The Stroke Continuum MA Department of Public Health 2010.

The Stroke Continuum

MA Department of Public Health

2010

CEU’s and CME’s

The Bureau of Infectious Disease Prevention, Response and Services,Massachusetts Department of PublicHealth, designates this educationalactivity for a maximum of 1 Credit.

Credits will be awarded after successfully completing this slide deck and obtaining atleast 80% correct answers on the post- test.

Learning Objectives

Define 2 most common types of stroke. Identify the stroke continuum. List 4 modifiable stroke risk factors. Name 3 observable stroke signs or

symptoms. Describe reason for calling 9-1-1 for

stroke signs and symptoms. Articulate “door-to-needle” goal for tPA

administration.


Prevention

Recognition

9-1-1

Emergency Medical Services

Emergency Department

Inpatient Hospitalization

Rehabilitation

Re-integration to the Community

Stroke: What is it?

Injury or death of brain tissue from oxygen deprivation.

A life threatening emergency.

Blood Supply to the Brain

Each artery supplies blood to specific areas of the brain.

Stroke occurs when one of these arteries to the brain either is blocked or bursts.

Source: National Stroke Association

Motor and Sensory Function

Transient Ischemic Attacks

Temporary blockage <24 hours duration.

Symptoms of numbness, trouble speaking, and loss of balance or coordination.

Increased risk of having stroke within 90 days.

Source: National Stroke Association

Ischemic Stroke

Clot cuts off oxygen to a part of the brain.

Most common stroke (80 – 85% of all strokes).

Types of Ischemic Strokes

Embolic A blood clot or

plaque fragment that forms in the body moving through the bloodstream to the brain.

ThromboticA blood clot thatdoes not travel butforms inside anartery supplyingblood to the brain.

Hemorrhagic Stroke

Burst blood vessel in brain that spills blood into brain tissue.

Accounts for about 15-20% of all strokes.

Types of Hemorrhagic Stroke

Intracerebral hemorrhage: Blood vessel bursts into the brain High blood pressure most common cause

Aneurysm: Weak spot on artery wall that balloons out,

forming a thin-walled bubble Leaks blood into or outside of the brain

Subarachnoid hemorrhage: Blood vessel bursts near surface of brain

pouring blood into area outside brain Increases pressure on brain

Facts About Stroke Stroke can happen at any time,

regardless of race, sex or age. Every 40 seconds someone in the US

has a stroke. Every 3-4 minutes, someone dies from

stroke. Two million brain cells die every minute

during stroke, increasing the risk of permanent brain damage, disability or death.

National Stroke Association

Facts About Stroke in Massachusetts

In 2007, stroke accounted for 5.1% (2,700) of all deaths and remains the third leading cause of death.

MA Vital Records 2007

In 2007, 2.4% of adults reported having had a stroke.

MA BRFSS 2007 Over 17,000 patients are hospitalized

for stroke every year.

MA Hospital Discharge Data 2004-2007

Disability

Stroke is a leading cause of adult disability in the US.

With timely treatment, the risk of death and disability from stroke can be lowered.

In 2010, stroke will cost the US $73.7 billion in health care services, medications, and lost productivity.

CDC; AHA


Prevention

Recognition

9-1-1




Rehabilitation


Modifiable Risk Factors for Stroke

High Blood Pressure Overweight/Obesity Diabetes High Cholesterol Tobacco Exposure Excessive alcohol consumption Drug Abuse Atrial Fibrillation

High Blood Pressure

High blood pressure – higher than 140/90. Approximately 30% of adults are unaware of

their high blood pressure. JNC-7

More than 40% of individuals with high blood pressure are not on treatment. JNC-7

2/3 of people with high blood pressure are not controlled to BP levels <140/90. JNC-7

26% of Massachusetts adults have high blood pressure. MA BRFSS 2007

47

Extent of Awareness, Treatment and Control of High Blood Extent of Awareness, Treatment and Control of High Blood Pressure by Age Pressure by Age (NHANES: 2005(NHANES: 2005--2006).2006).Source: NCHS and NHLBI.Source: NCHS and NHLBI.

53.8

33.127.9

67.2

48.8

77.279.9 82.4

45.9

0102030405060708090

Awareness Treatment Controlled

Pe

rce

nt

of

Po

pu

lati

on

Wit

h

Hyp

erte

ns

ion

20-39 40-59 60+

Awareness, Treatment and Control of High Blood Pressure by

Age

NHANES: 2005-2006. Source NCHS and NHLBI

High Blood Pressure in MA Adults by Age and Gender

MA BRFSS 2005, 2007

16%

28%

43%

53%56%

10%

23%

39%

56%62%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

35 - 44 45 - 54 55 - 64 65 - 74 75+

Per

cen

t o

f A

du

lts

age

35 a

nd

old

er Men Women

High Blood Pressure in MA Adults by Race, Ethnicity and Gender

MA BRFSS 2003,2005, 2007

0%

10%

20%

30%

40%

50%

WNHWomen

BNHWomen

Hisp.Women

WNH Men BNH Men Hisp. Men

Per

cen

t o

f A

du

lts

35 a

nd

old

er

2003 2005 2007

Overweight and Obesity in Massachusetts

56.1% of adults are overweight or obese.

