2/8/2011 1

Drip and Ship Thrombolytic Therapy

Jennifer Cohn, MSN, CNRN

IUH-Methodist Hospital

Indianapolis, IN

2/8/2011 2

Faculty Disclosure Information Elements

1. Jennifer Cohn, MSN, RN

2. Drip and Ship Thrombolytic Therapy

3. Genentech

1.Speakers Bureau

4. Codman and Shurtleff

1.Consulting

5. Unlabeled/Unapproved Uses Disclosure: Intra-

arterial tPA

2/8/2011 3

Overview of Presentation

• Discuss development of partnerships with Emergent

Stroke Ready hospitals

– to increase number of people in Indiana that receive

intravenous thrombolytic

– Insure patients admitted to these hospitals are cared for

according to most current AHA guidelines

• Review of Continuous Quality Improvement activities

– GWTG-Stroke and Telestroke data points

• Discuss Lessons Learned and Future Goals

2/8/2011 4

Background

• Approximately 25% of the US population lives in rural areas

• Many of these areas are considerable distances away from large medical centers

• In the state of Indiana, there are 35 critical access hospitals and 14 counties that have no existing hospital

• Currently large area of state do not have access to emergent neurological services

Leira, EC, et al. Archives Neurology 65(7), 2008.

2/8/2011 5

Denotes county

without

a hospital

PSC hospitals

PSC hospitals

2/8/2011 6

2/8/2011 7

2/8/2011 8

University of

Louisville

Fort Wayne Stroke

Network

Union Hospital/Lugar

Center for Rural

Health launching

Telestroke in fall

2010

Telestroke Landscape in Indiana

2/8/2011 9

IV tPA utilization by hospital 7/05-6/07

Stroke. 2009; 40:3580-3584

2/8/2011 10

Recommendations for Creating Hub and

Spoke Models of Care

• To overcome lack of stroke specialists and to increase

use of hyperacute stroke therapies telemedicine can

be used to carry out needed emergency evaluation

• Evidence-based care from the hubs is transmitted to

the spokes

• Emergency departments of spoke sites should be open

to collaboration, have CT available 24/7/365 and have

support of Administration

• Spoke sites should collect same stroke performance

measures as the hub site

Demaerschalk, et al.(2009)Mayo Clinic Proceedings, 84(1): 53-64

2/8/2011 11

Telestroke Team Membership

• Consists of a broad range of clinical, administrative, and research members at both sites

• No formal requirements that hub site telestroke practitioners are board certified vascular neurologists

• Most important element of successful telestroke program is good collaboration between neurology and emergency medicine practitioners

2/8/2011 12

Model of Telestroke Consultation

• The Stroke Chain of

Survival is interrupted for

patients who are

remotely located and

lack immediate access

to expert stroke care

• Goal of Telestroke

consultation is to avoid

interruption and

maximize patient

recovery

2/8/2011 13

Remote Supervision of IV-tPA for AIS

• Retrospective review of GWTG-Stroke database identified 296 patients that received IV tPA within 3h of symptom onset

– Complications and outcomes in outlying spoke hospital (OSH), “drip and ship”, population was compared to those in patients treated directly at regional hub

• Mortality, sICH, and functional outcomes were not different between OSH versus regional hub and telephone versus telestroke patients

• Outcomes in OSH drip and ship patients treated in hub and spoke network are comparable to those treated directly at regional hub

Pervez, MA, et al. (2010) Stroke; 41:e18-e24

2/8/2011 14

Our Experience

• 2009 IUH Stroke leadership team set goal to increase

partnership in rural health hospitals and across system

focusing on:

– Hyperacute and Acute care of Ischemic Stroke Patient

• Pre-hospital

• Emergency Department

• Inpatient

– Continuous Quality Improvement

• GWTG-Stroke

• Stroke I log

2/8/2011 15

Our Experience

• July 2009- Indiana State Rural Health Network (InSRHN) approached several providers across state to partner with developing Telestroke Network

