Rishi Gupta, MD
Susan Zimmermann, RN, BSN, CNRN Kerrin Connelly, RN, MSN, MPH
Rishi Gupta
FINANCIAL DISCLOSURE:
Consultant: Stryker Neurovascular, Covidien
DSMB: Rapid Medical, Reverse Medical
Associate Editor Journal of Neuroimaging
Susan Zimmermann
Kerrin Connelly
Cheri Kommor
FINANCIAL DISCLOSURE:
How an interventionist sees
patients Neurologists look
- Where must we go? (Vision) - How can we get there? (Strategy) - What is to be done next? (Tactics)
- How are we doing? (Assessment)
Styles and processes may differ with the type of organization and environment.
Vision must be clear, have laser focus and specific
Strategic plan must lay out the steps to achieve the vision over 1 year, 5 years and 10 years. Metrics must be developed to ascertain
success.
Example: Many facilities hire faculty, nursing to fulfill needs. Important
Direct Physician to Physician Contact
Selective in Patient Transfer Acceptance
Feedback Mechanisms
ER EMS Vascular Neurology IV tPA Anesthesia Endovascular NICU Referring Physician Telemedicine Radiology
Time of Arrival to Outside ER Time of CT Time of contacting INR Time contacting EMS Time EMS Arrives Time EMS Leaves Time EMS Arrives at your hospital Groin Puncture Time Imaging obtained Time Reperfusion achieved
The process where humans change their
behavior simply because they know they are
being studied
Implementation of quality assurance projects
aimed at measuring processes for the care of an
endovascular stroke patient
- Assess distance
- Assess EMS services available in county - Investigate helicopter options * Is there a helipad? * Where is origin of helicopter? - Traffic patterns - Weather
Telemedicine?
Tier 1: Excellent Neurology Coverage - Telephone call, transfer
Tier 2: Inconsistent Neurology - Image Transfer
- Phone call Tier 3: Rural areas - Telemedicine Tier 1 Tier 2 Tier 3 Impact is: - Meet needs - Less intrusive - Rapid triage - Build trust
Acute ischemic Stroke with NIHSS ≥ 8, Anterior circulation
Likely to Benefit
Age< 80 and Sx onset < 6 hrs
ASPECTS > 7 or MRI DWI or CTP < 1/3 MCA core
Transfer patient for IA therapy Notify INR team
Patient received IV tPA or > 1 hour In transportation Repeat CT Direct to IA < 1 hour in Transport and No IV tPA given
Onset 6-8 hours with < 1/3 MCA Core by DWI, CTP or ASPECTS Or if < 6 hours and age >80 with MCA or ICA occlusion
Uncertain Benefit
Decision between Vascular Neurology And INR attending, consider
Clinical trial
Transfer if agreement
Onset < 8 hours with >1/3 MCA involvement
Unlikely to benefit
Decision between Vascular Neurology and INR attending, family discussion
? Prevent hemicrani or selected reperfusion of eloquent cortex
Transfer if agreement or
0 50 100 150 200 250 300 2010 (431 total strokes) 2011 (632 total strokes) 2012 (824 total strokes) 2010 2011 2012 IV tPA (Grady) 28 56 78
IV tPA (outside facility) 5 61 97
Endovascular therapy 5 135 176
Any thrombolytic therapy 37 186 271
Refine internal processes
Educate key partners
Consult with key partners
What does your internal process look like?
Patient tracers
Current transfer protocols Registration
Imaging
Bed placement/ICU/nursing unit
Capability
Define and communicate what you do
Patient selection
Provide guidance
Contact options
Be consistent and reliable
Telemedicine/image transfer
What do you have to offer?
Current capability
What can you offer to complement it?
Current process
Does it include endovascular consideration?
Plan for transport
Is there a commitment from air and ground EMS?
Plan for education
Accepts images from any CT or MRI
Neutral viewing platform
Immediate, secure, eliminates need for CD
Improves patient selection
Refer back to community rehabilitation and
physicians
Feedback and kudos
Treatment, disposition and process Verbal, written, posters
Internal & external
trickle down effect
WellStar Kennestone Regional Medical Center
The largest of a 5 hospital system in Marietta Georgia
Reside 23 miles from our closest CSC
633 bed licensed beds with 120,000 annual ED visits
- Primary Stroke Center caring for 1,200 stroke/year - CARF certified Inpatient Rehab / Outpatient Rehab
Established acute stroke team in your facility Build professional relationships with CSC team
NETWORKING
Georgia Stroke Professional Alliance Association American Heart Association Support
Identification of the acute stroke patient and a clear last known well - Hemiplegia - Gaze preference - Language deficit - Profound aphasia
T-PA patient’s who do not show improvement
Last Known Well < 8
Hours
ED Champion
- Physician and Nursing
Neurology Champion
- Decision makers consulting the CSC
Strong Stroke Coordinator
- Protocols, support, dedicated to the team, keep good records
In-services provided by CSC Interventionalist
- Helped build rapport with Neurologist and ED Staff
at PSC
- Criteria for patient identification was provided - Phone numbers were made accessible
- Open communication was a clear focus - Incorporated regional PACS system
Daily communication between the Outreach Manager
of the CSC and the Stroke Program Leader of the PSC
Communication between Care Coordination at the
CSC and the PSC to determine eligibility for IRU
Open communication to Air Life GA discussing any
issues with transfer or safety
Quarterly rounds between Interventionalist at the CSC
and our Neurology and Emergency Physician Team.
