Acute Stroke Management in Northern Nevada and the Sierra Slopes

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Acute Stroke Management in Northern Nevada and
the Sierra Slopes
A Model for Rural Stroke Care Paul M. Katz,
M.D. Medical Director
Washoe Comprehensive Stroke Center Washoe Health
Systems Reno, Nevada
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Objective

• To determine if organized stroke care would
  increase the use of thrombolytic therapy and
  improve functional outcome in the greater Reno
  metropolitan area and the 25 rural hospitals
  serviced by Washoe Health Systems.
• To establish one standard of care throughout the
  region.

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Demographics

• Population 385,000 in Reno
• 300,000 in surrounding service areas
• One Third of all stroke admissions come from
  rural areas
• Number of ischemic strokes per year 800
• (Nevada Department of Health estimate)

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Our EMS Providers

• We have a highly sophisticated EMS network which
  includes ground and air transport
• Transport vehicles equipped with full monitoring
  capability
• ACLS trained medics and flight nurses with ICU
  training
• EMS providers are trained in
• gathering the time of symptom onset data
• trained in NIH Stroke Scale
• receiving facilities are alerted so that stroke
  team can be activated

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The Challenge

• To adopt a regional system for standardized
  triage and care of the stroke patient.

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Our Solution

• 24-hour Regional Stroke Team
• Stroke Neurologist
• Stroke Nurse
• Neuroradiologist
• Neurosurgeon
• Pharmacist
• ED personnel

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Our Solution (cont)

• Standard Pre-hospital and hospital protocols put
  in place in all communities
• Each Rural Hospital and EMS provider personally
  visited and inserviced on the protocols
• Teleradiology used for CT interpretation in rural
  hospitals (now available to stroke neurologist on
  PC)

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Our Solution (cont)

• Major public awareness campaign to educate
  Northern Nevada and Sierra Slopes communities as
  to the warning signs and risk factors for stroke
• Ultimately Telemedicine will optimize the
  evaluation of patients in rural hospitals (now
  being piloted in 3 locations)

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Results

• 9 of all patients receive thrombolytic therapy
• 1/5 of patients receive IV tPA in rural hospitals
  and are immediately transported to Reno for ICU
  care
• Mean NIH Stroke Scale Score 12 (range 3-24)

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Results (cont)

• At 3 months functional outcomes assessed using
  Barthel Index
• 68 of patients are living independently
• 32 dependent on caregivers or institutions
• Patients do not receive tPA after the 3 hour
  window

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Conclusion

• Our initial experience in Northern Nevada and
  the Sierra Slopes supports the concept that
  organized stroke care can, not only, increase the
  frequency with which we use thrombolytic therapy,
  but it improves outcomes as well.

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Conclusion (cont)

• The success of a regional comprehensive stroke
  center involving many rural hospitals depends
  heavily on standardized protocols for the
  pre-hospital and hospital settings as well as a
  careful assessment by the regional stroke team of
  the capabilities and limitations in each rural
  area.

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