kp stroke express - right care initiative · ekg most labs rooming do things at the same time...
TRANSCRIPT
KPNC Stroke EXPRESSEXpediting the PRocess of Evaluating & Stopping Stroke
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Jeffrey G. Klingman, MD
Disclosures
None
75% DTN < 6050% DTN < 45
Why should we care about DTN?: Time is brain
2 million nerve cells die per minute For every 15 minutes faster time:More go home Fewer die Fewer bleedMore are independent at discharge
Stroke.2006; 37: 263-266
JAMA. 2013;309(23):2480-2488. doi:10.1001/jama.2013.6959.
Endovascular stroke care: Time is Brain
Proven effective therapy Time sensitive Better reperfusion and outcomes with shorter door to groin
The challenge in the age of endovascular stroke treatment
Deliver IV t-PA as efficiently / quickly as possible (within 15-20 minutes)Rapidly select (and transfer) patients with large
vessel occlusion (LVO) for endovascular treatment (within 45 – 60 minutes)Rapidly retrieve clots (within 90-120 minutes)
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Why does it take so long to give IV alteplase?
Patient picked up and evaluated by
paramedics
Transport to hospital
Arrival in hospital
Nurse evaluation
EMS ring down
Roomed
ED doctor evaluation
Vitals, monitor
IV’s
Orders placed
Transport to CT Move to CT scan
Get CT scan
Read CT scan
Return to ED
ED doc calls Neurologist
“Go” for Alteplase decision
Order alteplase
Mix Alteplase
Deliver alteplase
Weigh Patient
Draw labs
Labs?
Medication double check
Recheck vitals Recheck exam
Push IV alteplase
Start drip
Blah blah blah
Blah blah blah
Blah blah blah
What’s wrong with this picture?
Which steps are value added? Which serial steps could be parallel? Where are duplications which could be removed? Where are non value added steps?
Keys to rapid IV alteplase treatment
Do as much as you can before the patient arrives Stroke neurologist involved from the beginning Direct to CT scan Order Alteplase ASAP Alteplase in CT scanner Stop doing things that don’t matter EKGMost labsRooming
Do things at the same time (parallel processing)
Labs and Alteplase
INR only for patients on warfarin PTT only for patients on heparin CBC / platelets only for patients with suspected abnormality Creatinine only for patients with known abnormality
AJNR NOVEMBER 2008 29: 1826-1830
Journal of NeurologyNovember 2007, Volume 254, Issue 11, pp 1491–1497
http://dx.doi.org/10.1161/STROKEAHA.107.482778Stroke. 2007;38:2364-2366
Improving DTN in a system:Kaiser Permanente Northern California (KPNC)
3.8 million members 21 Medical Centers 17,000 square miles > 8000 physicians 75 neurologists Thousands of ED MD’s + RN’s
KPNC Acute Stroke Care: prior to 1/2016
• Every KPNC hospital is primary stroke certified
• Each hospital with its own stroke alert process
• DTN variable among hospitals but across all medical centers 60% in 60 minutes
• Endovascular times vary by location and treating MD’s
The Neurologist challenge
Key component = early involvement of stroke neurologist Problem: small volumes cannot justify in house stroke
neurologist
Solution: video consultation + redesigned process
Teleneurology “Hub”
Small core group of stroke specialist neurologists who are involved in all stroke alerts Remote exam by teleneurologists with RN / ED MD
assistance Active 7am – midnight 7 days a week (rate very low in “off”
hours) Neurologist orders the t-PA and “runs” the stroke “code”
Serial vs. parallel processes
Patient arrival
RN evaluation
Stroke alert called
ED doctor evaluation
CT ordered
Lab drawn
Transport to CT
Roomed in ED
CT done
Transport back to ED
CT read and called to ED
doc
Call to Neuro Alteplase ordered
Alteplase prepared
Lab Resulted
Alteplasepushed
Back to CT for CTA
CTA done
CTA resulted
Ambulance called
Ambulance arrival
Transport
Stroke alert called
Patient arrival
Team evaluation in ambulance
bay: ED, RN, Stroke
Neurology
Alteplase, CT, CT, CTA< ambulance
ordered
Transport to CT
Alteplase prepared
CT read and called to
teleneurologyAlteplase given (in CT)
CTA doneAmbulance arrival
Transport
OLD: Serial NEW: Parallel
Stroke Neurologist involvement
Neurologist involvement
April 2015 – Sept 2016 ED DTN Results
16
% Door-to-Needle TPA < 45 mins
All sites live! % D
oor-to-Needle TPA <
45 min
# of
Stro
ke C
ases
that
rece
ived
TPA
Results: All Facilities Median DTN
First quarter 2015
Median = 54 minutes, 3% < 30 minutes
38 cases per month
First quarter 2016
Median = 32 minutes,45% < 30 minutes
80 cases per month
Results: All Facilities
Identification and transfer for large vessel occlusion
Order CCT ambulance BEFORE even getting initial CT in selected patients CTA on nearly all patients - without leaving CT scan Adds about 4-5 minutes With two IV lines we can do CTA while alteplase is infusing Immediate reading by neuroradiology Teleneurologist contacts endovascular treatment center
Rapid transfer
Early order of CCT rig vs 911 ambulance with nurse ride along Prep patient before leavingGownGroin prep Foley
Sign out on phone as rig is coming Grease the wheels with accepting centerRapid door to groinOne call referral Ideally able to review images
2016 arrival at outside hospital to groin at RWC
SWIFT PRIME OH Arrivals
SWIFT PRIME CSC Arrivals
SWIFT PRIME
Current KP OH arrival to CSC average
Complications?
2014 symptomatic bleed rate : 4.5% 2016 symptomatic bleed rate: 4.3%
Field based diversion vs rapid treatment and transfer
18% of acute strokes need endovascular treatment 82% DO NOT
5% of patients identified with acute strokes by paramedics need endovascular treatment 95% DO NOT
Field based diversion advantages the few to the detriment of the many
Endovascular treatment – first give IV t-pa
82% of acute ischemic strokes arriving in time window DO NOT have a large vessel occlusion Patients with large vessel occlusion benefit from IV t-pa Large strokes with vessel occlusion (NIHSS>10) substantially benefit
from t-pa with 35% vs 17% having good outcome (NNT = 7)
Stroke 2013 Nov 44(11):3109-13
Conclusions
World class DTN times can be achieved in a network of community hospitals Rapid IV t-PA treatment > identification of LVO > transfer >
endovascular treatment is possible across a large geographic network of community hospitals Successful field based diversion is unlikely to be practical
and would likely be inferior to rapid treatment and transfer
Thank You
KP EXPRESS (EXpedited PRocess for Evaluating and Stopping Strokes)
KPNC Stroke FORCE (Fast Operating Remote Cerebrovascular Experts)
Building County Wide Program
Population engagement and education DTN improvement efforts Expedited transfer protocols Facilitated imaging, contact, information exchange Expedited door to groin Results sharing