Transfer of the right patient
Discussion of treatment
Speed!
Critical care team of flight nurse and flight
paramedic
(and the pilot too) Higher level of care than average ground EMS transport
(because of flight RN on board)
Advanced training and capabilities to include:
RSI/intubation
Management of multiple drips (i.e., tPA, antihypertensives,
pressors, sedation, etc.)
Management of invasive lines
Ventilator management
Collaborative effort between Air Methods – Air
Life Georgia (ALG) and Marcus Stroke Center
(MSC) at Grady Hospital
Plan developed through strong working
relationships between ALG staff and neuro interventionalists from MSC
Relationships established as a result of the following
efforts:
MSC reaching out to provide info related to
capabilities/services of the comprehensive stroke center
ALG working to understand the types of patients best
Reduce the length of time from MD acceptance
to patient arrival
Reduce the need for additional imaging
Increase opportunities for pt to receive interventions
needed to improve morbidity and mortality
Average transport time prior to development
Identify the appropriate patient
Meetings to discuss key components/ways to
reduce time
Intercept the pt closer to the helipad
Develop a checklist to follow
Rapid assessment and pt report
Rapid transfer of tPA to flight crew IV pump
“Hot” load
Coordinate with sending hospital staff (CT, ED,
security), ALG flight crews, ALG dispatch, MSC
staff
Item Needed for Flight Transfer Please or Fill In Blank
1.Time of Last Known Normal Date 8/1/12 Time 1440
2. Last Blood Glucose Time: 1442 Result: 106 mg/dL Tx: None required
3. Significant medical history (if any) CAD/ Prior MI AFib/ Flutter
IDDM HF
Previous Stroke HTN
Hx Head Bleed Other
4. Does the patient take blood thinners at home? Yes No
5. Patient weight (in kg) Weight 100 kg
6. Patient allergies (list or indicate ‘none’) NKDA
7. tPA bolus amount given (list bolus, time given, or ‘none’) See t-PA protocol Woorksheet
8. tPA infusion (total amount to be infused or ‘none’) See t-PA protocol Worksheet
9. List any other drugs given while in the ED (list drug,
amount, and time given)
Drug Amount Time Given ASA 81 mg At home
10. Oxygen provided NC Facemask
11. Any other patient related concerns while in ED (markedly abnormal VS, seizure activity, dysrhythmias,
abnormal labs, etc or indicate ‘none’.)
None
12. Last set of vital signs (list the last set of vital signs) (See tPA protocol worksheet)
13. EMTALA transfer form completed Check to acknowledge complete
14. Patient’s Chart can be faxed to Marcus Stroke Center post transfer
X Check to acknowledge complete 404-616-5796 Grady Neuro ICU
15. Face sheet Check to acknowledge complete
16. EMS consent form Check to acknowledge complete
Training:
Sending hospital staff
Plan components Helipad safety
Flight crews
Plan components tPA drip transfer Communication “Hot” loading
Receiving hospital staff
Transfer papers to be faxed
Electronic transmission of CT films
Communication of ETA by flight crew and response to helipad
Dry runs (timed) – at various times of day, weekends
Establishing a “Go Live” date
Review each transfer
Tweak the plan as needed
Identify areas for improvement
Identify areas for additional training Evaluate effectiveness
Average transfer time after development of rapid
transport plan = 59 minutes (down from 90)
Reduced the number of patients requiring repeat CT =
50% (down from 71%)
0800 - 46 year old male LKN
0950 – patient witnessed to be driving
erratically, involved in a minor MVC
EMS assessment revealed right sided weakness
and aphasia
1034 – Arrival to Kennestone via ground EMS,
1039 – CT revealed left MCA thrombus
1047 – Grady neurointerventionalist paged
1102 - IV tpA administered
1120 – patient transported to helipad by ED
team to meet Air Life Georgia crew for rapid
transport
1130 – patient arrived at Grady
1148 – CT at Grady
1215 – groin puncture at Grady
