Acute Stroke Management in Northern Nevada and the

Sierra Slopes

A Model for Rural Stroke Care

Paul M. Katz, M.D.Medical Director

Washoe Comprehensive Stroke CenterWashoe Health Systems

Reno, Nevada

ObjectiveObjectiveTo determine if organized stroke care would increase the use of thrombolytic therapy and improve functional outcome in the greater Reno metropolitan area and the 25 rural hospitals serviced by Washoe Health Systems.

To establish one standard of care throughout the region.

DemographicsDemographics

Population 385,000 in Reno300,000 in surrounding service areas

One Third of all stroke admissions come from rural areas

Number of ischemic strokes per year: 800 (Nevada Department of Health estimate)

Our EMS ProvidersOur EMS Providers• We have a highly sophisticated EMS network which

includes ground and air transport• Transport vehicles equipped with full monitoring

capability• ACLS trained medics and flight nurses with ICU

training• EMS providers are trained in:

– gathering the time of symptom onset data– trained in NIH Stroke Scale– receiving facilities are alerted so that stroke team can

be activated

The ChallengeThe Challenge

To adopt a regional system for standardized triage and care of the stroke patient.

Our SolutionOur Solution

• 24-hour Regional Stroke Team:– Stroke Neurologist– Stroke Nurse– Neuroradiologist– Neurosurgeon– Pharmacist– ED personnel

Our SolutionOur Solution (cont’)

• Standard Pre-hospital and hospital protocols put in place in all communities

• Each Rural Hospital and EMS provider personally visited and inserviced on the protocols

• Teleradiology used for CT interpretation in rural hospitals (now available to stroke neurologist on PC)

Our SolutionOur Solution (cont’)

• Major public awareness campaign to educate Northern Nevada and Sierra Slopes communities as to the warning signs and risk factors for stroke

• Ultimately Telemedicine will optimize the evaluation of patients in rural hospitals (now being piloted in 3 locations)

ResultsResults

• 9% of all patients receive thrombolytic therapy

• 1/5 of patients receive IV tPA in rural hospitals and are immediately transported to Reno for ICU care

• Mean NIH Stroke Scale Score 12 (range 3-24)

ResultsResults (cont’)

• At 3 months functional outcomes assessed using Barthel Index– 68% of patients are living independently – 32% dependent on caregivers or institutions

• Patients do not receive tPA after the 3 hour window

ConclusionConclusion

Our initial experience in Northern Nevada and the Sierra Slopes supports the concept that organized stroke care can, not only, increase the frequency with which we use thrombolytic therapy, but it improves outcomes as well.

ConclusionConclusion (cont’)

The success of a regional comprehensive stroke center involving many rural hospitals depends heavily on standardized protocols for the pre-hospital and hospital settings as well as a careful assessment by the regional stroke team of the capabilities and limitations in each rural area.