP Should IV tPA Be Deferred? No. IV tPA should ever be deferred when indicated and able to be provided in a clinically effective, safe manner. No. IV tPA should ever be deferred when indicated and able to be provided in a clinically effective, safe manner. When IV tPA can be provided in a referring hospital, it should be given expeditiously When IV tPA can be provided in a referring hospital, it should be given expeditiously This is not a rationale for inter-hospital transfer This is not a rationale for inter-hospital transfer

25. Edward P. Sloan, MD, MPH FACEP The Preferred Approach All EDs provide IV tPA when indicated Transfer agreements for acute care or continued care if necessary Conduct research that answers the important questions of advanced diagnostics and therapeutics, including mechanical devices Determine over time how care should be divided up as the pie grows bigger

26. Edward P. Sloan, MD, MPH FACEP Key Clinical Questions cur When should the ED inter-hospital transfer of stroke patients to specialty stroke centers occur? Inter-hospital transfer should occur when it is apparent that advanced care is needed and/or that this advanced care is demonstrated to improved stroke patient clinical outcomes

27. Edward P. Sloan, MD, MPH FACEPConclusions Specialty care centers raise the bar Need to assess best outcomes and best use of resources Research will answer important questions Stroke care will improve Lessons can be learned from EU models of care

28. Edward P. Sloan, MD, MPH FACEPRecommendations Maximize the use of IV tPA Get buy-in for optimal stroke pt care Know when and how to transfer Study effectiveness locally Conduct multi-centered research (NETT) Continue to explore best approaches

29. Edward P. Sloan, MD, MPH FACEP Questions? www.FERNE.org edsloan@uic.edu 312 413 7490 ferne_eusem_2006_sloan_emstfer_100606_finalcd 5/13/2015 2:39 PM