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Endovascular Thrombectomy (EVT) – Moving Towards a Streamlined System

of Care: A Case Study Review

Dr. Grant Stotts, Director, Ottawa Stroke Program

Deputy Head, Division of Neurology, Ottawa Hospital

Provincial Stroke Rounds February 7, 2018

Questions: Send to sue532@hotmail.com

Evaluation: Link http://bit.ly/PSREval

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Scan the QR code here:

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Mitigating Potential Bias (Planning Committee)

The Provincial Stroke Rounds Planning Committee mitigated bias by ensuring there was no Industry involvement in planning or education content.

To comply with accreditation requirements of the College of Family Physicians of Canada and The Royal College of Physicians and Surgeons of Canada, speakers were provided with Declaration of Conflict of Interest forms, which were reviewed by the Ontario Regional Education Group (OREG) Host member on behalf of the Planning Committee and submitted to the NOSM CEPD Office.

The Ontario Regional Education Group (OREG) Host member on behalf of the Planning Committee reviewed the initial presentation supplied by the speaker to ensure no evidence of bias.

Presenter Disclosure

• Dr. Grant Stotts

• Relationships with commercial interests: – No Disclosures

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Presentation Outline

• Provincial EVT

– Current state of EVT in Ontario

– Priority Actions (Provincial EVT Steering Committee)

• Key strategies used in the successful delivery of EVT:

– System of Care (i.e. communication, transport and repatriation)

– Imaging (i.e. CT/CTA provincial imaging protocols)

– Door In Door Out Times at referring sites

EVT Centres in Ontario

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5

EMS

transfer

IV tPA (if

indicated)

Stroke

Symptom

Onset

EMS arrival at

ED (EVT

centre)

IV tPA (if

indicated)

Groin

Puncture

Critical Step-

Down Unit EVT Centre

Stroke Unit

EMS arrival

at scene

Reperfusion

Achieved

EVT

Procedure

CT/CTA

EMS arrival

at ED

(referring

site)

CT/CTA

Call

CritiCall

EVT: THE PATIENT

JOURNEY

Repatriated to

Community

Hospital with

Stroke Unit

Follow up with

Stroke

Prevention Clinic

Discharge

Home

911

Call

Discharge

Home

Inpatient

and/or

Outpatient

Rehab

Discharge

Home

1. Non-tPA Sites

• EMS Bypass and walk-in protocols are to be used for rapid transfer to a

tPA site or EVT site if significantly closer.

2. tPA Site

•

•

tPA may be delivered through Telestroke or an onsite stroke physician. Once patient eligibility for EVT is confirmed, referral is initiated through CritiCall Ontario.

3. EVT Intervention sites

• Sites provide EVT for appropriate patients based on CTA results & neurological exam

Current Infrastructure to Support and Guide EVT Implementation

1. EVT Steering Committee- Co-Chairs: Dr Grant Stotts and Dr Timo Krings a. Mandate: To advise CorHealth Ontario and collaborate with the eleven regional

stroke networks to: confirm stroke endovascular treatment best practices; provide expert advice on strategies to improve quality; inform development of tools and processes; and support knowledge translation.

b.Task Groups: i. EMS/Patient Transport

ii.Imaging

iii.Performance Measurement and Monitoring

iv.Implementation Framework

c. Membership: Stroke Neurologists, Neurointerventionalists, Base Hospital Physician, MOH EHS, MOH, RDAC, CritiCall, CorHealth, Best Practice Coordinators, Telestroke Neurologists

2. Regional and District Advisory Committee a. Implementation Framework Task Group

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Current Infrastructure to Support and Guide EVT Implementation

1. EVT Process Reporting

a. Purpose: To identify trends in inform quality improvement and system planning

b. Regional follow-up coordinated and forms monitored by CorHealth Ontario for trends to inform quality improvement and system planning

I. Recurring Themes:

i. Transfer

ii.Referral

iii.Imaging

iv.Technology ( ENITS, OTN)

