2015 ISC Hot Topics- Advancing Your Stroke

ProgramDebbie Summers, MSN, RN, ACNS-BC, CNRN, SCRN, FAHA, ANVP

Saint Luke’s Hospital Kansas City, MO

Speaker: Debbie Summers

Topic: 2015 ISC Hot Topics- Advancing Your Stroke Program

Disclosure: Covidien Ltd

Consultant

2

Objectives • Apply new research topics presented at the International Stroke

Conference • Discuss the relevance of at least two new practices that may influence

their own program/practice

• Forum for:• Disseminating clinical stroke trial results and • Sharing of best practices within the field

• Occurs annually in February• Pre-conferences 1day prior to meeting:

• Stroke in the Real World: Challenges to inpatient stroke care 2015• Emerging Trends for stroke trials

• Option to submit abstracts, projects and research is open to everyone at Strokeconference.org

ISC – What is it? And Why is it important?

The Changing Landscape of Stroke Treatment

IMS III• No clear benefit to intraarterial (IA) therapy

• Confirmation of occlusion was not required at the time of randomization, and 23% of the patients in the IA arm did not receive treatment

• Time to IA treatment was longer than 2 earlier trials potentially mitigating the benefit

• Limited use of new technologies (5 stent retrievers) • Full dose tPA only used in amendment 5 • Future trials are needed to determine whether any patient groups benefit from

IA treatment • Broderick JP et al. Stroke. NEJM 2013;368:893-903

8 |

++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10

IMS III did show that better revascularization leads to improved outcomes.++

TICI=0 TICI=1 TICI=2a TICI=2b TICI=3

% 90 Day mRS 0-2

N=32 N=16 N=67 N=80 N=5

3.1% 12.5% 19.4% 46.3% 80%

6.3% 35.5% P < .0001

13.9% 48.2% P < .0001

Differences between the two treatment groups across the entire distribution of the mRS (p = 0.06, van Elterin test)

IMS3 Did show an improvement in mRS 0-2 at 90 days for patients presenting with more severe strokes.++

++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10

IMS III Take-Aways

• Use of newer stent thrombectomy devices may improve long term neurological outcomes when studied in future randomized studies by providing higher rates of procedural recanalization

• Enrollment of confirmed large vessel occlusions, particularly ICA occlusions and patients with a higher incoming NIHSS score should represent a population more likely to benefit from endovascular therapy.

Up to date technology:Stent Retrievers

Clinical Trials – Mr. Clean

Clinical Trials – ESCAPE

Clinical Trials – EXTEND IA

Clinical Trial – SWIFT PRIME

Trial Summary

Lancet Neurol. 2014 Jun;13(6):567-74

Increased time to reperfusion was associated with a decreased likelihood of good clinical outcome (unadjusted relative risk for every 30-min delay 0·85 [95% CI 0·77–0·94]; adjusted relative risk 0·88 [0·80–0·98]).

Khatri P. Neurology 2009; 73 (13): 1066-1072

Time is Brain Stroke Systems of Care

We Have to Get Organized…• Pre-hospital Systems of Care

• Community education for symptoms & EMS activation• EMS education for recognition and empowered for activation to higher level

centers• Primary to comprehensive center network

• Limiting community hospital time/transfer time• Efficient in-house triage, activation, treatment with endovascular to ≤ 90 minutes

Manipulating the time window

• Increasing collateralization• Increasing Venous return/Volume – NS bolus• Attention to BP• Positioning• Balloon pumps/mechanical counter-pulsation• Neuroprotection agents; hypothermia

Collaterals

• Numerous stroke clinical trials are demonstrating the profound impact of collaterals

• Recanalization• Reperfusion• Smaller infarcts• Less hemorrhagic transformation• Better clinical outcomes

The Future

• We have gone from our first generation of clot removing procedures, which were only moderately good in reopening target arteries, to now having highly effective tools.

• Imaging from non-contrast CT to identification of salvageable tissue to looking at collateral flow.

