St. Jude Medical CenterSecrets of Surviving a Stroke

Stephen Waldman, M.D.,Ph.D.Neurologist,Co-Stroke Director

Sara Williams, R.N., CDirector of Care Transitions

Objectives

• Overview of Stroke

• Discuss treatment with rt-PA (tissue plasminogen activator)

• Discuss “Time is Brain” (tissue lost)

• Understand the importance of leadership support

• Define expertise for the ED, nursing staff, physician staff withsupport in lab, transportation and radiology

• Discuss ongoing efforts to maintain and improve outcomes

The Numbers of Stroke

• Stroke is a leading cause of death and disability worldwide

• In the U.S. – there are annually estimated 731,000 first-ever or recurrent strokes and 4 million stroke survivors.

• Financial burden – estimated direct & indirect costs total $40 billion annually

Types of Stroke

Ischemic stroke (83%)Hemorrhagic stroke (17%)

Atherothromboticdisease (20%)

Embolism (20%)

Lacunar small vessel disease (25%)

Cryptogenic (30%)

Intracerebralhemorrhage (59%)

Subarachnoid hemorrhage (41%)

The Stroke Belt

Stroke death rates, 1991-1995, adults aged 35 years or older, by county.

Data Source: US Census Bureau Postcensal Population Estimates and National Center for Health Statistics National Vital Statistics System (ICD9 Codes 430-438.9).

ED Assessment of the Suspected Stroke Patient: Goals

Rapid activation of stroke teamDifferential diagnosis

Rule out conditions mimicking strokeIschemic vs hemorrhagic stroke

Assess eligibility for thrombolysis or other acute interventionsDetermine location and etiology of strokePrevent and treat acute medical and neurologic complications

Adams HP Jr, et al. Stroke. 2007;38:1655-1711.

Intravenous rt-PA is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A).

rt-PA 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).

AHA/ASA Guideline Recommendations

rt-PA Should Be Used With Caution in Certain Patients

• Patients with severe neurologic deficit (eg, NIHSS >22) at presentation

• Patients with major and early infarct signs on a cranial CT scan (eg, substantial edema, mass effect, or midline shift)

• Patients of advanced age (eg, >75 years)• Due to the increased risk of misdiagnosis of acute

ischemic stroke, special diligence is required in making this diagnosis in patients whose blood glucose values are <50 mg/dL or >400 mg/dL

• Patients with minor strokes or rapidly resolving symptoms

IV rt-PA for Acute Ischemic Stroke: NINDS Trial

• Primary end point: Favorable outcome at 3 months

– Defined as normal or near normal neurological function using a global scale that incorporated 4 commonly used scales

– Odds ratio: 1.7 (95% CI, 1.2-2.6) favoring rt-PA over placebo

Includes an increased incidence of symptomatic ICH (6.4% vs 0.6%)

ICH = intracerebral hemorrhage.

Reprinted with permission from The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581-1587.

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26

21

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23

27

17

21

Rt-PA

Placebo

0 to 1 2 to 3 4 to 5 Death

mRS score (3 months)

Percentage of patients

Meta-Analysis of 6 Randomized, Placebo-Controlled Trials by Treatment Time

N = 2,776

Odds Ratio of Very Favorable Outcome at Day 90

Lancet 2004; 363: 768–774

rt-PA Use 3 to 4.5 Hours After Stroke

• Currently supported by only 1 large randomized trial (ECASS III)1

• Supported by 1 large pooled analysis2

• Not supported by FDA label3

• Now supported by a new AHA/ASA science advisory4

– Class I, Level of Evidence: B recommendation– European guidelines being modified

• Key point is to treat as soon as possible within either 3 hours or 4.5 hours

1. Hacke W, et al. N Engl J Med. 2008;359(13):1317-1329.2. Lansberg MG, et al. Stroke. 2009;40(7):2438-2441.3. Activase® (alteplase) full prescribing information.4. Del Zoppo GJ, et al. Stroke. 2009;40(8):2945-2948.

Treatment Delays

• Despite its effectiveness in improving neurological outcomes, many patients with ischemic stroke are not treated with rt-PA, because they arrive late or because of delays in assessment/administration of IV rt-PA

• Increased Treatment Opportunities– (reduce the door to needle time for IV rt-PA)

• Goal-Achieve a Door to Needle (DTN) Time within 60 minutes in at least 50% of ischemic stroke patients treated with IV rt-PA.

The sooner that rt-PA is given to stroke patients, the greater the benefit, especially if started within

90 minutes of symptom onset

Improved Treatment Over Time

GWTG-Stroke/ Use of IV rt-PA in Eligible Patients

42.09%

53.46%

65.00%69.10%

72.65% 72.84%

0%

20%

40%

60%

80%

100%

IV rt-PA 2 Hour

Baseline YR1 YR2 YR3 YR4 YR5

Opportunity for Improvement

Timeliness of IV rt-PA in Ischemic Stroke

24.10% 22.30% 24.70% 25.80% 27.40%

0%

20%

40%

60%

80%

100%

DTN within 60 min

2005 2006 2007 2008 2009

27.4%

50.0%

0%

20%

40%

60%

80%

100%

DTN within 60 min

Door-to-IV rt-PA within 60 minutes

GWTG-Stroke Database, data on file DCRI

Target: Stroke The Time is Now

2009 Goal

Target Stroke Goal

NIH-recommended ED Response Times

Bock BF. National Institute of Neurological Disorders and Stroke, National Institutes of Health; 1997.

