Hot Topics from 2014 International Stroke

Conference

Lori Massaro, MSN, RN, CRNP

Jeannie Luciano, MSN, RN, CRNP, CNRN, SCRN, FAHA

Claranne Mathiesen, MSN, RN, CNRN

Lynne Hundley, MSN, RN, APRN, CCRN, CNRN, CCNS

Disclosures

Lori Massaro is on the Genentech Speakers Bureau

Jeanie Luciano is on the Genentech Speakers Bureau

Claranne Mathiesen has no disclosures

Lynn Hundley has no disclosures

Objective:

• Apply new research topics presented at the

International Stroke Conference and discus

the relevance of at least two new practices

that many influence your 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 Feb• 1 day State of the Art Nursing Symposium held the day prior to

meeting• Additional preconference symposium offered this year:

– Stroke in the Real World: Emergency Stroke Care 2014– Translational Science – Animal models 2.0

• Options for submitting abstracts, projects, research is open to everyone at Strokeconference.org– 2015 Call for abstracts - May 21- Aug 12, 2014

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ISC Nursing Pre-conference

• Nursing attendance this year was close to 800

– The first year of the nursing symposium there were less

than 50 participants.

• The Afternoon offers many breakouts with mix of

research and clinical information

– Advances in clinical research and QI, Essentials of standard

clinical practice and stroke center development, Rehab and

recovery: an ongoing process, application of evidence based

practice

Stroke Facts – Update – 2014

• From 2000 to 2010, the annual stroke death rate decreased 35.8% and the actual number of stroke deaths declined 22.8%.

• Approximately 15% of all strokes are heralded by a TIA. Within 1 year of TIA, ≈12% of patients will die.

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Stroke Facts - Update

• More women than men die of stroke each year because of the larger number of elderly women. Women accounted for almost 60% of US stroke deaths in 2010.

• Estimates of the overall annual incidence of stroke in US children are: – 6.4 per 100 000 children (0 to 15 years) in 1999 in the GCNKSS163

and– 4.6 per 100 000 children (0 to 19 years) in 1997 to 2003.– Approximately half of all incident childhood strokes are hemorrhagic.

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Nursing Pre-conference – “Hot topics”

• Depression and it’s relationship to stroke

– 33% of all strokes patients develop depression

– Rehab outcomes are worse when depression is present

– Depression is a risk factor for recurrent stroke and CV disease

– Early treatment can be effective

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• Depression screening tools – most commonly used

– Beck Depression inventory

– PHQ -2

– PHQ-9

• Who screens?

• What do you do with information? D/C summary to

PCP?

• Follow up/ 7 day call/clinic visit

Nursing Pre-conference – “Hot Topics”

• Transitions of Care model heavily emphasized– Schedule and document that f/u appts are made prior to

D/C– Benefits of early f/u

• Medication reconciliation• Pending test review• Review d/c summary• Safety issues – falls• Social issues – PT/OT/SLP/home care RN

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Transitions of Care models for the stroke patient

• Likely will be a big focus on next review for both PSC or CSC’s

• Will help with decreasing readmissions, improve pt satisfaction, and pt care along the continuum

Stroke Trials Network Formation• NIH and NINDS have selected and funded 25 regional

stroke centers to serve as Regional Coordinating Centers –over 5 year period – (infrastructure support)

• Goal is to streamline clinical trials and improve enrollment• Investigator initiated and industry sponsored studies will be

included• National Coord. Center – Univ of Cincinnati – Joe Broderick-

PI and team• 3 areas of interest/work groups

– Acute stroke treatment– Prevention of stroke– Rehabilitation and recovery

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Stroke Trials Network

• Funding for education will be included

– Stroke fellowship – research

– Mentoring opportunities

• http://www.nihstrokenet.org/

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5 Centers in the Great Rivers affiliate

• UH Case, Cleveland - Regional Coordinating Center

• Ohio State University - Regional Coordinating Center

• University of Cincinnati - National Coordinating Center

• Greater Philadelphia NIH strokeNet

• University of Pittsburgh

Fast Mag Trial – Jeffrey Saver, UCLA

• Los Angeles and Orange County CA was location– 41 EMS agencies– 315 ambulances– 2988 EMS personnel trained– 60 hospitals– 700 Emergency Dept MD’s involved