• September 2009 - agreed to partner InSRHN to perform clinical and technical readiness assessment with 7 hospitals

• June 2010- began assessment of InSRHN spoke sites

• August 2010- agreed to serve as the clinical provider for InSRHN Telestroke Network

2/8/2011 16

Telestroke Readiness Assessments

• 7 Critical Access Hospitals participated

• Clinical assessment focused on evaluating if hospitals were emergent stroke ready

– Administrative Support/Stroke Team

– Process in ED

– Transfer Agreement

– Order sets/protocols

– Staff Education

– QI Work

• Telemedicine and IT assessment

2/8/2011 17

Findings from Clinical Assessment

• High level of engagement and plans were already being formulated around each of areas assessed.

• Common gaps – Designation of one standardized approach for response

to hyperacute stroke patients

– Presence of or updated protocols/order sets

– Use of NIHSS in assessment of stroke patients

– One standardized approach to obtain consultation from neurologists

– Education around tPA administration

– Written transfer agreement with expedited process

2/8/2011 18

Recommendations from Clinical

Assessments

• Solidify Stroke Team – meet at least monthly during initiation phase

– Share data reports with team and involved practitioners at least monthly

• Develop efficient feedback mechanisms around processes to ensure that near misses or misses are caught as quickly as possible and situation reviewed with involved practitioners

• Review current order sets/protocols on regular basis to make sure in alignment with current guidelines

• Stroke I process should include patients who arrive within 4 hours of onset

• Develop partnership with hospital that will solve for quick access neurology consultation and smooth transfer process

2/8/2011 19

Developing a Partnership

• Create hub-spoke model of care supported by IUH System

– 3 Regional Hubs across the State

• Supported by

– On-boarding of spoke sites in clinical processes and Telestroke platform

• Melding teams

– Local EMS Education

– One-call format to initiate consult and critical care transport

– Real time data collection and follow up by hub site with in one week

• Hub site participation in biweekly calls with spoke site hospitals

2/8/2011 20

IUH Telestroke Network

and Indiana State Rural

Health Network (InSRHN)

Partnership

2/8/2011 21

On-Boarding Process

• Review updated protocols and order sets

• Share spoke site packets

– Posters/pocket cards, Stroke I transfer sheets

• Set-up tPA administration in-services

• Mock Stroke Is

• Local EMS education

• Attend stroke team meetings monthly for at least a quarter and then on a quarterly basis

– Review GWTG-Stroke measures and stroke log and discuss opportunities for improvement

2/8/2011 22

Prehospital Management Focus

• EMT or Paramedic is our

lead healthcare team

member in field and

need to be have

education of regular

basis, perhaps as often

as twice a year (Class I,

Level of Evidence B)

Summer, et al. Stroke 40(8):2911-44, 2009

2/8/2011 23

LifeLine

• Critical Care transport

– Coordinates air or

ground transportation

across state

– 5 bases

– Crew trained in NIHSS

– Will provide educational

in-services to local EMS

crews

2/8/2011 24

Transferring Center ED or

Unit

ED physician/attending

physician initiates Stroke I

process by calling 24/7

Transfer Center at 877-247-

1177.

Relays following information:

1. Name of hospital ED/unit

and telephone #

2. Identify you have a Stroke I

patient

3. Name of patient

4. Time last seen normal or

onset of symptoms

Referring physician provides

report to neurologist when

transfer center conferences

physicians.

ED unit staff faxes face sheet to

24/7 Transfer Center at 317-

968-1000.

Information packet given to

family members.

Transfer Center

Pages neurologist on call

providing following

information (if no answer, call

cell and home):

Page with:

1. 911 Stroke 1 Transfer

from ____ (hospital)

2. Name of Patient

3. Time of Onset

4. Call Transfer Center at 963-

3333.

