Transcript 2015 ISC Hot Topics-Advancing your Stroke Program

2015 ISC Hot Topics- Advancing
Your Stroke Program
Debbie Summers, MSN, RN, ACNS-BC, CNRN, SCRN, FAHA, ANVP
Saint Luke’s Hospital
Kansas City, MO
Speaker: Debbie Summers
Topic: 2015 ISC Hot Topics- Advancing Your Stroke Program
Disclosure: Covidien Ltd
Consultant
2
Objectives
• Apply new research topics presented at the International Stroke
Conference
• Discuss the relevance of at least two new practices that may influence
their own program/practice
ISC – What is it? And Why is it important?
• Forum for:
• Disseminating clinical stroke trial results and
• Sharing of best practices within the field
• Occurs annually in February
• Pre-conferences 1day prior to meeting:
• Stroke in the Real World: Challenges to inpatient stroke care 2015
• Emerging Trends for stroke trials
• Option to submit abstracts, projects and research is open to everyone at
Strokeconference.org
The Changing Landscape of Stroke
Treatment
IMS III
• No clear benefit to intraarterial (IA) therapy
• Confirmation of occlusion was not required at the time of randomization, and
23% of the patients in the IA arm did not receive treatment
• Time to IA treatment was longer than 2 earlier trials potentially mitigating the
benefit
• Limited use of new technologies (5 stent retrievers)
• Full dose tPA only used in amendment 5
• Future trials are needed to determine whether any patient groups benefit
from IA treatment
• Broderick JP et al. Stroke. NEJM 2013;368:893-903
IMS III did show that better revascularization leads to
improved outcomes.++
% 90 Day mRS
0-2
TICI=0
TICI=1
TICI=2a
TICI=2b
TICI=3
N=32
N=16
N=67
N=80
N=5
3.1%
12.5%
19.4%
46.3%
80%
6.3%
13.9%
++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10
8
|
P < .0001
35.5%
48.2%
P < .0001
IMS3 Did show an improvement in mRS 0-2 at 90 days for
patients presenting with more severe strokes.++
Differences between the two treatment groups across the entire distribution of the
mRS (p = 0.06, van Elterin test)
++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10
IMS III Take-Aways
• Use of newer stent thrombectomy devices may improve long term
neurological outcomes when studied in future randomized studies by
providing higher rates of procedural recanalization
• Enrollment of confirmed large vessel occlusions, particularly ICA
occlusions and patients with a higher incoming NIHSS score should
represent a population more likely to benefit from endovascular
therapy.
Up to date technology:
Stent Retrievers
Clinical Trials – Mr. Clean
Clinical Trials – ESCAPE
Clinical Trials – EXTEND IA
Clinical Trial – SWIFT PRIME
Trial
Summary
Increased time to reperfusion was associated with a decreased
likelihood of good clinical outcome (unadjusted relative risk for every
30-min delay 0·85 [95% CI 0·77–0·94]; adjusted relative risk 0·88 [0·80–
0·98]).
Lancet Neurol. 2014 Jun;13(6):567-74
Khatri P. Neurology 2009; 73 (13): 1066-1072
Time is Brain Stroke Systems of Care
We Have to Get Organized…
• Pre-hospital Systems of Care
• Community education for symptoms & EMS activation
• EMS education for recognition and empowered for activation to higher level
centers
• Primary to comprehensive center network
• Limiting community hospital time/transfer time
• Efficient in-house triage, activation, treatment with endovascular to ≤ 90 minutes
Manipulating the time window
• Increasing collateralization
• Increasing Venous return/Volume – NS bolus
• Attention to BP
• Positioning
• Balloon pumps/mechanical counter-pulsation
• Neuroprotection agents; hypothermia
Collaterals
• Numerous stroke clinical trials are demonstrating the profound impact of
collaterals
•
•
•
•
•
Recanalization
Reperfusion
Smaller infarcts
Less hemorrhagic transformation
Better clinical outcomes
The Future
• We have gone from our first generation of clot removing procedures,
which were only moderately good in reopening target arteries, to
now having highly effective tools.
• Imaging from non-contrast CT to identification of salvageable tissue
to looking at collateral flow.
