Broward EMS Stroke Coalition Brijesh P Mehta M

Broward EMS Stroke Coalition Brijesh P Mehta, M. D. Neuro. Interventional Surgeon Director, Stroke & Neurocritical Care Memorial Neuroscience Institute

Good Outcome (%) Rankin 0 -2 at 90 days Positive Large Vessel Stroke Trials 2015 2 75 50 25 0 MR CLEAN REVASCAT ESCAPE SWIFT PRIME EXTEND-IA THERAPY P<0. 05 P<0. 001 P<0. 01 NS Endovascular 33% 44% 53% 60% 71% 38% Control 19% 28% 29% 36% 40% 30%

Renewed Focus on Work Flow Faster times Better studies Careful selection Improved Outcome Innovative devices

Stroke Care in Broward County • 8 Comprehensive Stroke Centers (CSCs) • Absence of a quality improvement oversight committee • EMS triage criteria based soley on distance and not on quality of care at destination • No transparency among CSCs for door-to-treatment times and clinical outcomes • Lack of research or QI collaboration among CSCs 4

Broward CSCs • Broward General • Broward Health North • Holycross Hospital • Florida Medical Center • Memorial Regional • Memorial West • Westside Medical Center • Aventura Medical Center 5

Broward EMS Stroke Coalition 6

BESC Mission • Improve the delivery of stroke care in Broward County – Standardized EMS and in-hospital protocols – Evidence-based medicine – Transparency among CSCs • Achieve best outcomes possible for our patients 7

Support of Local and National Groups • American Stroke Association • Broward Stroke Council • Fire Chief’s Association • GBEMBDA 8

SNIS Workflow Metrics 9

BESC Proposed Metrics Individual Time Points – ER arrival Key Intervals • – CT start (scout image) – Door-to-Picture <15 min – IV t. PA – Picture-to-Puncture <45 min – Puncture-to-Reperfusion <30 min – Groin puncture – Device deployment (first pass) – Final reperfusion 10 Door-to-Reperfusion 90 min • Outcomes – Initial NIHSS score – Discharge NIHSS score – 90 -day m. RS

CSC Survey Questions 11 • Workflow and evaluation • Metrics, Data Collection • Hospital Designation, Volume • Personnel • Resources • Outcomes

Aggregate BESC Survey Results • HCA not participating in survey • Cleveland Clinic a PSC – impact on EMS triage criteria • Only couple of hospitals have high volumes - i. e. , >50 EMS stroke alerts per quarter • Not all hospitals have pre-hospital EMS alert protocols 12

Aggregate BESC Survey Results • IV t. PA door-to-needle times are improving • Significant variability/delays in door-to-puncture times for strokes with Large Vessel Occlusions • Some hospitals have multiple NI cross covering • Few hospitals have no policies for NI response time • Most hospitals do not have a neurointensivist 13

Impact of EMS Alerts • Pre-alerts reduce time to treatment • RACE score 5 or higher has high probability for LVO • Encourage all stroke centers to initiate RACE training 14

Next Steps 15 • Finalize data collection variables this month at next BESC meeting on June 8 • Encourage all CSCs to participate in FL-PR stroke registry • Initiate data collection via UM-Sacco collaboration July 1 • Collect blinded data for 6 months and give hospitals opportunity to improve EMS and in-hospital stroke processes • January 2017 – CSC data will be unblinded, allowing EMS to make informed triage decisions

Contact Information Brijesh P Mehta, MD Neuro. Interventional Surgeon Director, Stroke & Neurocritical Care Memorial Neuroscience Institute 617 -775 -5204 brmehta@mhs. net 16

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