Dr. Todd CollierNeurologist

Royal Inland HospitalBC 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.

“How to Handle Hot Stroke or Hot TIA?”The only way is to have organized/systematic stroke careWhat is happening in BC and elsewhereWhat is IHA doing to achieve this

Stroke Risk Increases with Age

0

200

400

600

800

1,000

1,200

35–44 45–54 55–64 75+

www.statcan.ca

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Oxford Vascular Study: ResultsPopulation 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 leadershipOrganizes the annual National Stroke Course aimed at Internists and EM DocsNational Stroke Course, October 23-24, 2010, Marriott Chateau Champlain Hotel, Montreal

Primary PreventionRapid Assessment of TIA Patientst-PA thrombolysisASAOrganized Inpatient Care (Stroke Units)Organized Rehabilitation CareSecondary Prevention

Hypertension Hypertension HypertensionSmoking DiabetesHyperlipidemiaInactivityObesityHeavy Alcohol IntakeAtrial 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

TIA patients seen in Stroke Prevention Clinics◦ 8% ⇒ 17%tPA use for patients presenting within 2.5hrs◦ 5% ⇒ 14%Patients cared for in Stroke Units◦ 2% ⇒ 18%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 Guidelinebcguidelines.ca

Prepared by Global Medical Services

Emergency DepartmentCurrent Practice Indicators Project

July 2007

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Stroke/TIA Indicators – HA Averages

IH

HA Averages

8

49

28

7

30

81

29

6

37

73

5

67

155

31

73

15

86

26

85

0102030405060708090

100

Stroke patients received tPA Blood glucose checked onarrival

ECG performed in ED Patients ineligible forthrombolysis and given atleast 160 mg ASA therapy

initiated in ED

Indicators

Perc

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%)

IH ED Protocol Working GroupIH Stroke Leadership Committee Royal Inland Stroke Unit working groupLori Seeley, IH Clinical Lead, Stroke and Acquired Brain InjuryJaymi Chernoff RN, BScN, TIA Rapid Access Project Coordinator for Interior Health

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InteriorHealth

• 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 site4. Rural and Remote sites (too far away from tPA

enabled sites)

Primary PreventionRapid Assessment of TIA Patientst-PA thrombolysisASAOrganized Inpatient Care (Stroke Units)Organized Rehabilitation CareSecondary Prevention

Standard OrdersOngoing Education and Quality ImprovementIdentify the roles played by different staff:◦ Paramedics ◦ Family Doctors◦ EM Docs, Internists, Radiologists, Nurses◦ Physio, OT, Speech ◦ Clinical Nutrition, Social WorkClarify referral patterns for diagnostic tests, consultations, rehabilitation

Put the Stroke/TIA Emergency Diagnostics Order Set on the patients chart if you suspect a stroke.

KelownaKamloopsPentictonVernonCranbrookTrail

MigrainesSeizuresSubdural HematomaTumourMS Peripheral VestibulopathyBell’s PalsyHyper/HypoglycemiaSyncopeCNS InfectionDeliriumDrug toxicityTransient Global AmnesiaConversion Disorder

Strategic investment in Telestroke will act to:

• 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.

TELESTROKE

CranbrookSalmon ArmTrailVernonWilliams LakeKelownaPenticton

Dedicated stroke wardMultidisciplinary care teamNNT 33 to prevent deathNNT 20 to regain independence

A four bed room on 5 NorthOne RN for the four stroke patientsA flex bed always available on 5N wardThe least acute patient is moved out to the ward to allow new stroke admissionsTuesday 9am Multidisciplinary Stroke RoundsStandard order sets and proceduresEarlier rehabilitation assessment and planningt-PA patients come after 12hours in ER or Step Down Unit

No Foley catheterIn&Out catheterization q6H if unable to voidReduces length or stayReduces chance of infectionIncreases chances of regaining bladder controlEasier for patients to be mobilized

Treating TIA Urgently to Prevent Stroke

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

Five Priority Areas established in 2006/71. Standard Stroke Orders Sets in all BC Emergency

Departments2. TIA/Minor Stroke Rapid Assessment Programs for

all Health Authorities3. Telestroke4. Rehabilitation and Community Integration5. Monitoring and Evaluation

Late 2008 the Ministry of Health decided tPA should be made a priority again

Same mechanismMRI 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

Need urgent investigation and treatment

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Speech, motor, >10 min, age >60, diabetes

Stroke Risk after a TIAGladstone D et al. CMAJ. 2004 Mar 30;170(7):1099-104.

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12.7%

2.6% 2.6%

0%

5%

10%

15%

20%

25%

30%

Stroke RecurrentTIA

Cardio-vasc.

Death

10.5%

5.3%at

2 days

Post-TIA 90 day Outcomes

Johnston SC, et al. JAMA, 2000; 284:2901-2906

EXPRESS STUDY

90 DAY STROKE RISK:◦ BEFORE: 10%◦ AFTER: 2%

Also supported by FASTER and SOS-TIA Trials

EXPRESS Study 90 day Recurrent Stroke Rate

Rothwell Lancet 2007

Effect of Early Comprehensive Treatment on Risk of Stroke

Risk of recurrent stroke after first seeking medical attention in all patients with TIA or stroke who were referred to the study clinic.

60% were treated within one day

50% were treated by 20 days

Rapid Assessment Clinics for TIA and Minor Stroke

Currently operating in Kamloops and CranbrookReferral form faxed from any ER, GP office, or Clinic in Thompson Cariboo Shuswap Region or East Kootenay RegionAim to see all patients within 24-72hoursOnly for ambulatory outpatients

Rapid Assessment Clinic continued

Clinic Patients will get:◦ Consultation with a Neurologist/Internist◦ Immediate access to investigations◦ Education and Treatment

This Model Could Work for all of Interior HealthEach Health Service Area could set up a

similar clinic at a Regional Hospital◦ East Kootenay: Cranbrook◦ West Kootenay: Trail◦ Okanagan: Kelowna and Penticton◦ TCS: KamloopsPhysicians 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 After 3 months

NNT=3.5

Identify Atrial Fibrillation

MedicationsASA + Plavix for one month, then ASA aloneAntihypertensivesStatinsSmoking CessationDiabetic Management

Education of Patients and Family

Primary PreventionRapid Assessment of TIA patientsParamedic Stroke ProtocolsStandard Emergency Stroke Orders and ProtocolsStandard Stroke Admission OrdersStroke Unit CareStroke RehabilitationSecondary PreventionTelestroke/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.

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ABCD2

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

Stroke Risk after TIA: ABCD2 Score

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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