Aleš Tomek Neurology Department 2nd Medical Faculty of Charles University and University Hospital Motol Cerebrovascular Section of Czech Neurologic Society
Detection patient or bystander recognition of stroke signs, symptoms (FAST) and severity Dispatch and delivery immediate activation of EMS and prompt triage and transport to Stroke center/comprehensive Stroke center Diagnosis + drugs/devices Recanalization th. thrombolysis, endovascular Disposition timely admission to neurointensive care unit Stroke recurrence prevention Detailed diagnostic of etiology and adequate prevention Disability physiotherapy incl. speech th., dysphagia th., ergotherapy, social services
Every 1 minute will die: 1 900 000 neurons 14 000 000 000 synapses 12 km myelinated nerve fibres 90 minutes 180 minutes NNT 2 NNT 7 (3,1) 270 minutes NNT 14 Saver JL. Stroke 2006;37(1):263-6. Hacke W et al. NEJMN 2008;359:131729.
Stroke ready hospital (24/365) Dedicated stroke team and equipment Cerebrovascular neurologist, neurosurgeon, neurointensivist, neuroradiologist, neurointerventionalist, physiotherapy Stroke protocols and quality of care control AIMS to reduce mortality and morbidity: - shortening door to treatment time - increasing rates of recanalization therapy - Increasing rates of ICU hospitalized patients
EBM level I: SC compared to a general ward 18% relative reduction of mortality and dependent patients 3% absolute reduction in mortality = NNT 33 6% absolute increase in patients without functional deficit (mrs 0-2) = NNT 16 Stroke Unit Trialists, Cochrane Database Syst Rev 2007;(4):CD000197.
Canadian Stroke Network study (n = 6223) Comparing ischemic stroke mortality in stroke center vs. standard wards Lacunar stroke - 3,0 x 5,3% = OR death 0,48 Large vessel disease 7,5% x 14,5% = OR death 0,39 Cardioembolic 15,3% x 23,3% = OR death 0,46 Other causes of stroke 8,9% x 15,9% = OR death 0,45 Saposnik G et al. Int J Stroke 2011. 6(3):244-50.
Before 2001 without central accreditation of SC 2001-2009 Stroke centers accredited only by scientific society 2010 New system of SC/CSC accredited by Ministry of Health + scientific societies, operational from 1. 1. 2011 11 comprehensive stroke centers 34 stroke centers From 1. 1. 2013 Quality of care indicators (every 6 months) Compulsory triage for emergency services
STROKE CENTER (IKTOVÉ CENTRUM) NICU 8 beds Neurology 30 beds Early PT 30 beds Catchment area 400 000 inhabitants COMPREHENSIVE STROKE CENTER (KOMPLEXNÍ CEREBROVASKULÁRNÍ CENTRUM) NICU 13 beds Neurology 30 beds Neurosurgery 20 beds Early PT 20 beds Catchment area 800 000 inhabitants
Hl. m. Praha Nemocnice Na Homolce ÚVN FN Motol VFN FNKV + FTNsP Ústecký kraj Ústí n. Labem Chomutov Děčín Teplice Nem. Litoměřice Liberecký kraj KN Liberec Česká Lípa Královéhradecký kraj FN Hradec Králové Obl.nem.Trutnov Obl. Nem. Náchod Pardubický kraj Pardubice Litomyšl Situation 2014 Karlovarský kraj Nem. Sokolov Nem. Karlovy Vary Olomoucký kraj IFN Olomouc Prostějov Moravskoslezský kraj FN Ostrava MN Ostrava Vítkovická nemocnice Krnov Třinec Karviná Středočeský kraj Kolín Kladno Mladá Boleslav Příbram Zlínský kraj Zlín (T. Bati) Uh. Hradiště Plzeňský kraj I. FN Plzeň Jihočeský kraj Kraj Vysočina I. Nemocnice Č. Budějovice Jihlava Nové Město na Moravě II. Nemocnice Soláň Písek 13. - 14. 1. 2012 Jihomoravský kraj FNUSA + FN Brno Břeclav Znojmo Vyškov
12 compulsory biannual indicators defined by Ministry of Health and scientific societies 1x Emergency medical services rejected admission 3x Stroke epidemiology/coverage of care Center admission 2x primary and secondary catchment area Mortality 1x Length of stay 1x 3x Recanalization therapy % IVT, DTN time <60, % endovascular 1x Rehabilitation/PT admissions 3x Neuroradiology/neurosurgery Brain vascular surgery/interventions, cerebral vessels CAS/CEA
200 150 100 133 147 50 0 I. VI. 2013 VII. XII. 2013
60 58 56 54 53,5 53,6 52 50 I. VI. 2013 VII. XII. 2013
30 25 20 KL BV PA 15 10 5 0 MB BK LTMš Mean I.-VI. 2013 10,54%... Mean VII.-XII. 2013 10,86%
3000 2500 2391 2000 1500 1000 1067 1249 1614 1846 500 0 2009 2010 2011 2012 2013
100 90 80 70 60 50 40 30 20 10 0 55,29 61,51 I. VI. 2013 VII. XII. 2013
120 100 80 60 40 20 0
120 Orange 1 st half 2013 Blue 2 nd half 2013 100 80 60 40 20 0
7 6 5 4 3 2 1 0 6,65 6,4 I. VI. 2013 VII. XII. 2013
450 400 350 300 250 200 150 100 50 0 74 340 43 31 183 157 I-VI VII-XII 2013 SC CCV VII.-XII. 2013
The system of care was successfully launched and is having results Compulsory quality of care indicators beneficial even after 1 year Triage of emergency medical services leads to higher admittance level to stroke units = better coverage of stroke care Indicators covering also treatment effectiveness (mortality/morbidity) not just coverage would be reasonable