2.Monthly meetings with CritiCall Ontario

EVT Resource Centre

2017/18 Implementation Priorities Provincial Regional

Access Access

Volumes Volumes-Repatriation/Communication

Imaging Imaging

Door To Needle Time Door To Needle Times-Process Improvement

Performance Measurement and Monitoring

Education/Expertise Education/Expertise

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EVT Provincial Priorities

• Access – Align capacity to system needs

• Remote and rural gaps

– Revisit 2 hour transport time – In-hospital code stroke

• CritiCall role • Repatriation and communication

processes

• Volumes – Inform adequate volume based

funding – Plan for managing

simultaneous cases – Determine resource needs of

referring sites

• Imaging – Determine resource needs to

support access 24/7 – Support regional planning for

access 24/7

• Door to Needle Time – Include 30 minute target on

Stroke Report Card – Establish Telestroke site target

of DTN minutes

EVT Provincial Priorities

• Performance Measurement & Monitoring – Finalizing recommendation for

data collection and reporting • CIHI Special Project • Monthly meetings with CritiCall • EVT Process Reporting Form

• Education and Expertise – Embed EVT topics in Provincial

Stroke Rounds – Coordinate EVT focused

webinars – EVT Resource Centre – Utilize briefing note for updates

• Additional Provincial Priorities – Support changes to paramedic

prompt card – Determine process to monitor

impact of moving to 6.0 hour window

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Case #1: System of Care

• Snowy Monday

• Female in her 40s, right handed, healthy, married with two adult children, minimal risk factors (HRT, non smoker, minimal alcohol intake, physically active, no family history)

• At work, at approx. 0935, standing with coworkers, and reportedly developed sudden onset right side facial droop, garbled speech and right sided weakness.

• 911 call at 0945, EMS on scene with patient contact at 0953. Depart scene 1003 and arrived at District Stroke Centre at 1013 (approx. 12km)

• EMS initiated 18 gauge AC IV prior to scene departure

• Triaged at 1019 as CTAS 2, RVH ED physician at door upon arrival.

Assessment

• ED physician initial assessment found right sided facial droop, mild weakness to right arm and leg (able to lift against gravity only), dysarthria and inappropriate speech. RVH Acute Stroke Protocol activated, alerting Acute Stroke Team (AST) physician, Clinical Nurse Specialist, and CT technologist to activate ‘next on table’ protocol. This includes notification of interpreting RVH radiologist (in house).

• CT/mCTA head ordered STAT, as per provincial protocols. Patient was brought to CT on EMS stretcher. Door to CT = 5 minutes (1024)

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Assessment • AST neurologist initial patient contact at 1047. Patient had

completely resolved symptoms (NIHSS = 0) at this time.

• Discussion between RVH radiology and RVH AST neurologist, neurology suspicious of filling defect in the L-MCA region – proximal M1; final interpretation of CTA - left MCA M1 thrombus with good collateral perfusion. ASPECTS 8-9.

• In the absence of symptoms, decision to hold tPA was made, but further consultation for EVT was required

• Criticall initiated at 1127 for EVT consult

• Discussions with RVH and TWH surrounding treatment of LVO in the absence of symptoms. Decision to hold tPA and transfer for EVT consideration was made

• Patient accepted for EVT consideration at 1156 (total Criticall time 28 minutes)

CT-Angiogram

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Treatment • Significant discussion with family re treatment options

required (1156-1224)

• At 1224, while awaiting transport, patient had sudden reoccurrence of original symptoms (NIHSS 15, for right sided hemiplegia, significant aphasia, right facial droop)

• AST neurologist present, administered tPA bolus at 1228. Door to needle – 129 minutes, new symptom onset to tPA = 4 minutes

• TWH notified re new onset of symptoms

• Door out via Simcoe EMS at 1305 (DIDO = 166 minutes)

Outcome • Arrived at TWH at 1422 (285 min from original symptom onset, 116

min from second symptom onset)

• Triaged TWH = 1426, Groin puncture = 1459

• Time of revascularization = 1506 (331 min from original symptom onset , 162 min from second onset of symptoms)

• NIHSS 24h post = 1 (mild right arm drift)

• Upon discharge from TWH, she demonstrated mild expressive aphasia and mild weakness in right upper extremity

• Discharged home on day 3 with HCC support and outpatient rehab

• One month post stroke – post stroke fatigue and occasional word finding are chief complaints. Independent in all ALDs, MoCA 26/30

• RVH SPC follow up 19/1/2018

• Likely stroke etiology – hormone replacement therapy with superimposed migraine with aura. Thrombophilia work-up and 14 day Holter have been ordered and pending