22% of adults are obese. 73% do not eat the recommended.

five or more servings of vegetables and fruits a day.

49% do not get regular physical activity.

MA BRFSS 2007

Obesity Trends Among U.S. Adults, 1995

No Data <10% 10%–14% 15%–19%

Obesity Trends Among U.S. Adults, 2000

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends Among U.S Adults, 2005

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Diabetes

In Massachusetts, 7.4% of adults have been diagnosed with diabetes. MA BRFSS 2007

CDC estimates that an additional 2.2%

of Massachusetts adults don’t know that they have diabetes.

People with diabetes are two to four times more likely to have a stroke.

National Stroke Association

NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, NCHS.Source: Health, United States, 2006, NCHS.

4.06.16.5

5.0

11.3 10.5

17.017.5

02468

101214161820

6-11 12-19

Per

cent

of P

opul

atio

n

1971-74 1976-80 1988-94 2001-2004

Overweight and Obesity in US Children and Adolescents

High Cholesterol in MA

35.6% of MA adults have high cholesterol. MA BRFSS 2001-2007

The prevalence of high cholesterol has been increasing each year.

MA BRFSS 2001-2007

Low HDL cholesterol (the “good” kind) in men is a risk factor for stroke. American Stroke Association

TobaccoCigarette smoking

approximately doubles a person’s risk for stroke. CDC

In MA, the cities of Springfield, Fall River, New Bedford, Lowell, and Worcester have significantly higher rates of smoking than MA overall. MA BRFSS 2007

Excessive Alcohol Consumption

Chronic, excessive alcohol intake can precipitate hemorrhagic stroke:No more than 2 drinks per day for men

and no more than 1 drink per day for non-pregnant women. AHA

Most risk from excess alcohol intake is likely due to high blood pressure and impaired blood clotting mechanisms. National Stroke Association

Drug Abuse

Use of cocaine, amphetamines, and heroin associated with an increased risk of stroke.

Strokes caused by drug abuse are often seen in a younger population.

American Heart Association

Atrial Fibrillation

Characterized by an irregular and frequently fast heartbeat, atrial fibrillation (AFib) is the most common form of heart arrhythmia.

Associated with a five-fold increase in risk for stroke.

About 15% of people with strokes have Afib.

Increases the risk of death from stroke. National Stroke Association


Prevention

Recognition

9-1-1




Rehabilitation


Signs and Symptoms

Only 23.3% of Massachusetts adults recognize all stroke signs and symptoms.

MA BRFSS 2007

Stroke Heroes Act FASTEducational kit for Train the

Trainer Model. Media campaign – TV, radio,

newspaper and transit ads.Cultural adaptation – English,

Spanish, Portuguese, and Khmer.

Stroke Heroes Act FAST

ADD ANIMATION HERE

F = Face Droops on left or right side Sudden drooling Numbness

Ask person to smile

A = Arms Look for difficulty holding things or putting on

clothing Numbness One arm drifts down or

won’t go up May have trouble walking

Ask person to raise both arms

S = Speech Slurred speech Doesn’t make sense May not understand what other people are

saying Forgets how to

read or write

Ask to repeat phrase

or name object

T = Time Time lost is brain lost Save time and brain cells, go in an

ambulance

At any sign, Call 9-1-1

The “Suddens” SuddenSudden numbness or weakness of face, numbness or weakness of face,

arm, or leg, especially on one side.arm, or leg, especially on one side. SuddenSudden confusion, trouble speaking or confusion, trouble speaking or

understanding speech.understanding speech. SuddenSudden trouble seeing in one or both trouble seeing in one or both

eyes.eyes. SuddenSudden trouble walking, dizziness, loss of trouble walking, dizziness, loss of

balance or coordination.balance or coordination. SuddenSudden severe headache with no known severe headache with no known

cause.cause.


Prevention

Recognition

9-1-1




Rehabilitation


Time Lost = Brain Lost

Delays in calling 9-1-1:Most strokes are painless.Symptoms can be subtle.Person having a stroke may be unaware or unable to communicate.

Observers do not recognize it as a serious problem.

EMS Care is Critical

Identification of stroke by conducting stroke scale assessment.

Establish “last known well” time.Pre-notification to hospital to

activate stroke team.Transport to most appropriate

hospital for stroke care.


Prevention

Recognition

9-1-1




Rehabilitation


Primary Stroke Service (PSS) in MA

MDPH regulations passed by the state legislature in 2004.

Assure ambulances take patients to hospitals that can provide definitive care.

Improve coordination of care/pre-hospital care for persons experiencing stroke symptoms.