Notify Lifeline immediately of

pending transport. Lifeline will

check weather and obtain OCC

while awaiting transport

decision from referring

physician.

When accepting physician

returns page, conference with

referring physician and

Lifeline.

Once accepted:

1. Instruct Lifeline to start

transport.

2. Group page via AMCOM

“Stroke-Transfer Center”

providing following

information:

1. FYI ONLY – Stroke 1

Transfer OSH to EMTC.

2. Accepting Physician

3. Name of Patient

4. Time of Onset

5. Type of treatment (drip and

ship, IV tPA, Interventional)

6. ETA: (ie. 11:00)

Lifeline Communications

*Arranges/coordinates

transport

*Provides ETA

*Flight followed and ETA

updated, when necessary.

Neurologist

Receives Stroke I page and

calls Transfer Center back at

963-3333.

Conferenced with referring

physician.

*May opt to preview radiology

via iPhone

*Connects to hospital network

via laptop computer

*Utilizes OsiriX software to

view patient CT study

*When necessary, physician

places video call to referring

site.

Patient treatment is determined.

Notifies EMTC

Chaplaincy

Notified through Stroke I

Meets family and escorts to

ED waiting room or Radiology

Waiting area, if requested.

Informs ED staff or

interventional staff that family

has arrived.

Provides update (if available)

to family.

EMTC Staff

ED Charge RN will look for

face sheet and report sheet on

fax machine from transfer

center.

*Registers patient

*Enters Pending Arrival

*Anticipates arrival *Alerts ED

triage that pt is expected and

plan of care

*Have stroke team paged upon

pt arrival (Call Operator).

*ED physician will get report

from accepting physician

-Based upon case may order

additional scans, prepare for

intubation after medical and

neuro exam completed.

Stroke I Transfer Program

***If referring physician or

referring ED asks for the

interventionalist, page them

instead of the neurologist.

Revised 11/3/10

Stroke I Transfer Process

2/8/2011 25

Telemedicine Platform

2/8/2011 26

Continuous Quality Improvement

• What is the common experience amongst all

hospitals?