• Protocol– Magnesium (neuroprotective effect) 4 GM IV load vs placebo– Pt treatment initiated in patients who are within 15 min LKW but less than 2 hrs

LKW• Demographics of group

• Mean NIHSS = 11• Mean onset to treatment = 45 min• 74% were treated within 60 minutes

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Fast Mag trial results• No difference in outcome (modified rankin scores) for

placebo vs Magnesium group• No harm – Mg is safe

• Successful in devising system to treat patients in first minutes after stroke

• Implications – it is possible to train EMS providers to recognize stroke symptoms and initiate treatment prior to hospital delivery

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CLEAR III - interim analysis - Johns Hopkins Univ• Severe IVH patients with 3rd and 4th ventricle obstruction and

small parenchymal hemorrhages• All patients have EVD as standard of care• Treatment groups - EVD plus TPA vs EVD plus placebo

• Interim analysis of the first 250 patients– No DSMB endpoints reached– 30 day mortality – 12% (historically thought to be 50-80%)– Symp ICH 1-2% within 72 hrs of last dose of tpa/placebo– Asymp ICH 16% within 72 hrs of last dose of tpa/placebo – most were

catheter track hemorrhages– CNS infection rates – 2% bacterial meningitis and 5% chemical

meningitis

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CLEAR III – interim analysis• EVD plus TPA is not standard of care at this time

• The initial investigation reveals safety

• Will continue trial to determine stability and outcomes

• Goal is 500 patients enrolled.

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CRYSTAL AF Trial results• Largest randomized trial of Cryptogenic stroke and the

presence/detection of underlying atrial fibrillation as cause.• Patient type included –

– Non lacunar strokes - embolic appearing on imaging– No clear source (no proximal vessel stenosis/occlusion)– TEE with no clear cardioembolic source (obtained in all patients)– 24 hr ECG monitor during index hospitalization without evidence of

afib• Randomized to 1 of 2 groups

– Standard management (24 holter monitor, 48 hr holter monitor)– Implantable SQ Reveal XT monitor (w/ local anesthetic – size of

thumb drive with sensitivity to detect a fib and store information including ventric rate, duration of afib, etc)

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CRYSTAL AF trial results• Duration of monitoring – 3 years• Results – implanted device was far superior in detecting afib at 6

months, 12 months and 3 years

• 2.5 % complication rate – pocket infections most common• Implications

– Improved detection of AFib will increase treatment – 97% of pts with afib in both arms – received treatment with anticoagulation

– 90% of pts who had afib detected – had greater than 6 minutes of afib/day

– With greater evidence/documentation of duration of afib – less doubt about need to anticoagulate amongst health care team

• Limitations - expensive of device

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URICO-ICTUS• Trial conducted in 10 centers in Spain• 411 patients – all received IV Tpa –• Administered uric acid to 50% of patients who were treated

with IV tpa - potent antioxidant effect

• Results– 39% good outcome in UA plus IV tpa– 33% good outcome in IV tpa alone

– More benefit seen in moderate-severe strokes ( NIHSS 6-25)– More benefit in women– More benefit in patient with elevated glucose

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Pregnancy and Stroke• Observational study – included cohort of pregnant patients - who

within 1 year also had diagnosis/coding of stroke, MI, and VTE

• Results – suggest that there is an increase risk of thrombotic events that continue out to 12 weeks post partum

• It was previously thought that risk of thrombosis was present out to 6 weeks post partum

• Implications – more surveillance and awareness of risk in this patient population

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Target Stroke - report• Program to encourage improved treatment rates and

analyze/reduce door to needle times• Over 1000 hospitals contributed data• Data analysis – 2009 - 2013

– 2009 - < 30% of IV tpa patients received treatment with in 60 min of arrival

– 2013 - >50% of IV tpa patients received treatment within 60 min of arrival

• Conclusions – It is safe to expedite screening and treatment - No increase in bleeding

rates– Increased likelihood of D/C to home– More effective and safe with lower mortality rates

