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    CPMC Comprehensive Stroke Care Program: An Update

    By David Tong, M.D., FAHA, FAAN

    Thrombolysis rates remain high



    Figure 1: CPMC rt-PA Treatment Rate: Q3 2008 - Q4 2009
    CPMC Continues to treat patients with thrombolytic therapy at many times the national average of ≤ 3-5%
    Q3 2008: 24%; Q4 2008: 28%
    Q1 2009: 21%; Q2 2009: 23%
    Q1 2009: 21%; Q2 2009: 23%
    Q3 2009: 27%; q$ 2009: 29%


    Figure 2: CPMC Versus Major IV rt-PA Studies
    Chart showing cpmc IV tPA rate in a study

    Good Outcome: Rankin 0-1 for NINDS/ECASS3 trial/CPMC data.
    SITS-MOST/ECASS 3 excluded patients > 80 y, stroke > 1/3 MCA, or “severe”, NIHSS > 25, ECASS 3 also excluded DM + prior stroke
    First bar= Average IV rt-PA (5 studies, n=8497): 46%
    Second bar= Average placebo (3 studies, n=1460): 33%
    Third bar=CPMC (n=138): 59%

    Symptomatic ICH
    First bar= Average IV rt-PA (5 studies, n=8497): 6.7%
    Second bar= Average placebo (3 studies, n=1460): 2%
    Third bar=CPMC (n=138): 1.5%

    Mortality (7%) and symptomatic hemorrhage rates (1.5%) remain low.
    First bar= Average IV rt-PA (5 studies, n=8497): 13%
    Second bar= Average placebo (3 studies, n=1460): 18%
    Third bar=CPMC (n=138): 7%

    The increase in the time window for IV rt-PA to 4.5h has now been officially endorsed by the American Stroke Association expert guidelines committee1, which has further increased the eligibility of patients for thrombolytic therapy and was already adopted by California Pacific in 2008.

    New facilities

    Since the last newsletter, the Stroke program has made the Davies Campus Critical Care unit the primary admitting unit for the program. This has substantially increased capacity by providing not only more ICU and TICU beds but also a state-of-the-art combined surgical and angiography suite sited at Davies. However, the Pacific Campus remains an integral part of the system, and all stroke/ neurocritical care and interventional services are available at both campuses. These facilities are also Joint Commission Accredited Primary Stroke centers, and have achieved American Stroke Association Gold Certification for >85% compliance with national stroke treatment guidelines.

    In addition, as part of continuing efforts towards excellence in stroke care, a stroke/neurocritical physician fellowship-training program has been established, as well as a stroke/neurocritical care nurse practitioners program. Moreover, to bolster research efforts, a research coordinator and database manager have also been added to our growing research program.

    Enhancing patient care: The S.M.A.R.T. Approach

    Ongoing research at California Pacific has determined that many criteria for thrombolytic therapy are unnecessarily complex. The S.M.A.R.T (Simplified Management of Acute Stroke using Revised Treatment Criteria) approach is an inventive new method created to permit a more streamlined approach of determining thrombolytic treatment eligibility. (2) This approach significantly reduces the number of barriers to administering thrombolytic therapy, while maintaining the safety and efficacy of treatment. An effort to distribute this information to other medical centers is ongoing, and hospitals interested in taking part in this innovative program are welcome to contact the Stroke Center for further information.

    Neuroimaging

    Figure 3: CT scan with multiple brain imagesThe use of neuroimaging, particularly CT perfusion (CTP), in the assessment of stroke and other cerebrovascular disease continues to be a major focus. California Pacific was proud to be chosen by General Electric to receive one of the first whole-brain CTP consoles in the country. Previously, CTP was limited by the inability to scan the entire brain due to technical barriers. This new technology provides, for the first time, complete brain coverage in a fast, simple package that is ideal for acute stroke management (Figure 3). Importantly, this technology does not require an expensive CT scanner upgrade, and does not significantly increase radiation exposure. Several research projects assessing the utility of this new technology are ongoing.

    Telemedicine: Role in Enhancing Stroke Care

    Among the new innovations at California Pacific, is the use of video teleconferencing (telemedicine) for remote evaluation and management of stroke patients. Given the relative lack of vascular neurological subspecialists at many hospitals, there is an increasing need for 24/7 clinical expertise in stroke management. A method of increasing the availability of experts to the community is clearly needed. Moreover, given the time-sensitive nature of stroke treatment, the ability to deliver prompt care is paramount.

    Dr. David Tong using telemedicine technologyThe use of telemedicine for stroke treatment is a relatively new phenomenon, although its use for other medical purposes has been established for more than 25 years. Previously the high costs associated with providing real-time telemedicine dramatically limited its availability and use. Fortunately, recent advances in audiovisual technology and the Internet have combined to make this far less expensive and more accessible. This technology has been shown to significantly improve the accuracy of stroke diagnosis and treatment. (3)

    At California Pacific various forms of telemedicine have been in use for several years. It is used primarily for the rapid evaluation of acute-stroke patients, mostly in the emergency room setting for triage and acute management of patients, including the use of thrombolytic therapy. The technology permits two-way audiovisual communication between the referring physician, patient, and the California Pacific neurological specialist. At many hospitals, few if any patients receive thrombolytic treatment because no stroke expertise is readily available. Given the short time window for treatment of only a few hours, a high proportion of hospitals cannot administer this treatment to any of their patients. Telemedicine changes all that. With this equipment, many patients can be treated who otherwise could not have been. The video evaluation also allows the neurological expert to determine whether certain patients do not require urgent intervention, allowing them to stay at the local institution, usually to the great satisfaction of patients and their treating physicians.

    “We have found it to be an extremely useful tool for triage and acute management of stroke patients,” notes David Tong M.D., director of the California Pacific Comprehensive Stroke Care Center. “Not only do the physicians greatly appreciate the ready access to our highly trained experts, but patients also appreciate the ability to bring this expertise to them, without the need to transfer the patient from their local area.”

    Given the success of the California Pacific telemedicine program, we are actively recruiting sites to participate in our network. We are also participating in a research study to determine the optimal use of this technology as well as quantify it’s benefit to patients.

    References

    1. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP, Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke; a journal of cerebral circulation. 2009;40:2945-2948

    2. Tong D, Barazangi N, Rose J, Thomas J, McDermott D, Chen S, Phan J, Bedenk A. Increasing iv rt-pa use using modern eligibility criteria. The simplified management of acute stroke using revised treatment(smart) criteria study: Feasibility, safety and efficacy. International Stroke Conference. 2010

    3. Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA, Rao R, Thomas RG, Lyden PD. Efficacy of site-independent telemedicine in the stroke doc trial: A randomized, blinded, prospective study. Lancet Neurol. 2008;7:787-795