• GWTG-Stroke – Build Stroke I data points in the

optional field section

• ESR Telemedicine Timeline Targets

• Stroke I transfer report, Stroke I log

2/8/2011 27

Stroke I Transfer Report

2/8/2011 28

ESR Telemedicine Timeline Targets

2/8/2011 29

Maintenance of Partnerships

• Follow up on patients transferred to Hub site

within one week

• Attend Stroke Team meetings quarterly

• Participation in educational opportunities for

EMS, RNs and physicians

• Annual Community outreach programs

• Continual Telestroke platform support

2/8/2011 30

2/8/2011 31

Review of Outcomes

2/8/2011 32

0

1

2

3

4

5

6

7

2009 2010 2011

% Drip/Ship Thrombolytic Patients

2009

2010

2011

Percentage of Drip and Ship

Thrombolytic Patients

2/8/2011 33

2010 Drip and Ship Data

Time of

onset to

Arrival

Time to

Treatment

Time of

onset to

Treatment

Pre-TX

NIHSS

D/C

NIHSS

1hr 7 mins 1hr 5 mins 2h 22

mins

11 5

Discharge Disposition

Acute Rehab

Home

RHC

2/8/2011 34

IRHA GWTG-Stroke Data

2/8/2011 35

IRHA GWTG-Stroke Data

2/8/2011 36

IRHA GWTG-Stroke Data

2/8/2011 37

IRHA GWTG-Stroke Data

2/8/2011 38

IRHA GWTG-Stroke Data

2/8/2011 39

IRHA GWTG-Stroke Data

2/8/2011 40

IRHA GWTG-Stroke Data

2/8/2011 41

IRHA GWTG-Stroke Data

2/8/2011 42

IRHA GWTG-Stroke Data

2/8/2011 43

Why We Do It…

2/8/2011 44

Case Scenario: LF

• 65 yo male with sudden onset of left sided weakness at 1900

• Past Medical Hx of HTN, CAD, MI, PVD, ex-smoker

• Presents to OSH at 2030 and MH neurologist consulted

• Case reviewed with ED physician and decision made to treat

• Pt treated at 2137

2/8/2011 45

Case Scenario: LF

• Pt transferred via lifeline

to MH EMTC and arrived

at 2230

• CTP shows perfusion

deficit in right MCA

territory

• Upon arrival NIHSS 16,

but she was improving

2/8/2011 46

Case Scenario: LF

• Patient found to have Afib, cardiology consulted and coumadin started

• Dysphagia screen completed, rehab services evaluated and found to be good rehab candidate

• Left-sided weakness improved to drift and slight facial droop

• Discharged on day 5 to acute rehab with NIHSS 3

2/8/2011 47

Case Scenario: LG

• 68 yo female sudden onset right sided weakness,

aphasia and last known normal at 9am; found by son

at 1030

• Arrived at OSH and MH neurologist consulted via

transfer center; case reviewed, head CT WNL and

decision to treat made

• Past Med Hx of hyperlipidemia, DM, TIAs

• IV tPA started at 1300 and transferred by air

2/8/2011 48

Case Scenario: LG

• Upon arrival, patient is

globally aphasic, could

not follow commands,

severe central facial

paresis, drift of right arm

and leg, sensory deficit

on left

– NIHSS 12

2/8/2011 49

Case Scenario: LG

• The morning after admission she began to regain her speaking ability and her functionality in her right arm and leg with only mild right facial droop remaining

• MRI shows acute infarct and previous lacunar infarcts

• Pt found to be hypertensive and started on medication

• Discharged to home on day 3 with NIHSS 1 on:

Lisinopril, pravastatin, and plavix

2/8/2011 50

Case Scenario: ML

• 78 year old female with previous history of afib, MVR and on Coumadin.

• Patient experienced sudden onset of right sided weakness (RLE flaccid and slight weakness in RUE) at 2045.

• NIHSS was assessed at 11

• INR was 2.4 and initial head CT with no hyper dense MCA sign.

• ED physician consulted MH neurologist and decision made to emergently transferred to Methodist Hospital

2/8/2011 51

Case Scenario: ML

• Upon arrival at Methodist, the

stroke CT protocol was

initiated, revealing thrombus in

the left M1/M2 segment of the

Middle Cerebral Artery.

• The patient was transferred to

the angio suite for possible

mechanical intervention.

2/8/2011 52

Case Scenario: ML

• INTERVENTION

• Using a combination of

Merci and Penumbra,

flow was reestablished in

both the M1 and M2

segments.

2/8/2011 53

Case Scenario: ML

• PROCEDURAL OUTCOME

• Follow up CT demonstrated left sylvian fissure SAH and small sub insular infarct.

• Patient was extubated the morning after the procedure.

• The patient’s NIHSS was 1 with RLE having a drift.

2/8/2011 54

Lessons Learned

• Address how to handle pumps from outside

hospitals

• GWTG-Stroke data points

• Onsite is always better than over the phone

especially in the beginning

• Transfer Center is great way to assist in

tracking data and reviewing calls

• Build it and they will come….

2/8/2011 55

Next Steps

• Build out program across entire IUH system

• Expand imaging protocols in hospitals that have

capability

• Include Interventional Neuroradiologists in call

• Begin measuring spoke site and patient/family

satisfaction

2/8/2011 56

Stroke System Hospitals

Legend

American Stroke

Association ‘Get with

the Guidelines’ facility

2/8/2011 57

Thank You

• IUH-MH Stroke Team

• Participating InSHRN Hospitals

• IUH Telemedicine Team

• Silver Hill Technologies

• LifeLine Critical Care Transport

• IUH Transfer Center

• IRHA

• GWTG/AHA Indianapolis Affiliate