• Phase II target stroke data starting

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Telestroke – Abstracts

• Improving nursing practice thru telestroke partnerships - “Stroke care and patient outcomes are directly impacted by the level of nursing knowledge and practice at the bedside. Telestroke partnerships between comprehensive centers and community hospitals strengthen the nursing practice levels in the community hospital setting” Kathy Morrison Jennifer Humbert Penn State Hershey Medical Ctr Hershey PA

• Stroke Mimics in Telestroke - after education provided – “These educational endeavors have decreased the number of stroke mimics that are treated with tPA via our telestroke network from 14% to 9%” Rayetta K. Johnson Wake Forest Baptist Medical Ctr Winston-Salem NC

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Identifying Unmet Needs 30-days Following Ischemic Stroke:

The Post Stroke Checklist

• The Post Stroke Checklist (PSC) is a simple tool recently developed by a global panel of stroke experts to identify the unmet needs of stroke survivors.

Conclusion - The PSC proved to be a useful tool at 30 days to identify important unmet needs in stroke survivors with mild deficits.

Kathy Morrison Raymond K Reichwein Penn State Hershey Medical Ctr Hershey PA; Vernon M Chinchilli John M Graybeal Julie M Vonhauser Xue Feng Penn State Coll of Med Hershey PA; David C Good Penn State Hershey Medical Ctr Hershey PA

Defining the Role of the Nurse in Transitions of Care Within a

Comprehensive Stroke Center (CSC)

– At 1 year 75% of patients received a structured post-discharge phone call which continues to identify opportunities to assist with scheduling follow up care support early recognition of post stroke depression and ensure caregivers utilize respite resources.

– 30 day readmission rates in our ischemic stroke patients decreased to 7% an overall 5% reduction from previous year.

Conclusion - Assessment of patient and caregiver needs after discharge can be difficult and requires a coordinated multidisciplinary effort with multi-prong interventions. Development of a Stroke Care Continuum team allowed the CNS and Stroke Director to work with both inpatient and outpatient stakeholders

• Claranne Mathiesen Erin M Conahan Lehigh Valley Health Network Allentown PA

Appropriate Stroke Team Activations Through Use of

Los Angeles Pre-hospital Stroke Scale (LAPSS)

• Implemented screening tool for Medical Command to use with EMS personnel.

Conclusion - A higher percentage of patients can be treated with DTN times under 60 minutes without overburdening the Stroke Team when procedures are in place for optimum specificity to identify those patients who would benefit from rapid team activation and stroke interventionMartha Power Frank Bittner Patricia Horstman Owen Lander Thomas Marshall Jay Sherman Tanya Smith West Virginia Univ Hosp Morgantown WV; Laurie Gutmann Univ of Iowa Iowa City IA

Clinical Practice Guidelines and Statements

• Updated as new information/recommendations for

care is discovered or confirmed by research findings.

• All can be found on the AHA/ASA website

• If you are a member, you will also receive emails

when new CPG or statements are available.

2014

• Guideline for Management of patients with valvular

heart disease

• Guidelines for the prevention of stroke in women

• Recommendations for the mgmt of cerebral and

cerebellar infarction with swelling

• Risk adjustment of ischemic stroke outcomes for

comparing hospital performance - statement

2013

• Heart disease and stroke statistics – 2014 update

• Interactions within stroke systems of care

• Management of atrial fibrillation

• Dysphagia screening: state of the art: invitational

conference proceeding from state of the art nursing

symposium ISC 2012

• Guidelines for the early Management of patients

with acute ischemic stroke

Congratulations to all• Your involvement and care have:

– Improved treatment rates for eligible stroke patients

– Improved outcomes for patients who received treatment

– Elevated the standard of care for patients who present to

your hospitals.

Be proud of these accomplishments and congratulate your

team members.

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massaroll@upmc.eduJeanie.Luciano@uphs.upenn.edu

QUESTIONS????

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