Debbie Summers MSN RN ACNSBC CNRN SCRN FAHA ANVP Saint Lukes Hospital Kansas City MO Speaker Debbie Summers Topic 2015 ISC Hot Topics Advancing Your Stroke Program Disclosure ID: 807534
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2015 ISC Hot Topics- Advancing Your Stroke Program
Debbie Summers, MSN, RN, ACNS-BC, CNRN, SCRN, FAHA, ANVPSaint Luke’s Hospital Kansas City, MO
Slide2Speaker: Debbie Summers
Topic: 2015 ISC Hot Topics- Advancing Your Stroke Program
Disclosure:
Covidien LtdConsultant
2
Slide3Objectives
Apply new research topics presented at the International Stroke Conference
Discuss the relevance of at least two new practices that may influence their own program/practice
Slide4Forum for:
Disseminating clinical stroke trial results and Sharing of best practices within the field
Occurs annually in February
Pre-conferences 1day prior to meeting:Stroke in the Real World: Challenges to inpatient stroke care 2015
Emerging Trends for stroke trials
Option to submit abstracts, projects and research is open to everyone at Strokeconference.org
ISC – What is it?
And Why is it important?
Slide5Slide6The Changing Landscape of Stroke Treatment
Slide7IMS III
No clear benefit to intraarterial
(IA) therapy
Confirmation of occlusion was not required at the time of randomization, and 23% of the patients in the IA arm did not receive treatmentTime to IA treatment was longer than 2 earlier trials potentially mitigating the benefit Limited use of new technologies (5 stent retrievers) Full dose tPA only used in amendment 5 Future trials are needed to determine whether any patient groups benefit from IA treatment
Broderick JP et al. Stroke. NEJM 2013;368:893-903
Slide88
|
++Broderick,
Joeseph
, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10
IMS III did show that better revascularization leads to improved outcomes.++
TICI=0
TICI=1
TICI=2a
TICI=2b
TICI=3
% 90 Day
mRS
0-2
N=32
N=16
N=67
N=80
N=5
3.1%
12.5%
19.4%
46.3%
80%
6.3%
35.5%
P < .0001
13.9%
48.2%
P < .0001
Slide9Differences between the two treatment groups across the entire distribution of the
mRS
(
p =
0.06
,
van
Elterin
test)
IMS3 Did show an improvement in
mRS
0-2 at 90 days for
patients presenting with more severe strokes.++
++Broderick,
Joeseph
, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10
Slide10IMS III Take-
Aways
Use of newer stent
thrombectomy devices may improve long term neurological outcomes when studied in future randomized studies by providing higher rates of procedural recanalizationEnrollment of confirmed large vessel occlusions, particularly ICA occlusions and patients with a higher incoming NIHSS score should represent a population more likely to benefit from endovascular therapy.
Slide11Up to date technology:
Stent Retrievers
Slide12Clinical Trials – Mr. Clean
Slide13Slide14Slide15Slide16Slide17Slide18Clinical Trials – ESCAPE
Slide19Clinical Trials – EXTEND IA
Slide20Clinical Trial – SWIFT PRIME
Slide21Trial
Summary
Slide22Lancet Neurol.
2014 Jun;13(6):567-74
Increased time to reperfusion was associated with a decreased likelihood of good clinical outcome (unadjusted relative risk for every 30-min delay 0·85 [95% CI 0·77–0·94]; adjusted relative risk 0·88 [0·80–0·98]).
Slide23Khatri P. Neurology 2009; 73 (13): 1066-1072
Slide24Time is Brain Stroke Systems of Care
Slide25We Have to Get Organized…
• Pre-hospital Systems of Care
Community education for symptoms & EMS activation
EMS education for recognition and empowered for activation to higher level centersPrimary to comprehensive center networkLimiting community hospital time/transfer time
Efficient in-house triage, activation, treatment with endovascular to ≤ 90 minutes
Slide26Manipulating the time window
• Increasing collateralization
Increasing Venous return/Volume – NS bolus
Attention to BPPositioningBalloon pumps/mechanical counter-pulsationNeuroprotection
agents; hypothermia
Slide27Slide28Collaterals
Numerous stroke clinical trials are demonstrating the profound impact of collaterals
Recanalization
ReperfusionSmaller infarctsLess hemorrhagic transformationBetter clinical outcomes
Slide29The Future
We have gone from our first generation of clot removing procedures, which were only moderately good in reopening target arteries, to now having highly effective tools. Imaging from non-contrast CT to identification of salvageable tissue to looking at collateral flow.
Slide30Collateral Flow Grading
Slide31American Society of Interventional and Therapeutic
Neuroradiology Collateral Grading System
Grade
Cerebral
Collateral Flow Grading
Description
Grade 0
no collaterals visible to ischemic site
Grade 1
slow collaterals to the periphery of the ischemic site with persistence of defect
Grade 2
rapid collaterals to the periphery of ischemic site with persistence of some of the defect and to only a portion of the ischemic territory
Grade 3
collaterals with slow but complete angiographic blood flow of the ischemic bed by the late venous phase
Grade 4
complete and rapid collateral blood flow to the vascular bed in the entire ischemic territory by retrograde perfusion
Slide32Collateral Flow with Time
Slide33The Future
Collateral therapeutics may entail use of readily available hemodynamic manipulations such as head positioning, hypervolemia
, hypertensive therapy, or partial aortic obstruction in selected cases.
Slide34Theory of Collateral Flow
The connection between
leptomeningeal
collateral flow (LMF) and the survival of brain parenchyma during acute ischemia has been confirmed in a large number of clinical studies Bang OY. Stroke. 2011;42:2235-2239.
Slide35Collaterals Avert HT
Data revealed that therapeutic recanalization in the setting of poor collaterals resulted in a high frequency of HT with worsened clinical neurological status.
Poor collateral status at baseline may limit effective reperfusion, even when
recanalization is successful.Bang OY. Stroke. 2011;42:2235-2239.
Slide36CTA to Obtain Collateral Flow
Slide3710 point quantitative topographic CT scan score to assess early ischemic changes of the MCA region
Assessed at 2 standardized regionsGanglionic Level where the thalamus, basal ganglia and caudate are visible Supraganglionic
level which includes the corona
radiata and centrum semiovale
Alberta
Stroke
Program
Early
CT
Score
(ASPECT)
Slide38Slide39Normal ASPECT score
is 10 Deduct 1 point for each area involved.
A score of 7 or less
Correlates with poor functional outcome and hemorrhage.
*Limitation – Only scores the MCA
ASPECT
score
Slide40HOUSTON MSU Standard 12 foot ambulance
Slide41Slide42BEST MSU Study
Benefits of Stroke
T
reatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by EMS Aims
Determine the logistic and clinical outcomes of MSU
vs
SM in the U.S. – speed, #, first hour.
Can MD/Nurse be replaced by Telemedicine?What is the Cost Effectiveness?
Slide43WHY is Nursing
Research I
mportant?
Build the scientific foundation for clinical practicePrevent disease and disabilityManage and eliminate symptoms caused by illness
Slide44Home Care
Nutrition
Acute Rehab/SNF
Pharmacy
STROKE Program
Social Work/Clinical Resource Management
Physical Therapy
Palliative Care Hospice
Multidisciplinary Care
Primary Care
Family
Care Givers
Community Resources
Slide45Steps in Research
Process
Identify the problem or question.
Does Red Print or Blue print on patient education materials improve patients retention of knowledge?Review the literatureLit search on patient education materials and retention – variables that influenceDevelop hypothesis
Red print educational materials result in higher stroke knowledge retention
Methodology - Decide how you will investigate the question/hypothesis?
50 patients will be given red print and 50 patients will be given black print. A post test will be developed and provided. Variables such as age, race, sex, highest completed education, NIHSS will be collected in addition to results.
Slide46Research Design
Retrospective
versus
Prospective research
Use of Databases
Get With The Guidelines-Stroke
University Health Consortium (UHC)
Home grown databases
Slide47Steps in Research
Process
Institutional Review Board (IRB)process.
Implement methodology/collect dataAnalyze results - statistics
Slide48Steps in Research
Process
Draw conclusions
Share conclusionsImplement change
Slide49Integrating Research Findings
One example is the updates to clinical practice guidelines – developed by AHA/ASA work groups.
When published, we need to compare to current practice
Discuss gaps/changes recommended in stroke team meetingsWork with E record, nursing focus groups, etcChange protocols, documentation records, educate all team membersMeasure
Slide50Slide51Nursing Symposium
Slide52Slide53Slide54Slide55Slide56Slide57Slide58Slide59Slide60Slide61Slide62Slide63Slide64Slide65Slide66Slide67Slide68Slide69Slide70Slide71Slide72Slide73Georgia Stroke Professional Alliance
Slide74Slide75Slide76Slide77Slide78Slide79Slide80Slide81Slide82Slide83Gulf Coast Medical Center
Slide84Reducing Readmission Rates
Higher than national average readmission rates (Range 14.9%-18.6%)
Implemented discharge rounds to decrease rate
Evolution of processPhone conference decreased from 18% to 8.9%Unit level conference further decreased to 8.4%Bedside, nurse led DC rounds further decreased to as low as 5.3%Rounding tool usedPT, OT, SLP recommendations
New medications
DC
plan – social/family
concerns
Slide85Nursing Symposium
Many more….
Nursing & EMS – Bridging the great divide
Head up vs head down in acute strokeEvaluating care giver needsTransitions of carePalliative careToo many to review all!!
Slide86Slide87Slide882016 Call for abstracts:
May 20- Aug 11, 2015
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