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Key Strategies/Messages • Public awareness FAST • Rapid triage, assessment and brain vascular imaging

– including multiphase vascular imaging to assess site of occlusion, access, and status of intracranial collateral supply) of acute ischemic stroke patients who are potential candidates for EVT

• Collaboration all system players (local team members and across sites)

• Utilization of Telestroke to support identifying eligible patients wherever possible

• Informed consent - dialogue with patient and family influenced by complexity

• Ready response for fluctuating symptoms • Finalizing processes, completing education for various

stakeholders, efforts to reduce time to therapy, ongoing quality improvements

Process Reporting Form

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Current Infrastructure to Support and Guide EVT Implementation

1. EVT Process Reporting

a. Purpose: To identify trends in inform quality improvement and system planning

b. Regional follow-up coordinated and forms monitored by CorHealth Ontario for trends to inform quality improvement and system planning

I. Recurring Themes:

i. Transfer

ii. Referral

iii.Imaging

iv.Technology ( ENITS, OTN)

2. Monthly meetings with CritiCall Ontario

EVT Resource Centre

Question & Answers

Send questions to sue532@hotmail.com

2/6/2018

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Case #2: Imaging • 50 yo female at home in small rural community 57 km from

Belleville Ontario (District Stroke Centre) • At 0800 hrs she was holding a coffee pot and about to pour her

husband a coffee when she dropped the coffee pot • Husband found her confused, unable to speak, and unable to

move her right hand so he called 911 • Paramedics arrived and found her aphasic with right facial droop

and right hemiparesis. • Acute Stroke Protocol activated by paramedics and closest

community hospital bypassed to bring her to Belleville General Hospital (BGH)

• Pre-arrival activation of ‘code stroke’, occurred at BGH, including an overhead page, to ensure that ‘Code Stroke Team’ of nurses and physicians were waiting in the BGH ED when the patient arrived and patient pre-registered.

• Ambulance arrived at the doors of the BGH ED at 0923 hrs

• According to the ‘Race Care Pit Stop Model of Stroke Care’, rapid assessment of the patient occurred in the hallway just inside the ED doors on the paramedic stretcher. This involved simultaneous history taking and patient assessment by physician, with establishment of IV’s and drawing of bloodwork by Code stroke team nurses.

• NIH Stroke Scale = at least 19

• Paramedics then carried on to the CT Scanner, patient still on the ambulance stretcher. The ‘Code Stroke Team’ accompanied the patient.

• CT scanner had been cleared by the diagnostic imaging staff, and was available and waiting for the patient.

• Door to CT time was 6 minutes.

Assessment

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• Stroke physician signed request for plain CT head and mCTA (as per provincial imaging protocol) and signed the emergency consent form for IV contrast

• Criticall contacted by the stroke physician, using a designated mobile phone, to access telestroke while patient in the CT scanner being imaged

• CT head immediately followed to mCTA

• CT programmed to automatically push images to ENITS to be rapidly available to the telestroke neurologist

• Local In house radiologist contacted by the stroke physician to provide a rapid assessment

• Plain CT head = no acute cortical infarction, hemorrhage, hydrocephalus, mass effect or midline shift with a hyperdensity noted in the left MCA. mCTA = extensive occlusion left ICA.

Assessment

NCCT BGH 0930 hours

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CTA BGH – Axial and Coronals 0933 hours

• tPA delivered at 0943hrs, door to needle = 20 minutes

• The telestroke neurologist in Hamilton reviewed the plain CT and mCTA on ENITS and felt this was an ideal case for EVT.

• The regional EVT centre for Belleville is Kingston.

• Criticall then arranged for a conference call between the telestroke neurologist in Hamilton, the neurologist and interventional radiologist at the Kingston Health Sciences Centre (KHSC), and the stroke physician in Belleville.

