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Rapid Reperfusion in Acute Stroke The Memorial Healthcare Experience
Brijesh P Mehta, M.D. NeuroInterventional Surgeon
Director, Comprehensive Stroke Centers
Memorial Neuroscience Institute
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Disclosures
None
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Background
Dr. Brijesh P Mehta
– Acute strokes, carotid stenosis, intracranial stenosis
– Aneurysms, AVMs, tumors
• Massachusetts General / Brigham
– Internal Medicine
– Neurology
– Stroke & Neurocritical Care
– Endovascular Neurosurgery
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Stroke Systems of Care
4
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Code Stroke
5 Teleb MS, et al. J NeuroIntervent Surg 2016
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Sequential process
Significant
Delay!!!
Sequential Stroke Work Flow
Sequential Process
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Sources of Delays – LEAN Analysis
Delay in
arrival to
angio suite
4) Decision
to treat
3) MRI scan
• Discussion of benefit from IAT
• Patient transferred back to ED bay instead of
directly to angio suite
• Elective intubation in ED
• Consent for clinical trial only after MRI completed
• Difficulty in contacting healthcare proxy for consent
• Patient not transferred until nursing pass off
1) ED arrival
• No advance ED2CT page
• Lack of transport
equipment when patient
ready for scanner
• Patient unstable, requiring
intubation
2) CT scan
• Scanner occupied by different
patient
• No scan order in system
• Awaiting labs before giving
contrast or treating with IV tPA
• Difficult IV access
• Neuroradiology fellow not
available for rapid scan
interpretation
• Late notifcation to neuroIR team
despite high clinical suspicion
for vessel occlusion
• Scanner occupied by different patient
• No scan order in system
• MRI checklist not completed
• Lack of MRI-compatible EKG leads
• Needed to change equipment for
MRI scan
• Research fellow not present for
clinical trial consideration
• Awaiting renal function labs
• Patient movement during scan
• Neuroradiology fellow not available
for rapid scan interpretation
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Parallel Work Flow in Acute Stroke
8 Mehta BP, et al. JAHA 2014.
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Memorial Stroke Redesign
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Major Goals
• Redesign IV tPA Work Flow
– Goal DTN consistently < 30 minutes
– Adopt ASA Target Stroke guidelines
• Revamp Endovascular Stroke Work Flow
– Goal Door-to-Reperfusion time < 90 minutes
– Run it as a Code Heart
– Parallel Activation of NeuroInterventional team
– Process map posted in ED, angio suite, inpatient units
– Track core metrics for continuous process improvement
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Reduce IV tPA Door‐to‐Needle Times
– Pre-hospital notification
– Stroke alert system - StatLinx
– Bypass ED bay, go straight to CT scanner
– Keep IV tPA in ER
– Pre-mix IV tPA
– Rapid CT interpretation
– Await labs only if concern for coagulopathy
– Administer tPA while in CT scanner
Xian et al. Stroke 2014.
