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.
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Denotes county
without
a hospital
PSC hospitals
PSC hospitals
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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
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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
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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
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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
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IUH Telestroke Network
and Indiana State Rural
Health Network (InSRHN)
Partnership
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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
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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
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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
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Telemedicine Platform
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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
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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
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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
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IRHA GWTG-Stroke Data
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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
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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.
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Case Scenario: ML
• INTERVENTION
• Using a combination of
Merci and Penumbra,
flow was reestablished in
both the M1 and M2
segments.
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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