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Stroke Care at Boca Raton Regional Hospital and The

Marcus Neuroscience Institute

Brian M. Snelling, MD

Director, Cerebrovascular & Endovascular Neurosurgery Medical Director, Marilyn & Stanley Barry Center for Cerebrovascular Disease & Stroke

Stephanie Rubenstein RN, SCRN

Stroke Program Coordinator

A Brief Overview

400 Beds Marcus Neuroscience Institute 8 Bed dedicated Neuro ICU 12 Bed Neuro Stepdown Unit 20 Bed neuro tele/nsd capable Unit EMU Unit Approx. 650 stroke alerts annually Participate in GWTG/Florida Registry We Do NOT sample data Joint Commission Accredited

2 Interventional Radiologists 1 Dual trained neurosurgeon 9 Neurologists 5 Neurosurgeons 24/7 Stroke Clinicians Cleveland Clinic Tele-Neurology Program (Nights and Weekends) 7/1/2019 Neuro Residency Program

Core Stroke Team and Key Players

STROKE ALERTS Vs FINAL CODED STROKES 2018

58 57 62

47 52

40

54 47 44

49 53

71

47 39

54

36 37

26

39 36 28

35 39

43

0

10

20

30

40

50

60

70

80

Jan Feb Mar Apr' May Jun Jul Aug Sep Oct Nov Dec

STROKE ALERTS Total Strokes

459 639 72.4%

Total Strokes Stroke Alerts Accuracy Rate

Observations: ● These five measures have improved the most over the past years ● Measures shown represent Stroke Alert Median times in minutes, where lower times are better, and American Heart Association (AHA) Getting With The Guidelines additional measures, where a higher compliance is better ● Targets taken from 2019 report benchmarks for comparison purposes

↓ = Lower numbers are better ↑ = Higher numbers are better

86.5

67

46 46 37 36

0

20

40

60

80

100

2013 2014 2015 2016 2017 2018

Door to TPA Minutes (median)

Door to TPA Minutes (median) Target

↓

26 30 31.5

21

16

9.5

0

10

20

30

40

2013 2014 2015 2016 2017 2018

Door to CT Scan Minutes (median)

Door to CT Scan Target

↓

86.3% 89.5%

93.6% 96.7%

99.1% 97.5%

75%

80%

85%

90%

95%

100%

105%

2013 2014 2015 2016 2017 2018

Dysphagia Screen

Dysphagia Target

↑

96.4%

92.2% 94.7%

97.7% 100.0% 99.2%

75%

80%

85%

90%

95%

100%

105%

2013 2014 2015 2016 2017 2018

LDL Documented

LDL Documented Target

↑

35.1% 27.9% 39.8%

54.5%

86.7% 98.0%

0%

50%

100%

150%

2013 2014 2015 2016 2017 2018

Intensive Statin Therapy

Intensive Statin Target

↑

Stroke Measures Improvement CY13-CY18

86.5

67

46 46

37 36

0

20

40

60

80

100

2013 2014 2015 2016 2017 2018

Door to TPA Minutes (median)

Door to TPA Minutes (median) Target

↓

Stroke Measures Improvement CY13-CY18

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

2013 2014 2015 2016 2017 2018 2019

% Patients Tx With Thrombolytic Therapy

% tx IV TPA % Tx Thrombolytics

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

2013 2014 2015 2016 2017 2018 2019

IV Thrombolytic Complications

0

20

40

60

80

100

120

2013 2014 2015 2016 2017 2018

Average Age of Treated Patients

13.5

7

10 9

7 6.5 7

10.5

14

7

11

8

0

5

10

15

20

25

30

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Door to CT Scan 2016-2018 2016 2017 2018 Target

PI project completed

• Emergency Service Personnel and EMS Chiefs were educated by

our EMS Liaison prior to the change in process. This education

was provided in person in the Emergency Department and at local

Fire Stations.

• ED Physicians, ED RN’s, Paramedics and Stroke Clinicians as

well as the Charge Nurses in our Marcus Neuroscience Center

were educated prior to the change in process via huddles and

staff meetings. A Straight to CT Workflow chart was developed

and disseminated to all involved departments. This was a truly

collaborative initiative.

• The process was streamlined by centralizing a location for stroke

alert patient assessment by the EDMD on a dedicated weighted

stretcher, and fast-tracking the patient to CT. This change in

process reduced door to treatment times.