Collateral Flow Grading
American Society of Interventional and Therapeutic
Neuroradiology Collateral Grading System
Grade
Cerebral Collateral Flow Grading Description
Grade 0
no collaterals visible to ischemic site
Grade 1
slow collaterals to the periphery of the ischemic site with
persistence of defect
Grade 2
rapid collaterals to the periphery of ischemic site with persistence of
some of the defect and to only a portion of the ischemic territory
Grade 3
collaterals with slow but complete angiographic blood flow of the
ischemic bed by the late venous phase
Grade 4
complete and rapid collateral blood flow to the vascular bed in the
entire ischemic territory by retrograde perfusion
Collateral Flow with Time
The Future
• Collateral therapeutics may entail use of readily available
hemodynamic manipulations such as head positioning,
hypervolemia, hypertensive therapy, or partial aortic
obstruction in selected cases.
Theory of Collateral Flow
• The connection between leptomeningeal collateral flow (LMF) and the survival of
brain parenchyma during acute ischemia has been confirmed in a large number of
clinical studies Bang OY. Stroke. 2011;42:2235-2239.
Collaterals Avert HT
• Data revealed that therapeutic recanalization in the setting of poor
collaterals resulted in a high frequency of HT with worsened clinical
neurological status.
• Poor collateral status at baseline may limit effective reperfusion, even
when recanalization is successful.
• Bang OY. Stroke. 2011;42:2235-2239.
CTA to Obtain Collateral Flow
Alberta Stroke Program Early CT Score
(ASPECT)
• 10 point quantitative topographic CT scan score to assess early ischemic
changes of the MCA region
• Assessed at 2 standardized regions
• Ganglionic Level where the thalamus, basal ganglia and caudate are visible
• Supraganglionic level which includes the corona radiata and centrum semiovale
ASPECT score
Normal ASPECT score is 10
Deduct 1 point for each area involved.
A score of 7 or less
Correlates with poor functional outcome and hemorrhage.
*Limitation – Only scores the MCA
HOUSTON MSU Standard 12 foot
ambulance
BEST MSU Study
• Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit
Compared to Standard Management by EMS
• Aims
• Determine the logistic and clinical outcomes of MSU vs SM in the U.S. – speed, #,
first hour.
• Can MD/Nurse be replaced by Telemedicine?
• What is the Cost Effectiveness?
WHY is Nursing Research Important?
• Build the scientific foundation for clinical practice
• Prevent disease and disability
• Manage and eliminate symptoms caused by illness
Social Work/Clinical
Resource
Management
Primary Care
Home Care
Physical
Therapy
Family
Care Givers
Nutrition
STROKE
Program
Pharmacy
Acute Rehab/SNF
Multidisciplinary Care
Palliative Care
Hospice
Community
Resources
Steps in Research Process
• Identify the problem or question.
• Does Red Print or Blue print on patient education materials improve patients retention of
knowledge?
• Review the literature
• Lit search on patient education materials and retention – variables that influence
• Develop hypothesis
• Red print educational materials result in higher stroke knowledge retention
• Methodology - Decide how you will investigate the question/hypothesis?
• 50 patients will be given red print and 50 patients will be given black print. A post test
will be developed and provided. Variables such as age, race, sex, highest completed
education, NIHSS will be collected in addition to results.
Research
Design
Use of
Databases
Retrospective
versus
Prospective research
• Get With The Guidelines-Stroke
• University Health Consortium (UHC)
• Home grown databases
Steps in Research Process
• Institutional Review Board (IRB)process.
• Implement methodology/collect data
• Analyze results - statistics
Steps in Research Process
• Draw conclusions
• Share conclusions
• Implement change
Integrating Research Findings
• One example is the updates to clinical practice guidelines – developed by
AHA/ASA work groups.
•
•
•
•
•
When published, we need to compare to current practice
Discuss gaps/changes recommended in stroke team meetings
Work with E record, nursing focus groups, etc
Change protocols, documentation records, educate all team members
Measure
Nursing Symposium
Georgia Stroke Professional Alliance
Gulf Coast Medical Center
Reducing Readmission Rates
• Higher than national average readmission rates (Range 14.9%-18.6%)
• Implemented discharge rounds to decrease rate
• Evolution of process
• Phone conference decreased from 18% to 8.9%
• Unit level conference further decreased to 8.4%
• Bedside, nurse led DC rounds further decreased to as low as 5.3%
• Rounding tool used
• PT, OT, SLP recommendations
• New medications
• DC plan – social/family concerns
Nursing Symposium Many more….
• Nursing & EMS – Bridging the great divide
• Head up vs head down in acute stroke
• Evaluating care giver needs
• Transitions of care
• Palliative care
• Too many to review all!!
2016 Call for
abstracts:
May 20- Aug 11, 2015