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Improving Stroke Care in NEBRASKA

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

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Improving Stroke Care in NEBRASKA

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  1. Improving Stroke Care in NEBRASKA 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. Purpose of the NSAC 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.

  4. 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

  5. Stroke Chain of Survival and Recovery FAST

  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). Expansion of Time Window for Treatment of Acute Ischemic Stroke. Stroke. 2009;40:000-000. Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655–1711.

  7. Adjusted Odds of a Favorable 3 Month Outcome by Time From Stroke Onset to Start of Treatment (OTT) N=3670 OR 2.55 OR 1.64 OR 1.34 OR 1.22 ECASS, ATLANTIS, NINDS, EPITHET Lees et al, Lancet 2010 375:9727:1695-1703

  8. IV TPA Symptomatic HemorrhageRate = 6% SymptomaticHemorrhage NIHSS NINDS t-PA Stroke Study Group, Stroke 1997

  9. NINDS Time Goals for Stroke

  10. Barriers to tPA UseMedical 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

  11. Barriers to tPA UseMedical-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

  12. Risk / Benefit and Medicolegal Issues • Medicolegal issues are reported as a barrier to administration of tPA • Administration of tPAis 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 2008. 65(11). 1429-1433

  13. Hospital Medicare ReimbursementStroke • 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

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

  15. Proposal for Stroke Centers Designation by the NSAC Working Group 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

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

  17. Level 1 Comprehensive Stroke Center • 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

  18. Level 1 Comprehensive Stroke Center • 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

  19. Level 2 Primary Stroke Center (JC Certified) • 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

  20. Level 2 Primary Stroke Center (JC Certified) • 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 Communityand EMS • Written protocol for receiving stroke patients transferred from other facilities • Utilize telemedicine network

  21. Level 3 Advanced Stroke Capable Hospital • 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

  22. Level 3 Advanced Stroke Capable Hospital • 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

  23. Level 4 Basic Stroke Capable Hospital • 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,

  24. Level 4 Basic Stroke Capable Hospital • 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

  25. Non-Acute Stroke Care Capable Hospital 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

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

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

  28. 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 plasminogenacitvator, ischemic stroke, and potential legal issues. Neurology. 2008. 65(11). 1429-1433. • Lees et al, Lancet 2010 375:9727:1695-1703 • Nebraska Vital Records 2008 • Nebraska BRFSS 2008 • Nebraska Hospital Discharge Data2008 • 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 2007:369:299-305 • Schwamm et al, Recommendations for the Establishment of Stroke Systems of Care Stroke. 2005;36:690-703 • Del Zeppo et al. Expansion of Time Window for Treatment of Acute Ischemic Stroke with Intravenous Tissue Plasminogen Activator, Stroke 2009. • Alberts et al., Recommendations for Establishment of Primary Stroke Centers, JAMA 2000: 283 (23) 3102-3109. • .

  29. NSAC Membership Committee Members • 2012 NSAC ChairDenise Gorski, The Nebraska Medical Center • 2012 NSAC Steering CommitteeJames Bobenhouse, M.D. - Neurology Associates PCKaren Bowlin - NE EMS AssociationCherie Boxberger - American Heart AssociationJose Cardenas, MD, Neurology Associates of Great Plains Tam Christen - Bryan LGH – StarCareTeresa Cochran - Nebraska PT AssociationDean Cole - NDHHS – EMSScott Crawford - Omaha Fire and RescueJanet Dooley - CIMRO of NebraskaJill Duis - Jefferson Comm. Health Center & Stroke SurvivorPierre Fayad, M.D. - UNMC Dale Gibbs - Nebraska Telehealth Network/Good Samaritan Hospital Maria Hines - Minority HealthMary Ellen Hook – Bryan LGH Katherine Jones – UNMC Brian Krannawitter - American Heart AssociationBeth Malina - St. Elizabeth Regional Medical CenterMitch Marsh – St. Elizabeth Regional Medical Center Marcia Matthies – NE State Stroke Association Rita Parris - Public Health Association of NebraskaJoann Schaefer, M.D. - NDHHS – Chief Medical OfficerFrancis Sparby, St. Francis Medical Center Bill Thorell, M.D. – UNMC Thaddeus Woods, M.D. - Critical Care Associates • 2012 NSAC Ad Hoc MembersP.J. Richards - Genentech, Inc. • NSAC Staff Support: NDHHS – Cardiovascular Health Program StaffJamie Hahn - Program Manager - (402) 471-3493Kari Majors - Heart Disease & Stroke Prevention Coordinator - (402) 471-1823David DeVries - Health Surveillance Specialist - (402) 471-3279 Verify Members

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