• Data was collected from October 2017 thru January 2018

measuring Arrival to CT, Arrival to IV TPA administration, and

Arrival to Interventional Radiology. This was compared to data

from the same months of the previous year.

• National guidelines recommend imaging within 25min of ER arrival

and TPA within 60 min of ER arrival for patients with acute stroke

• BRRH ER did not send patients straight to CT prior to 10/2017

• Prompt treatment provides the patient an opportunity to achieve

functional independence after having a stroke

• In Stroke Alert Patients does immediate CT completion compared

to triage in an ER bed affect treatment times of TPA and IR

interventions?

• By going straight to CT our stroke alert patients will experience a

reduction in treatment times. This is best practice and is shown to

be effective by the American Heart Association’s “Get with the

Guidelines”.

• Our goal is to reduce door to treatment times by 10% compared

to current practice .

• This EBP study result supports the implementation of Stroke

Alert patients bypassing ED beds and going straight to CT.

• Best Practice reflects the approach advocated by the AHA Get

With The Guidelines that implementing this workflow leads to

faster treatment for patients with acute stroke.

• Limitations: In December 2017 31% (13/41 patients) of the

stroke alerts not called by EMS were found and called in house.

Door to CT average for Stroke alerts not called by EMS was 38

minutes. Also, 1/13 patients received IV TPA and Door To TPA

was 85 minutes.

• Going forward the EMS Liaison, Stroke Coordinator and Clinical

Manager from BRRH ER will be visiting EMS stations and

provide additional education.

• As of March 15, 2018 we no longer require an Istat to test

Creatinine which will reduce Door to Treatment Times even

further.

• Overall it is skilled communication, true collaboration and

effective decision making that drives EMS, ER Staff and Hospital

staff to be the patients advocate .

AHA/ASA Guideline - Stroke. (n.d.). Retrieved September 10, 2017

from http://www.bing.com/cr

Ruff, I. M., et al. “Improving Door-to-Needle Times: A Single Center

Validation of the Target Stroke Hypothesis.” Stroke, vol. 45, no. 2,

July 2014, pp. 504–508., doi:10.1161/strokeaha.113.004073.

Improving Door to Treatment Times in Stroke Alert Patients Debbie Falls BSN RN CEN, Matt Berrios RN, Latoya Francis BSN RN, David Natarus RN

William Chalman RN, Dr. Aryeh Pessah , Dawn Cooper RN CEN, Candace Stickley MSN RN CNL,

Stephanie Rubenstein RN

Background and Significance

PICO, Purpose and Objectives

Outcomes

Implementation Plan & Evaluation Method

Conclusion

References

Boca Raton Regional Hospital Emergency Room Department

0

5

10

15

20

25

Oct Nov Dec Jan

Previous Year'16-'17 19.4 20.6 17 21.6

Current Year'17-'18 13.6 9.4 22 15.4

M

i

n

u

t

e

s

Door to CT

0

10

20

30

40

50

60

Oct Nov Dec Jan

Previous Year '16-'17 41 44 57 59

Current Year '17-'18 14 36 36 36

M

i

n

u

t

e

s

Door to TPA

0

20

40

60

80

100

120

Oct Nov Dec Jan

Previous Year '16-'17 99 119 80 103

Current Year '17-'18 53 53 39

M

i

n

u

t

e

s

Door to Interventional Radiology

• Average times from Door to CT were reduced by 4.6 minutes over a

four month period. In December 2017 13/41 patients arrived via EMS

and were not called in the field Average times from Door to TPA were

reduced by 19.75 minutes over a four month period. Average times

from Door to Interventional Radiology were reduced by 52 minutes

over a 3 month period . There were no IR cases in October 2017.

MARCUS STROKE NETWORK

MARCUS STROKE NETWORK: COORDINATED SYSTEM OF STROKE CARE

Becoming an Institute:

2018 & 2019 Neurology Residency program Expansion for third INR Suite VIZ.AI/Rapid Software (parallel) TSC Initial Survey Third Annual Neuro Symposium Radial Access Training Course South Florida Systems of Care Conference Continued partnership and training with

EMS Stroke Team IR Cross Training Golden 30/60/90 Posterior Circulation/SAH Training Better ways/scales to track outcomes Stroke Clinicians to 24/7 Expand Research Aneurysm Screenings Primary prevention strategies Ambulance to Angio Protocol