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From Scene to Suite: Central South �Regional Stroke Paramedic Stroke Workshop�Stroke Hyperacute Outcome Data/�Paramedic Hyperacute Stroke Feedback

Rhonda Whiteman and Stefan Pagliuso

September 14, 2023

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Objectives

Review Key Metrics related to Stroke Thrombolysis and Endovascular Therapy in Central South Ontario

Volumes

Treated/Not Treated

Patient Characteristics

Outcomes

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Stroke Thrombolysis

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As you can see on this map, I have circled those centres who provide hyperacute stroke therapies – thrombolysis (tPA or TNK) and/or EVT

Within our Region we have 6 thrombolysis-delivery centres. Those are: Grand River Hospital, Guelph General Hospital, Brantford General Hospital, Joseph Brant Hospital, the Niagara General Hospital and the Hamilton General Hospital.

All of these sites work to optimize the time it takes from when the patient gets to their doors to the time they deliver thrombolysis. Every minute counts in hyperacute stroke care, so these quality improvement projects are very important.

The Hamilton General hospital is the only EVT or clot retrieval centre within our Region. So every EVT case from all of our regional hospitals are transferred to the General for EVT.

If, for any reason, the Hamilton General is not able to accommodate a case (for example if we are in a downtime), a provincial system is in place where the potential EVT patient would be referred to an R2 centre or a back up EVT centre – in our area, our R2s are either London Health Sciences or Trillium Health Partners (depending on which hospital is sending the patient)

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New to the Canadian Stroke Best Practices in 2022 was the addition of Tenecteplase or TNK

TNK may be considered as an alternative to alteplase (or tPA) within 4.5 hours of acute stroke symptom onset

Within our Region we have had 3 hospitals switch over from using tPA to TNK – Hamitlon Health Sciecnes, Grand River Hospital and Guelph General Hospital. In the coming 6 months, we will likely see our other thrombolysis centres in Central South switch over to TNK as well.

All inclusion and exclusion criteria for TNK is the same as for tPA and all post administration care is the same as for tPA.

The main difference between using TNK and tPA is that TNK is delivered as a single bolus rather than a bolus and an infusion – so as you can imagine this is less resource-intense for our Emergency Room Partners.

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Regional Data�**includes all hyperacute stroke hospitals – HGH, GGH, GRH, NH (NFS), JBH**

Indicator (22/23 Q4 YTD)	Range
Proportion of Stroke/TIA patients who arrived at ED via Ambulance	61% - 74.1%
Median Door To Needle Time among patients who received acute thrombolytic therapy	42.5-65 minutes
Proportion of ischemic stroke patients received thrombolytic therapy	11.1%-20.1%
Proportion of ischemic stroke/TIA patients discharged from the ED and referred to secondary prevention services	88.7%-95.2%

As a Regional Stroek Network, we have a table called our Regional Stroke Monitoring and Evaluation Committee or RSMEC for short.

This committee has representation from around the Region including all stroke hospital acute and rehab sites as well as community stroke rehabilitation partners.

At that table we meet on a quarterly basis and create a regional scorecard that allows us to share data readily, openly and transparently.

Having this table is a huge advantage for our region as the stroke centres can learn from one another – where there are successes and where there are opportunities for improvement.

This data is pulled from our RSMEC table. What you are seeing on the chart is from 2022/2023 Q4 Year to Date data – so this is the full data from last year and includes data from all of our stroke thrombolysis centres.

So as you can see, within our Region:

The proportion of patients with Stroke or TIA who arrive to the ED via ambulance ranges from 61% to 74.1! In 2021, the Ontario average was approximately 64%, so generally good performance within our Region
The median door to needle time among patietns who received acute thrombolytic therapy ranged from 42.5 to 65 minutes. In 2021, the Ontario median DTN time was just below 45 minutes.
For the proportion of patietns who reiceive thrombolysis you can see that within our Region we range between 11.1% up to 20.1%. In 2021, the provincial average was at approximately 10.5%
Finally, I thought it would be good to include those TIA cases who get discharged from the ED. I think it is very important to speak specifically to these cases because we know that persons who have a TIA are at an incredibly high risk of stroke in the short time after TIA so it is vitally important to get them to the ED and then have them followed up very quickly in Stroke Prevention Clinics. In our Region you can see that at our stroke centres, those patients who are discharged with TIA directly from ED, between 88.7 and 95.2 percent of them are referred directly to Stroek Prevention Services – this is crucial!! In 2021, the province averaged approximately 82% of patients being referred to SPCs.