Collateral Flow Grading

American Society of Interventional and TherapeuticNeuroradiology Collateral Grading System

Grade Cerebral Collateral Flow Grading DescriptionGrade 0 no collaterals visible to ischemic siteGrade 1 slow collaterals to the periphery of the ischemic site with

persistence of defect

Grade 2 rapid collaterals to the periphery of ischemic site with persistence of some of the defect and to only a portion of the ischemic territory

Grade 3 collaterals with slow but complete angiographic blood flow of the ischemic bed by the late venous phase

Grade 4 complete and rapid collateral blood flow to the vascular bed in the entire ischemic territory by retrograde perfusion

Collateral Flow with Time

The Future

• Collateral therapeutics may entail use of readily available hemodynamic manipulations such as head positioning, hypervolemia, hypertensive therapy, or partial aortic obstruction in selected cases.

Theory of Collateral Flow

• The connection between leptomeningeal collateral flow (LMF) and the survival of brain parenchyma during acute ischemia has been confirmed in a large number of clinical studies Bang OY. Stroke. 2011;42:2235-2239.

Collaterals Avert HT• Data revealed that therapeutic recanalization in the setting of poor

collaterals resulted in a high frequency of HT with worsened clinical neurological status.

• Poor collateral status at baseline may limit effective reperfusion, even when recanalization is successful.

• Bang OY. Stroke. 2011;42:2235-2239.

CTA to Obtain Collateral Flow

• 10 point quantitative topographic CT scan score to assess early ischemic changes of the MCA region

• Assessed at 2 standardized regions• Ganglionic Level where the thalamus, basal ganglia and caudate are visible • Supraganglionic level which includes the corona radiata and centrum semiovale

Alberta Stroke Program Early CT Score (ASPECT)

Normal ASPECT score is 10 Deduct 1 point for each area involved.

A score of 7 or less Correlates with poor functional outcome and hemorrhage.

*Limitation – Only scores the MCA

ASPECT score

HOUSTON MSU Standard 12 foot ambulance

BEST MSU Study

• Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by EMS

• Aims• Determine the logistic and clinical outcomes of MSU vs SM in the U.S. – speed, #,

first hour. • Can MD/Nurse be replaced by Telemedicine?• What is the Cost Effectiveness?

WHY is Nursing Research Important?

• Build the scientific foundation for clinical practice• Prevent disease and disability• Manage and eliminate symptoms caused by illness

Home CareNutrition

Acute Rehab/SNF

Pharmacy

STROKE Program

Social Work/Clinical Resource

Management

Physical Therapy

Palliative Care Hospice

Multidisciplinary Care

Primary Care

Family Care Givers

Community Resources

Steps in Research Process• Identify the problem or question.

• Does Red Print or Blue print on patient education materials improve patients retention of knowledge?

• Review the literature• Lit search on patient education materials and retention – variables that influence

• Develop hypothesis• Red print educational materials result in higher stroke knowledge retention

• Methodology - Decide how you will investigate the question/hypothesis?• 50 patients will be given red print and 50 patients will be given black print. A post test will be

developed and provided. Variables such as age, race, sex, highest completed education, NIHSS will be collected in addition to results.

Research Design

Retrospective versus

Prospective research

Use of Databases

• Get With The Guidelines-Stroke• University Health Consortium (UHC)• Home grown databases

Steps in Research Process

• Institutional Review Board (IRB)process.• Implement methodology/collect data• Analyze results - statistics

Steps in Research Process

• Draw conclusions

• Share conclusions

• Implement change

Integrating Research Findings

• One example is the updates to clinical practice guidelines – developed by AHA/ASA work groups.

• When published, we need to compare to current practice • Discuss gaps/changes recommended in stroke team meetings• Work with E record, nursing focus groups, etc• Change protocols, documentation records, educate all team members• Measure

Nursing Symposium

Georgia Stroke Professional Alliance

Gulf Coast Medical Center

Reducing Readmission Rates• Higher than national average readmission rates (Range 14.9%-18.6%)• Implemented discharge rounds to decrease rate• Evolution of process

• Phone conference decreased from 18% to 8.9%• Unit level conference further decreased to 8.4%• Bedside, nurse led DC rounds further decreased to as low as 5.3%

• Rounding tool used• PT, OT, SLP recommendations• New medications• DC plan – social/family concerns

Nursing Symposium Many more….

• Nursing & EMS – Bridging the great divide• Head up vs head down in acute stroke• Evaluating care giver needs• Transitions of care• Palliative care

• Too many to review all!!

2016 Call for abstracts: May 20- Aug 11, 2015