Assure hospitals have systems in place to accurately diagnose and treat, 24 hours per day, 7 days per week.

Primary Stroke Service (PSS) in MA

Assure data available to monitor system performance.

Emergency diagnostic and therapeutic services provided by a multidisciplinary team.

Time targets: Door-to-stroke team: 15 minutes Door-to-CT scan: 25 minutes Door-to-needle: 60 minutes

Stroke Treatment

Activase® (alteplase, recombinant, IV-tPA, tPA), was approved by the FDA for the treatment of acute ischemic stroke. IV-tPA is recommended for selected patients

within 3 hours of “last known well”. (Class I, LOE A)

IV-tPA should be administered to eligible patients within 3.0-4.5 hours of “last known well”. (Class I Recommendation, LOE B)

Adams, Stroke 2007

Meta-Analysis of the major IV tPA trials shows clear benefit up to 3 hrs and NOW beyond

Lancet, 2004; 363: 768–74

NINDS 12% ECASS3 7%

Door to Needle Time

The benefit of IV-tPA in stroke is strongly time dependent.

It is best right after symptom onset and declines steadily thereafter:1.9 million neurons lost per minute,For every 10 minute delay in tPA

delivery, 1 less patient improves. BAC/AHA/NIH recommendation: door to

needle time < 60 minutes. Only 27% of tPA patients at PSS hospitals

were treated within 60 minutes of arrival.

Impediments to tPA Use

Patient arrival at Emergency Department beyond 3-hour window.

Clinician acceptance of tPA due to risk of bleeding complications.

Institutional attitude and support related to the ability of medical systems to rapidly evaluate and treat stroke within the timeframe.

CDC’s Paul Coverdell National Acute Stroke Registry

Goal: to ensure that all Americans receive the highest quality of acute stroke care currently available and to reduce the number of untimely deaths attributable to stroke, prevent stroke-related disability, and prevent stroke patients from suffering recurrent strokes.

Focus: monitoring and improving the quality of stroke care for acute (Emergency Department), inpatient and secondary prevention (discharge) performance measures.

Get With The Guidelines (GWTG)-Stroke

Quality improvement for in-hospital acute care.

National program with over 1,600 hospitals and 1 million patient entries in registry.

Data management tool by Outcomes Science.

Stroke Performance Measures

In 2007, The Joint Commission, CDC, and the American Heart Association formed a Consensus Group to harmonize the stroke measures being collected by the three organizations. The result was the set of 10 consensus measures.

Consensus MeasuresConsensus Measures(* = Get With The Guidelines Performance (* = Get With The Guidelines Performance Measure)Measure)

1. Thrombolytic Therapy Administered*2. Antithrombotic Therapy by end of hospital day 2*3. DVT Prophylaxis*4. Discharged on Cholesterol Reducing Medication*5. Discharged on Antithrombotics* 6. Patients with A-Fib receiving Anticoagulation Therapy*7. Smoking Cessation/Advice/Counseling*8. Dysphagia Screening9. Stroke Education10. Assessed for Rehabilitation

Massachusetts Stroke Registry

Collaboration between MDPH, American Stroke Association, and PSS Hospitals, focusing on quality improvement, standardized performance measures, and systems changes.

IV-tPA Use at SCORE Hospitals

Data from 56 SCORE hospitals Registry data from 1/07-12/08~8,000 statewide ischemic stroke patients

entered into registry~1,000 ischemic stroke patients with no

contraindications to tPA arrived within 2 hrs of last known well

~550 eligible ischemic stroke patients or 55% received tPA

SCORE Acute Measures

67%

56%

68%71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

tPA within 3hrs of Onset

% A

dhere

nce

2006 2007 2008 2009

SCORE Inpatient Measures

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dysphagia Screen DVT Prophylaxis Antithroms by Day 2

% A

dher

ence

Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009

SCORE Discharge Measures

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

D/ C onAntithroms

D/ C onAnticoagsfor Afib

SmokingCessation

D/ C on aStatin

StrokeEducation

Rehab

% A

dhere

nce

Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009


Prevention

Recognition

9-1-1




Rehabilitation


Transition of Care from Hospital to Outpatient Services

Improving hospital discharge. Better coordination of care. Improve communication between

sending and receiving healthcare providers.

Improve patient safety. Reduce medication errors.

CEU’s and CME’s

To apply for CME/CEU credits, fill out the post-test at:

http://bit.ly/10mJhof

Credits will be awarded after successfully completing this slide deck and obtaining atleast 80% correct answers on the post- test.

Questions, Comments…

Mirian Barrientos, MPH, CPHQHeart Disease & Stroke Prevention & Control Program

Massachusetts Department of Public Health250 Washington Street, 4th FloorBoston, MA 02108Tel: (617) 624-6065Fax: (617) [email protected]

The Stroke Continuum MA Department of Public Health 2010.

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Transcript of The Stroke Continuum MA Department of Public Health 2010.