The World is Flat: A Brief Future of Acute Stroke Care

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The World is Flat A Brief Future of Acute
Stroke Care

• David C. Hess M.D.
• Professor and Chairman
• Co-Director, Brain and Behavior Discovery
  Institute
• Department of Neurology
• Medical College of Georgia

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Disclosures

• Genentech Speakers Bureau
• Boehringer Ingelheim Speakers Bureau
• Co-Founder REACH CALL, Inc, Board of Directors

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The Geographic Penalty

• The quality of stroke care is dependent upon the
  hospital you go to
• If you live in a rural area or underserved acute
  stroke care area you will NEVER receive tPA
• There is a GEOGRAPHIC penalty for stroke care

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Rural Hospitals are Plentiful

• 5759 Hospitals in the United States
• 4919 Community Hospitals
• 2003 Rural Hospitals (AHA Hospital Statistics
  2006)
• 1464 Community Hospitals in a network
• 2669 Hospitals in a system

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The Limited Resource the Willing Neurologist

• 40 of Emergency physicians reluctant to use tPA
  (want a Neurologist)
• In 2006-7 only 32 Fellows in approved Vascular
  Neurology Fellowships in U.S
• By comparison, during same period, 2300 Fellows
  in Cardiology Fellowships in U.S.
• Many Neurologists abandoning Emergency Department
  call

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Limited resources for tPASupply and Demand

• Limited supply of willing Neurologists
• Geographically clustered at urban academic
  medical centers

• 50 of US Hospitals lt100 beds
• High ED Staff turnover
• IT infrastructure limited
• Rural, frontier locations

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Stroke System Models

• The COMMANDO model stroke specialist drives to
  urban/suburban hospitals
• Telephone drip and ship
• Helicopter ship and drip
• Telestroke
• Telestroke with helicopter

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U.S. Stroke Belt
Source US Census Bureau Postcensal Population
Estimates (IDC9 430-438.9) (1991-1995)
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REACH Hub Spoke Telestroke Model
Hess DC et al. Lancet Neurol. 2006365275-8
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Components of Decision making

• Reliability of NIH Stroke Scale Scores
• Review of images (CT head)
• History-taking (time of onset)
• Lab results, BP
• Eye in the ED

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Feasibility and Reliability of NIHSS via
Telestroke
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Prospective, Randomized Trial of Telemedicine vs
Telephone(Meyer BC et al, Lancet Neurol 2008)
No difference in 90 day functional outcome
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The Underserved Rural Sites
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REACH Mobile Cart in ED
Remote evaluation cart is mobile and can be
moved throughout Emergency Department
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Remote Neurologist Consultant Laptop
Wang S, et al. Stroke. 2004351763-8
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Video and CT scan viewing on Consultant laptop
Wang S, et al. Stroke. 2004351763-8
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Georgia REACH Telestroke Network
Hess DC, et al Stroke. 2005 36(9)2018-2
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Rural Georgia REACH Network

• 152 patients treated with tPA
• Mean age 66 56 women 40 African American
• Mean NIHSS 13 median 11
• Mean door to needle 80 min
• 47 treated lt 2 hrs 16lt 90 min
• sICH 3 (5/146) NINDS
• 0 SITS MOST

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Comparison of Onset to Treatment times (OTT)
between systems (Switzer et al J Emergency
Medicine, 2008 )
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IV tPA Plus

• Bridging with IV tPA to IA tPA
• Merci Device and other mechanical thrombolysis
  methods
• Use of transcranial doppler to use
  ultrasound-enhanced thrombolysis

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Telestroke

• More than a tPA treatment tool
• Only about 15-20 of consults at MCG result in a
  tPA treatment
• Many other acute disorders are identified

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ECASS III

• Window extended safety to 4.5 hours
• But TIME still CRITICAL!!!!
• Having more time does not mean we should take
  more time

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SITS MOST Study (Lancet 2007 369275)

• European Union required a registry of tPA
  (Alteplase) treated patients
• 6483 patients from 285 European centers
• ICH in 1.7 7.3 vs 8.6 (randomized studies)
  using Cochrane definition
• tPA can be given safety and effectively in MANY
  centers

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NY State Rural Telestroke system enabled by REACH
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Most urgent needs

• Systems of stroke care organized by regional or
  state health departments
• Every patient should have quality stroke care
  regardless of geography
• This will best be achieved with telestroke
  systems

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Georgia Coverdell-Murphy Bill Signed into law
May 14, 2008

• Establishes two tiers of stroke centers
• Primary Stroke Centers (Joint Commission
  certified)
• Remote Treatment Stroke Centers (new level of
  identification for hospitals utilizing
  stroke-specific telemedicine technology)

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Statewide Telestroke system with MCG Campus Hubs
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Fixed vs Web-based Telestroke

• Fixed uses dedicated ISDN lines
• Consultant must travel to dedicated sites
• Tempis (Bavaria) Mass General, BST

• Mobile uses the web (broadband access)
• Consultant can be anywhere
• Fast access
• REACH, BF (USCD)

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Telestroke Issues

• State licensure issues and credentialing
• Reimbursement (NY State Medicaid solving problem
  in NY)
• Medicolegal (advantages of recording,
  documentation)
• Cost

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Conclusions

• Telestroke can flatten stroke care and bring a
  stroke specialist to ANY rural, community
  hospital
• Web-based telestroke systems are fast with
  potentially very short onset to treatment times
• Academic Medical Centers should become Hubs and
  support community hospitals as Spokes

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Acknowledgements
MCG REACH TEAM