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EMS Pre-Hospital Alert
12
Actionable information
for IV tPA and/or
early cath lab activation
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FaceTime for EMS Stroke Alerts
13
Updated October 17, 2014
Call Dr. Brijesh Mehta NeuroInterventional Surgeon
Stroke Alerts RACE Score >5
Phone Number 617-775-5204
Available 24/7 for any Stroke Questions
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Ambulance Magnets
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NITRO Stroke Parallel Process
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NITRO Parallel Workflow Neuro Interventional Thrombectomy Recanalize Occlusion
• Any patient with disabling deficits = Possible ELVO
• Goal Picture-to-Puncture <60 minutes
EMS stroke alert call NeuroInterventionlist BEFORE imaging
Dial *61 for ‘Brain Attack’ cath lab if gaze preference or global aphasia
Get brain attack CT/CTA head & neck (scan first, labs later)
Keep patient in holding area near scanner; do not return to ER
Rads will provide prelim read <5 min; call Dr Mehta if any delays
Update Neurologist / NeuroInterventionlist of scan results
Administer IV tPA bolus if patient eligible
Take patient immediately to cath lab neuro room #12
Goal to cath lab <10 min after scan completion
Do not wait for consent; thrombectomy a standard of care
Updated 7.1.15 by Dr Brijesh P Mehta
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CT/CTA MRI
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All of the below must be metClinical
NIHSS ≥ 6 for anterior circulation (variable for posterior circulation)Age < 90LKW ≤ 24 hours anterior circulation/≤ 48 hours posterior circulationPremorbid condition
-Normal baseline functional status (mRS < 2)-Life expectancy > 6 months-Reperfusion reasonably expected to prevent infarction of tissue at risk
RadiologicalAnterior circulation
ASPECTS > 6 (NCCT) or Infarct core < 70 cc (DWI)Proximal arterial occlusion (ICA, M1 or proximal M2 )
Posterior circulationMinimal brainstem or thalamic infarct coreProximal arterial occlusion (basilar artery or dominant vertebral artery)L
ike
ly t
o B
en
efit IAT Selection Criteria
Created by: BP Mehta, MD Phone: 617-775-5204
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One of the below needs to be metClinical
NIHSS < 6Age > 90LKW > 24 hours Anterior circulation/> 48 hours Posterior circulationUnknown Last Known WellPremorbid condition
-Moderate-severe dementia (leading to loss of independence)-Significantly impaired baseline functional status (mRS ≥4; inability to walk and attend to activities of daily living) -Life expectancy of < 6 months
RadiologicalAnterior
ASPECTS ≤ 6 (NCCT) or infarct core > 100 cc (DWI) Distal arterial occlusion (Mid-M2, A2 or distal)
PosteriorPontine, midbrain or thalamic infarcts > 50% of the territoryProximal vertebral arterial occlusion Distal arterial occlusion (isolated PCA )
Uncert
ain
to B
enefit IAT Selection Criteria
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Cath Lab = Nascar Pit Stop
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NeuroInterventional Suite
• NeuroInterventionalist will be the leader of the team
• Suite arrival to groin puncture goal time < 10 minutes
• Everyone should know their roles/responsibilities
• Focus on BP management
• IV sedation vs general anesthesia
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BRISK Kit for Rapid Prep
23
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Standardized Cath Lab Process
24
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Cath Lab Teamwork
25
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Inviting EMS Crew to Observe Cases
26
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Procedure Time Log
27
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EMS Stroke Alert Utilization
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EMS Tour of CSC Stroke Process
29
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EMS Seeing Good Outcomes Firsthand
30
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Annual Stroke Survivors & EMS Recognition Dinner
31
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Annual Stroke Survivors & EMS Recognition Dinner
32
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Community Events to Increase Awareness
33
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EMS Group on WhatsApp
34
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Annual EMS Stroke Update
35
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Impact of EMS Alert on Door-to-tPA Times
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Faster tPA Process = Rapid Time to Cath Lab
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Impact of Early Cath Lab Activation
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South Florida Stroke Coalition
39
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EMS Landscape in South Florida
40
Palm Beach
Coral Springs
Margate
Hollywood
PPines
BSO
Miramar
Hallandale
Davie
Seminole
Miami-Dade
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ASA Certified Stroke Centers
41
hospitalmaps.heart.org