The above clearly shows that our region performs well with regards to acute thrombolysis and are early adopters of cutting edge stroek best practices!!

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Stroke Endovascular Therapy

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5.0%

3.6%

4.2%

6.9%

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81%

43.5%

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Central South Regional Stroke Network Regional Transferred Cases FY 2022/23 Q3 N=74 Cases

16 cases transferred

81.25% Treated

19 Cases Transferred

73.6% Treated

22 cases Transferred

86% Treated

22 Cases

Transferred

84% Treated

9 cases Transferred

100% Treated

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�

Regional EVT Cases Transferred Not Treated Cases - Reasons Not Treated

FY 2022/2023 YTD Q3 N=18 cases

When looking at the reasons why some cases are transferred but not treated, we are able to break down into many different categories.

The majority of cases that are transferred but are not treated have clinically improved. 44% of those cases who were not treated had clinilcal improvement and or the vessel had recanalized.

28% of cases not treated had worsened on imaging and seen decay in their ASPECTS score. The ASPECTS score is a 10 point quantitative topographic CT scan score. The lower the score the worse the CT scan – so as more areas of the brain are impacted by the stroke, the ASPECTS score gets lower. So for those patietns who may have left a hospital with an ASPECTS score of 8, upon reimaging, their score may have dropped to a 4 or 3 and are now no longer candidates for EVT.

17% of those cases may saw the clot migrate distally and thus were no longer appropriate for intervention

And 6% of cases no longer met EVT critieria.

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Who are we Treating?

Age

Average: 70
Median: 72
Range: 18 - 94

Site of Occlusion

M1 (40%)
Carotid T (26%)
ICA (12%)
ACA/M2 (14%)
Basilar (7%)

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Who are we Treating?

Percentage treated with Thrombolysis

44.6%

Stable vs. Unstable Cases

Stable: 76.9%
Unstable: 23.1%

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National Institute Health Stroke Scale (NIHSS)

An improvement of 8 or more points on the NIHSS reflects a clinical significant improvement in neurological status

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Functional Outcomes

Patient Presentation

Median Admit NIHSS Score: 17

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Functional Outcomes

Patient Presentation

Median Discharge NIHSS Score: 7

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Overall EVT Cases �Functional Outcomes

Length of Stay

Median Acute LOS: 5 days

Discharge Disposition

Directly Home: 18%
Acute Repatriation: 50%
Rehabilitation: 13%
Deceased/Hospice: 18%
Long Term Care: 1%

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One of the most incredible advances in the last 5 years has been the expansion of the time window for EVT.

EVT previously was only able to be offered to patients in the 0-6 hour window.

With the implementaiton of automated software with artificial intelligence, the window for EVT has expanded to up to 24 hours!

The automated software used in our Region is called RAPID and it is available at every stroke thrombolysis centre in our Region. We are the only region in the province to have a system like this!

These patients who fall into the expanded window category are often patients who wake up with strokes or are found at the end of the day with stroke symtpoms and the onset time is not known!

For the patients in the expanded window, the median NIH score is 16 prior to treatment and 11 when discharged from the acute stroke centre after an average length of stay of 5 days.

I do want to note here that although the window for EVT has expanded, every second still counts. The faster we can get patients to the stroke centre, the better their outcome!!

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OUTCOME FEEDBACK

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Paramedic Outcome Feedback

What consistent outcome metrics would be most meaningful/helpful for paramedics?

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Questions

pagliuso@hhsc.ca

mcnicolr@hhsc.ca