Door-to-needle time ≤60 minutes

0 10 15 25 45 60Minutes:

Suspected stroke patient arrives at ED

Stroke teamnotified

Initial MD evaluation

CT scaninitiated

CT & labsinterpreted

tPA givenif patientis eligible

The “golden hour” for evaluating and treating stroke

Time is Brain

• STARS Registry– 38 community, 18 academic hospitals, 389 IV TPA pts– Median door to needle time: 96 minutes

• CDC 4 State Pilot Acute Stroke Registry– 98 hospitals, 6867 acute patients, 118 IV TPA– Treatment within target 60 minutes: 14.4%

=

Target Stroke at St. Jude

• Median Door to Needle Time– 2009 66 Minutes– 2010 63 Minutes– (STARS Registry-96 Minutes)

• Treatment within Target 60 Minutes– 2009 41.8%– 2010 46.4%– (CDC 4 State Pilot-14.4%)

Program Beginnings

•Multidisciplinary Team• Neurologists• ED Physician Champion• ED Nurse Manager• Stroke Nurse Practitioner• Ancillary Department

Managers• Executive Team Support

•Stroke Team Meetings• Code Stroke Review• Stroke Leadership Team• Stroke Neuro Excellence• Regional Stroke

Meetings

Best Practices

Advance Hospital Notification by EMS• Orange County Stroke/Neuro Receiving Centers

– Spoke and Hub Hospitals– Quarterly Paramedic Education (Cincinnati Pre-hospital Scale)

Rapid Triage Protocol and Stroke Team Notification• Protocol and Order Set Development

– Developed by multidisciplinary team– Physician education

• Rapid Stroke Team Activation by ED Physician– Call to hospital operator– Can be activated after base station contact

Code Stroke Physician Checklist

Best Practices (contd.)

Stroke Tools• Guidelines• Algorithms• NIH Stroke Scale• Stroke Specific Order Sets

– Code Stroke– Ischemic Stroke– Hemorrhagic Stroke

Rapid Acquisition and Interpretation of Brain Imaging• Radiologist paged for Code Stroke• Clear 64-Slice CT Scanner when Code Stroke Called• Radiologist communication with ED Physician

Best Practices (contd.)

Rapid Laboratory Testing• Lab draws immediately after Code Stroke called

– INR– CBC– Creatinine

• Labeled as “Code Stroke”

Rapid Access to Intravenous rt-PA• Pharmacist part of Code Stroke Team

– Tackle box– “Time out” with nurse– Mixed at bedside-

• Turn around time-5 min.

Best Practices (contd.)

Team-Based Approach• Multidisciplinary meetings• Frequent meetings• Ad hoc meetings

Prompt Data Feedback• Monthly Code Stroke Review• One-on-one Education with MD/Nurse• Fallouts discussed with team within one week

Code Stroke Review

transferred to acute rehab then home 3/2/10Outcome

right hemisphereLocation of Stroke

No bleed post tpa

Notes2/19/10 CVADischarge Date/Dx

Pharmacist2Discharge NIHSS

Neuro9 to a 2 after tpaAdmission NIHSS

ED Nurse1705Pharmacy-tPA to RN

ED Physician1652Pharmacy Call Time

Yes< 45 min19 min1621/1640ECG

Yes< 45 min25 min1621/1646CXR

Yes< 45 min26 min1621/1647Creatinine

Yes< 45 min23 min1621/1644PT

Yes< 45 min11 min1621/1632CBC

Yes< 60 min133 min from LKW55 min1713Door to tPA

Yes< 45 min12 min15 min1633Door to CT Results

Yes< 25 min6 min1624Door to CT Performed

3 min1621Code Stroke Called

1618Arrival Time

Goal MetGoal TimesTurn Around TimesAccrual TimeTime

Onset: 1500. Left sided weakness, fell at home, wife called 911

Patient Age 91 M Date Arrival Mode: OC EMS

Community Education

• Sudden numbness or weakness of the face, arm or leg – especially on one side of the body

• Sudden confusion, trouble speaking or understanding

• Sudden trouble seeing in one or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden severe headaches with no known cause

F.A.S.T.

Success Story

Initial MD Evaluation - 3 minutes

Stroke Team Notification - 4 minutes

CT Scan Initiated - 6 minutes

CT Scan Interpreted - 15 minutes

Lab Results Received - 26 minutes

rt-PA given - 55 minutes

Outcome - NIHSS upon arrival-9, NIHSS at discharge-1, transferred to Acute Rehab and discharged home 2 weeks later.