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EMS Stroke Triage in Thrombectomy Era
42
Rural United States South Florida
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EMS Nomogram for Triage to CSCs
43
Field to ER Arrival Time (minutes)
Fie
ld t
o P
un
ctu
re T
ime
CSC #1 120 min
CSC #2 100 min
CSC #3 60 min
130m
10m 20m 30m
Median Door-to-Puncture Times
120m
90m
Triage Based on Distance + In-Hospital Process
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SFSC Mission
• Improve quality of stroke care in tri-county region
– Educate EMS and hospitals utilizing evidence-based
guidelines
– Standardize EMS and in-hospital care protocols
– Data transparency among PSCs and CSCs to assist
with EMS triage decisions
– Move beyond AHCA self-attestation to TJC certification
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Supporters
• Tri-county NeuroInterventionalists
• American Stroke Association
• EMS Chiefs Council
• EMS Medical Director’s Association
• Fire Chief’s Association
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Updated February 2019
Tri-County Hospital Participation TJC CSC, TJC TCSC, *AHCA CSC, PSC
*BOCA RATON REGIONAL HOSPITAL *DELRAY MC
GOOD SAMARITAN MC *JFK MC
*JFK MC – N. CAMPUS
*JUPITER MC PALM BEACH GARDENS MC
*SAINT MARY’S MC WEST BOCA MC
Palm Beach County (9/12 FSR Hospitals)
BROWARD HEALTH CORAL SPRINGS *BROWARD HEALTH MC
*BROWARD HEALTH NORTH *CLEVELAND CLINIC FLORIDA
*FMC - CAMPUS OF NORTH SHORE *HOLY CROSS HOSPITAL
MEMORIAL HOSPITAL PEMBROKE *MEMORIAL HOSPITAL WEST
*MEMORIAL REGIONAL HOSPITAL NORTHWEST MEDICAL CENTER
*WESTSIDE REGIONAL MC
Broward County (11/14 FSR Hospitals)
*BAPTIST HOSPITAL Coral Gables Hospital
Hialeah Hospital *JACKSON MEMORIAL HOSPITAL
Jackson North MC Jackson South Hospital
*MOUNT SINAI MC *NORTH SHORTE MC
*PALMETTO GENERAL HOSPITAL South Miami Hospital
University of Miami Hospital West Kendall Baptist Hospital
Miami-Dade County (12/16 FSR Hospitals)
UM Florida Stroke Registry
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6) EMS Medical
Directors request copies from Hospitals
Palm Beach EMS Medical Director
Broward Hospitals Palm Beach Hospitals
A, B, C, D, E, F, G, H, I J A, B, C, D, E, F, G H
Broward EMS Medical Director
5) Hospitals
download their Regional Dashboards
7) Hospitals provide
copies to EMS Medical Director
Steps 5-7 are at the hospitals
discretion and timeline
1) Download and clean data- (up to 3 weeks)
2) Develop Dashboard graphs (1 week)
3) Upload to secured website (2 days)
4) Notify hospitals to visit secured website (1 day)
Regional Dashboards- Dissemination Process
UM FSR team Florida Stroke Registry Secure Website
FSR Hospital
UM Florida Stroke Registry
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Dashboards
• Ischemic stroke volume
• IV tPA treatment rates
• IV tPA door to needle times
• Thrombectomy treatment rates
• Thrombectomy door to puncture times
• Outcomes
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Median Door to Needle Time among those receiving IV tPA
2018 Q1
UM Florida Stroke Registry
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Median Door to Groin Time among those receiving EVT
2018 Q1
UM Florida Stroke Registry
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Percent mRS 0-2 at Discharge among those receiving EVT
2018 Q1
Included: • Ischemic Stroke patients who
received EVT at this hospital with modified Rankin score 0 to 6 at discharge
Excluded: • Age<18 • clinical trial • Stroke occurred after hospital arrival
note: The UM FSR metrics are NOT available in IQVIA
UM Florida Stroke Registry
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Strategy for Data Transparency & Utilization
• Three-pronged strategy to promote data transparency
– Inform EMS medical directors of dashboards being
available starting end of q1 2019
– Letter from behalf of EMS Medical Directors to all
thrombectomy stroke centers requesting dashboards to
be shared with EMS
– Proactive stroke centers in each county to lead the way
with sharing of dashboards with EMS
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Letter to Hospitals
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Meeting with senators in Tallahassee April 2019
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Meeting with senators in Tallahassee April 2019
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Florida Stroke Legislation 2019
• Require all stroke centers in Florida to be certified by nationally
recognized organizations such as the Joint Commission by
2021
• List all nationally certified thrombectomy stroke centers on
AHCA website for improved EMS and public understanding
• Require all stroke centers to submit data to statewide stroke
registry
• Develop EMS pre-hospital stroke protocols with appropriate
scales and triage pathways PSC vs CSC
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Thank You
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Contact Information
Brijesh P Mehta, MD
NeuroInterventional Surgeon
Director, Comprehensive Stroke Centers
Memorial Neuroscience Institute
617-775-5204
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