Dr. Todd Collier Neurologist Royal Inland Hospital BC Stroke

Dr. Todd Collier
Neurologist
Royal Inland Hospital
BC Stroke Strategy Steering Committee Member
“Stroke, the world’s third most common
cause of death and disability, neglected
for so long, remains a treatable and
preventable catastrophe. Organized
stroke care improves outcomes, but
remains the exception nearly everywhere.”
Recent quote from Dr. V. Hachinski and Dr. J. Norris who
created the first Canadian Stroke Unit in Toronto in 1975.
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“How to Handle Hot Stroke or Hot TIA?”
The only way is to have organized/systematic
stroke care
What is happening in BC and elsewhere
What is IHA doing to achieve this
Stroke Risk Increases with Age
1,200
Annual stroke risk
per 100,000
1,000
800
600
400
20
0
0
35–44
45–54
55–64
75+
Age groups
www.statcan.ca
Oxford Vascular Study:
Results
Population of 91,106 in Oxfordshire, UK in 2002-2005
Rothwell PM et al. Lancet 2005; 366:1773-1783
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A national organization of neurologists
dedicated to stroke research and clinical
leadership
Organizes the annual National Stroke
Course aimed at Internists and EM Docs
National Stroke Course, October 23-24,
2010, Marriott Chateau Champlain Hotel,
Montreal
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Primary Prevention
Rapid Assessment of TIA Patients
t-PA thrombolysis
ASA
Organized Inpatient Care (Stroke Units)
Organized Rehabilitation Care
Secondary Prevention
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Hypertension Hypertension Hypertension
Smoking
Diabetes
Hyperlipidemia
Inactivity
Obesity
Heavy Alcohol Intake
Atrial Fibrillation
1. An analysis of 2.5 million stroke admissions in the USA revealed:
2. A similar analysis of 26,000 stroke admissions in Canada found
the same pattern:
Stroke Mortality in Canadian Hospitals can vary dramatically, even
when hospital size and other factors are matched:
Neurology® 2007;69:1142–1151
Canadian Stroke Strategy:
Changing Systems and Lives
Overview and Background Information
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TIA patients seen in Stroke Prevention Clinics
◦ 8% ⇒ 17%
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tPA use for patients presenting within 2.5hrs
◦ 5% ⇒ 14%
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Patients cared for in Stroke Units
◦ 2% ⇒ 18%
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Hospital Length of Stay
◦ 7.7 days ⇒ 6.5 days
Organized Stroke Care:
Projected Benefit for BC
Provincial Health Services Authority
EMERGENCY DEPARTMENT PROTOCOL WORKING GROUP (EDPWG)
Implementation of TIA/STROKE Protocols in Emergency Departments
Project Charter
(May 2006)
Guidelines & Protocols Advisory
Committee (GPAC)
Highlights from the New GPAC Stroke/TIA Guideline
bcguidelines.ca
Emergency Department
Current Practice Indicators Project
July 2007
Prepared by Global Medical Services
Stroke/TIA Indicators – HA Averages
IH
Percentage (%)
HA Averages
100
90
80
70
60
50
40
30
20
10
0
86
85
81
73
67
73
49
37
30
31
28 29 26
15 15
8 7
6 5
5
Stroke patients received tPA Blood glucose checked on
arrival
ECG performed in ED
Patients ineligible for
thrombolysis and given at
least 160 mg ASA therapy
initiated in ED
Indicators
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IH ED Protocol Working Group
IH Stroke Leadership Committee
Royal Inland Stroke Unit working group
Lori Seeley, IH Clinical Lead, Stroke and
Acquired Brain Injury
Jaymi Chernoff RN, BScN, TIA Rapid Access
Project Coordinator for Interior Health
Interior
Health
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You need to know what type of stroke care
site you are:
1. tPA capable (Regional Stroke Centre or Primary
Stroke Centre)
2. tPA potential (has a CT scanner but site not
organized yet to deliver tPA)
3. Transfer to tPA capable site
4. Rural and Remote sites (too far away from tPA
enabled sites)
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Primary Prevention
Rapid Assessment of TIA Patients
t-PA thrombolysis
ASA
Organized Inpatient Care (Stroke Units)
Organized Rehabilitation Care
Secondary Prevention
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Standard Orders
Ongoing Education and Quality Improvement
Identify the roles played by different staff:
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Paramedics
Family Doctors
EM Docs, Internists, Radiologists, Nurses
Physio, OT, Speech
Clinical Nutrition, Social Work
Clarify referral patterns for diagnostic tests,
consultations, rehabilitation
Put the Stroke/TIA Emergency Diagnostics Order Set on the patients chart if you suspect a stroke.
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Kelowna
Kamloops
Penticton
Vernon
Cranbrook
Trail
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Migraines
Seizures
Subdural Hematoma
Tumour
MS
Peripheral Vestibulopathy
Bell’s Palsy
Hyper/Hypoglycemia
Syncope
CNS Infection
Delirium
Drug toxicity
Transient Global Amnesia
Conversion Disorder
TELESTROKE
Strategic investment in Telestroke will act to:
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Equalize patient access to life-changing effects of TPA
Build stroke management capacity province-wide
Make more effective use of scarce health human resources
Reduce transfers between EDs and tertiary facilities
Enable stroke rehabilitation/recovery closer to home
Increase access of rural and remote clients to acute stroke
interventions.