• Decision was made to urgently transfer patient to Kingston

• Paramedic transfer urgently arranged

• A nurse was sent with the patient because tPA was still running and the patient did have some altered level of consciousness

• Door in Door out time = 67 minutes

Treatment

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• KGH Door to repeat CT- 10 min

• KGH CT to Groin Puncture – 22 mins

• KGH CT to First reperfusion - 40 min

Treatment

EVT KGH – 1158 hours

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EVT KGH – 1158 hours

EVT KGH – 1158 hours

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• Following EVT therapy the patient was admitted to KHSC for 13 days then repatriated to BGH

• Patient underwent a 9-day stay on in patient rehabilitation and was then discharged home

• Fully independent with ADLs. Full recovery of mobility, fine motor and balance. Moderate impairment auditory/verbal language and verbal expression.

• Modified Rankin at discharge from Inpatient Rehabilitation = 2

• Home & community care rehab (SLP and OT follow up, no PT follow up required)

• Outpatient follow up arranged at the local Stroke Prevention Clinic

Outcome

Key Strategies/Messages

• Rapid Door to CT – “Race Care Pit Stop Model of Stroke Care”

• CTA immediately following CT head (while still on table) as per Provincial Imaging Protocol for Telestroke Centres

• Use Established System of Care – Telestroke, Criticall

• Rapid Door to Needle Time

• Collaboration with EMS

• Nursing Escort for Drip & Ship Transfer

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Ontario CT/mCTA Protocol

5 series of images, in the following order: 1. Non-contrast CT Head (axial) 2. CTA neck and head 1.25 – 2 mm (axial) 3. 5 mm MIP Axial CTA head (2nd phase of multiphase) 4. 5 mm MIP Axial CTA head (3rd phase of multiphase) 5. 5 mm MIP Coronal CTA neck and head

Total: Approx. 520 images Access through: ENITS (Emergency Neuro Image Transfer System)

Ontario Stroke EVT Imaging Subcommittee

Question & Answers

Send questions to sue532@hotmail.com

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Case #3: Door In Door Out Times

History: • 36 year old male developed left sided facial droop

and left sided weakness at 12:30 hours while at work.

• EMS was called and patient was taken under Stroke Protocol to the Greater Niagara General Hospital (GNGH)

• PMHX: – Query heart murmur – No medications – No allergies

Assessment

• On arrival to GNGH Hospital at 13:10 hours:

– NIHSS was 11

– CT/mCTA was completed at 13:24 hours

– CT –ASPECTS – 10

– mCTA showed right M1 occlusion

• Insert Imaging – Leanne - CT

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Treatment • tPA was administered at 13:36 hours - DTN - 26 minutes • Stroke Neurologist at GNGH consulted CritiCall at 13:40 hours for

consideration for EVT • Patient was transferred Code 4 Transfer to HGH at 13:53 hours for

EVT – DIDO – 43 minutes • On arrival to HGH at 15:00 hours:

– NIHSS was 17 – Repeat CT completed at 15:05 - ASPECTS remained 10 – Consent was obtained from wife and patient taken to the

Neuroangiosuite at 15:17 hours – Groin was punctured at 15:33 hours and TICI 3 recanalization was

achieved at 15:44 hours - Groin to Recanalization – 11 minutes – Post procedure NIHSS was 2 – Patient was transferred to Neurosurgical Level 2 SDU for ongoing

monitoring post procedure – Patient transferred to Acute Stroke Unit next morning for ongoing

stroke care and stroke work-up

Outcome

• Patient was discharged home within 5 days:

– Discharge NIHSS - 1

– Discharge MRS - 2

– Day 3 Alpha FIM® - 107

– Referral to local Stroke Prevention Clinic

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Key Strategies/Messages

• Stroke Protocol Pre-Alert

– Tandberg up and Neurologist on stand-by with history

• Resuscitation “pit stop”<10 mins

• Stroke Nurse Specialists in ED Resuscitation complete NIHSS connect with Neurology

• Stay on EMS stretcher to CT, TOA and transfer to weight stretcher in CT, and EMS “Hold” in ED for max 15 mins awaiting EVT decision

Question & Answers

Send questions to sue532@hotmail.com

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Key Strategies/Messages Summary

• Use the established system (i.e. Criticall, Telestroke)

• Collaborate with EMS

• Use CT/CTA Protocol

• Speed up Door In Door Out Times

• EVT Process Reporting Form

• Time is Brain! – FAST!

Question & Answers

Send questions to sue532@hotmail.com

2/6/2018

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Evaluation: Link http://bit.ly/PSREval

OR

Scan the QR code here: