2015 ISC Hot TopicsAdvancing Your Stroke

Program
Debbie Summers, MSN, RN, ACNS-BC, CNRN, SCRN, FAHA, ANVP
Saint Lukes Hospital
Kansas City, MO

Speaker: Debbie Summers

Topic: 2015 ISC Hot Topics- Advancing Your Stroke Program
Disclosure: Covidien Ltd
Consultant

Objectives
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

ISC What is it? And Why is it important?

Forum 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

The Changing Landscape of Stroke Treatment

IMS 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 treatment
Time 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

IMS III did show that better revascularization leads to

improved outcomes.++

% 90 Day
mRS 0-2

TICI=0

TICI=1

TICI=2a

TICI=2b

TICI=3

N=32

N=16

N=67

N=80

N=5

3.1%

12.5%

19.4%

46.3%

80%

6.3%
13.9%

++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10

8
|

P < .0001

35.5%
48.2%

P < .0001

IMS3 Did show an improvement in mRS 0-2 at 90 days for

patients presenting with more severe strokes.++

Differences between the two treatment groups across the entire

distribution of the mRS (p = 0.06, van Elterin test)
++Broderick, Joeseph, et. Al. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. NEJM. vol. 368 no. 10

IMS 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 recanalization
Enrollment 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.

Up to date technology:
Stent Retrievers

Clinical Trials Mr. Clean

Clinical Trials ESCAPE

Clinical Trials EXTEND IA

Clinical Trial SWIFT PRIME

Trial
Summary

Increased time to reperfusion was associated with

a decreased likelihood of good clinical outcome
(unadjusted relative risk for every 30-min delay
085 [95% CI 077094]; adjusted relative risk 088
[080098]).
Lancet Neurol.2014 Jun;13(6):567-74

Khatri P. Neurology 2009; 73 (13): 10661072

Time is Brain Stroke Systems of Care

We 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 centers
Primary to comprehensive center network
Limiting community hospital time/transfer time

Efficient in-house triage, activation, treatment with endovascular

to 90 minutes

Manipulating the time window

Increasing collateralization
Increasing Venous return/Volume NS bolus
Attention to BP
Positioning
Balloon pumps/mechanical counter-pulsation
Neuroprotection agents; hypothermia

Collaterals

Numerous stroke clinical trials are demonstrating the

profound impact of collaterals

Recanalization
Reperfusion
Smaller infarcts
Less hemorrhagic transformation
Better clinical outcomes

The 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.

Collateral Flow Grading

American 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

Collateral Flow with Time

The 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.

Theory 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.

Collaterals 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.

CTA to Obtain Collateral Flow

Alberta Stroke Program Early CT Score

(ASPECT)
10 point quantitative topographic CT scan score to assess early
ischemic changes of the MCA region
Assessed at 2 standardized regions
Ganglionic Level where the thalamus, basal ganglia and caudate are
visible
Supraganglionic level which includes the corona radiata and centrum
semiovale

ASPECT score

Normal 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

HOUSTON MSU Standard 12 foot

ambulance

BEST MSU Study

Benefits of Stroke Treatment 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?

WHY is Nursing Research Important?

Build the scientific foundation for clinical practice
Prevent disease and disability
Manage and eliminate symptoms caused by illness

Primary Care

Social
Work/Clinical
Resource
Management

Home Care

Physical
Therapy

Family
Care Givers

Nutrition

STROKE
Program
Pharmacy

Acute Rehab/SNF

Multidisciplinary Care

Palliative Care
Hospice

Community
Resources

Steps 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 literature

Lit search on patient education materials and retention variables that influence

Develop 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.

Research
Design

Use of
Databases

Retrospective
versus
Prospective research
Get With The GuidelinesStroke
University Health Consortium
(UHC)
Home grown databases

Steps in Research Process

Institutional Review Board (IRB)process.
Implement methodology/collect data
Analyze results - statistics

Steps in Research Process

Draw conclusions
Share conclusions
Implement change

Integrating 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 meetings
Work with E record, nursing focus groups, etc
Change protocols, documentation records, educate all team
members
Measure

Nursing Symposium

Georgia Stroke Professional Alliance

Gulf Coast Medical Center

Reducing Readmission Rates

Higher than national average readmission rates (Range 14.9%-18.6%)
Implemented discharge rounds to decrease rate
Evolution of process
Phone 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 used

PT, OT, SLP recommendations
New medications
DC plan social/family concerns

Nursing Symposium Many more.

Nursing & EMS Bridging the great divide
Head up vs head down in acute stroke
Evaluating care giver needs
Transitions of care
Palliative care
Too many to review all!!

2016 Call for

abstracts:
May 20- Aug 11, 2015