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Cranbrook
Salmon Arm
Trail
Vernon
Williams Lake
Kelowna
Penticton
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Dedicated stroke ward
Multidisciplinary care team
NNT 33 to prevent death
NNT 20 to regain independence
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A four bed room on 5 North
One RN for the four stroke patients
A flex bed always available on 5N ward
The least acute patient is moved out to the
ward to allow new stroke admissions
Tuesday 9am Multidisciplinary Stroke Rounds
Standard order sets and procedures
Earlier rehabilitation assessment and
planning
t-PA patients come after 12hours in ER or
Step Down Unit
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No Foley catheter
In&Out catheterization q6H if unable to
void
Reduces length or stay
Reduces chance of infection
Increases chances of regaining bladder
control
Easier for patients to be mobilized
Treating TIA Urgently to
Prevent Stroke
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Modeling suggests Rapid Assessment and
Treatment of TIA and Minor Stroke will have a
bigger impact on overall Stroke Morbidity and
Mortality than:
◦ tPA
◦ Stroke Units
Projected Annual TIA Incidence
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Five Priority Areas established in 2006/7
1. Standard Stroke Orders Sets in all BC Emergency
Departments
2. TIA/Minor Stroke Rapid Assessment Programs for
all Health Authorities
3. Telestroke
4. Rehabilitation and Community Integration
5. Monitoring and Evaluation
™ Late
2008 the Ministry of Health decided tPA
should be made a priority again
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Same mechanism
MRI studies reveal small Strokes in many “TIA
patients”
TIA and Minor Stroke patients are at high risk
for subsequent Strokes:
◦ 5% in 2 days
◦ 10% in 90 days
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Need urgent investigation and treatment
Stroke Risk after a TIA
Gladstone D et al. CMAJ. 2004 Mar 30;170(7):1099-104.
Speech, motor, >10 min, age >60, diabetes
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Post-TIA 90 day Outcomes
30%
25%
20%
15%
12.7%
10.5%
10%
5%
5.3%
at
2 days
2.6%
2.6%
0%
Stroke
Johnston SC, et al. JAMA, 2000; 284:2901-2906
Recurrent CardioTIA
vasc.
Death
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EXPRESS STUDY
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90 DAY STROKE RISK:
◦ BEFORE: 10%
◦ AFTER:
2%
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Also supported by FASTER and SOS-TIA Trials
EXPRESS Study 90 day Recurrent
Stroke Rate
Effect of Early Comprehensive
Treatment on Risk of Stroke
50% were treated by 20 days
60% were treated within one day
Risk of recurrent stroke after first seeking medical attention in all patients with TIA or
stroke who were referred to the study clinic.
Rothwell Lancet 2007
Rapid Assessment Clinics for
TIA and Minor Stroke
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Currently operating in Kamloops and
Cranbrook
Referral form faxed from any ER, GP office, or
Clinic in Thompson Cariboo Shuswap Region
or East Kootenay Region
Aim to see all patients within 24-72hours
Only for ambulatory outpatients
Rapid Assessment Clinic
continued
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Clinic Patients will get:
◦ Consultation with a Neurologist/Internist
◦ Immediate access to investigations
◦ Education and Treatment
This Model Could Work for all
of
Interior
Health
` Each Health Service Area could set up a
similar clinic at a Regional Hospital
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East Kootenay:
West Kootenay:
Okanagan:
TCS:
Cranbrook
Trail
Kelowna and Penticton
Kamloops
Physicians with an interest in Stroke could
staff these clinics, most likely as part of other
On-Call or ER or Hospital Clinic duties
Jaymi Chernoff, IH TIA Rapid Access Lead
How does Rapid Assessment
of TIA reduce stroke?
Identify Symptomatic Carotid
Stenosis
Carotid Angiogram Showing
Severe Stenosis
Symptomatic Carotid Stenosis
>70% Timing of Surgery
Within 2 weeks of Symptoms
NNT=3.5
After 3 months
Identify Atrial Fibrillation
Medications
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ASA + Plavix for one month, then ASA alone
Antihypertensives
Statins
Smoking Cessation
Diabetic Management
Education of Patients and
Family
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Primary Prevention
Rapid Assessment of TIA patients
Paramedic Stroke Protocols
Standard Emergency Stroke Orders and
Protocols
Standard Stroke Admission Orders
Stroke Unit Care
Stroke Rehabilitation
Secondary Prevention
Telestroke/Telerehab
“Stroke, the world’s third most common
cause of death and disability, neglected
for so long, remains a treatable and
preventable catastrophe. Organized
stroke care improves outcomes, but
remains the exception nearly everywhere.”
Recent quote from Dr. V. Hachinski and Dr. J. Norris who
created the first Canadian Stroke Unit in Toronto in 1975.
ABCD2
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A – Age 60 years or older (1 point)
B – BP elevation on first assessment after TIA
(1 point; systolic ≥140 mm Hg or diastolic)
C – Clinical features of TIA
(unilateral weakness, 2 points;
or speech impairment without weakness, 1
point)
D – Duration of TIA
(≥60 minutes, 2 points; 10–59 minutes, 1
point)
D – Diabetes (1 point)
Johston, Rothwell, et al. Lancet 2007; 369:283-92
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Stroke Risk after TIA: ABCD2 Score
Interpretation of ABCD2
Score:
Score Points
2-day risk
High Risk
6-7
8.1%
Moderate Risk
4-5
4.1%
Low Risk
0-3
1.0%
Rothwell Lancet 2006
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