De­vis­ing faster, bet­ter stroke care

Modern Healthcare - - BEST PRACTICES - By El­iz­a­beth Whit­man

When a pa­tient has a stroke, time is brain, as the say­ing goes.

In an ef­fort to im­prove a pa­tient’s func­tion and re­cov­ery af­ter a stroke, Kaiser Per­ma­nente of North Cal­i­for­nia re­designed treat­ment pro­to­cols in a pro­gram it dubbed Stroke EX­PRESS, with EX­PRESS stand­ing for EX­pedit­ing the PRocess of Eval­u­at­ing and Stop­ping Stroke. Key to its suc­cess were telemedicine, spe­cial­ized treat­ment and a stan­dard­ized ap­proach, which led to faster di­ag­no­sis and treat­ment.

“We re­moved a lot of steps that used to hap­pen in se­ries,” said Dr. Jeff Kling­man, the chief of neu­rol­ogy at the Per­ma­nente Med­i­cal Group and who helped de­velop the pro­gram. “In­stead, we do a lot of things in par­al­lel.”

Ev­ery year, more than 795,000 peo­ple have strokes in the U.S. About 130,000 of them die, mak­ing strokes the fifth­lead­ing cause of death among Amer­i­cans. Strokes cost about $33 bil­lion ev­ery year, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

The Stroke EX­PRESS pro­gram ad­dresses the long-stand­ing chal­lenge of re­duc­ing lag time in treat­ing strokes.

For ex­am­ple, emer­gency med­i­cal ser­vices be­gin trans­port­ing to the hos­pi­tal a man whose face is droop­ing and who can’t speak. They call ahead to the emer­gency room and say they might have a stroke vic­tim. The nurse who takes the call di­als an on-call te­leneu­rol­o­gist who con­nects with the lo­cal telemedicine robot and opens the in­com­ing pa­tient’s chart, pro­vided paramedics are able to iden­tify him and his chart is ac­ces­si­ble to the Kaiser net­work.

Once at the ER, a physi­cian be­gins a clin­i­cal as­sess­ment along with a stroke neu­rol­o­gist, who ob­serves and par­tic­i­pates via the robot’s high-qual­ity au­dio and video. The goal is to as­sess the pa­tient in five to 10 min­utes.

If they de­ter­mine that the pa­tient is hav­ing an acute stroke, the team orders al­teplase, a med­i­ca­tion that dis- solves clots. The phar­macy mixes the med­i­ca­tion as the team wheels the pa­tient down to a CT scan­ner. If they sus­pect the stroke is caused by a clot in a large blood ves­sel, they also or­der a crit­i­cal-care am­bu­lance to ar­rive at the emer­gency de­part­ment, just in case.

The CT scan checks for bleed­ing that would con­traindi­cate the al­teplase. If the CT scan shows it’s safe, the team ad­min­is­ters al­teplase in­tra­venously. A CT an­giogram looks for any blood clots large enough that they need to be ex­tracted, a pro­ce­dure that needs to be done at a com­pre­hen­sive cen­ter or a com­mu­nity hos­pi­tal. If a large clot is seen on the CT an­giogram, the crit­i­cal­care am­bu­lance is ready to go.

Re­searchers com­pared data from the first six months of the pro­gram to data from the year be­fore and found that the time from the pa­tient’s ar­rival to ad­min­is­ter­ing of al­teplase dropped from a me­dian of 52 min­utes be­fore Stroke EX­PRESS to 33 min­utes dur­ing the pro­gram. Door-to-nee­dle times of less than 30 min­utes oc­curred 46% of the time un­der the pro­gram, com­pared to 5% of the time the pe­riod be­fore.

The me­dian num­ber of al­teplase cases per month also rose from 38 to 80. Yet the num­ber of stroke dis­charges didn’t change, said Dr. Mai Nguyen-Huynh, a stroke neu­rol­o­gist and a re­search sci­en­tist at Kaiser Per­ma­nente of North Cal­i­for­nia who led a re­gional tele­stroke team.

In other words, a greater pro­por­tion of pa­tients were be­ing treated with al­teplase. Nguyen-Huynh at­trib­uted that to the stroke neu­rol­o­gists in­volved early on in treat­ment. “Stroke neu­rol­o­gists are much more up-to-date on treat­ment pro­to­cols and reg­u­la­tory guide­lines,” Nguyen-Huynh said.

Stroke EX­PRESS could also cut dis­par­i­ties in treat­ment and out­comes. Stud­ies sug­gest timely treat­ment with al­teplase varies by age, race and gen­der, but when the re­searchers ex­am­ined data from the first six months of the Stroke EX­PRESS pro­gram, they found no dis­par­i­ties in the use of al­teplase or door-to-nee­dle time based on race, gen­der, age or Kaiser Per­ma­nente mem­ber­ship.

Over­all, those pos­i­tive re­sults may be due to the pro­gram’s stan­dard­ized ap­proach, Kling­man said.

Stroke EX­PRESS be­gan as a pi­lot at two med­i­cal cen­ters in Septem­ber 2015. By Jan­uary 2016, it was at 21 cen­ters.

The pro­gram had to pull stroke neu­rol­o­gists out of clin­ics so they could be on call. It had to set up te­leneu­rol­ogy equip­ment at their homes and of­fices. Now, they’re hop­ing to ex­pand the pro­gram to other re­gions and have spe­cial­ists on call 24/7.

“This is a tremen­dous ef­fort,” said Nguyen-Huynh, adding that it is rare for a huge sys­tem to col­lect that type of data. “We’re con­tribut­ing in terms of do­ing bet­ter in clin­i­cal care, but also pro­vid­ing the re­search data that’s needed in or­der to help an­swer a lot of ques­tions to move the field for­ward.”

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