- [Larissa] Well it's right at noon central time,
so we'll go ahead and get started.
Thank you everyone who's joined us.
My name is Larissa De Luna
with the American Heart Association.
And I'm happy to welcome you
to the American Heart Association stroke webinar series.
Today's webinar will focus on a model
for statewide rural outreach
for hyperacute stroke treatment.
These are educational webinars
that are brought to you by the Southwest
Affiliate Stroke committee.
All of these past webinars are posted at our website,
heart.org slash es-tee-dee-way quality.
Before we get started today,
I'd like to go over a few housekeeping items.
To avoid background noise,
all lines have been placed on mute.
For questions you can unmute your line
by pressing star six,
or you can type into the Q&A section of WebEx.
Although this event is not accredited
for CME or CE credits,
attendees will receive a certificate of participation
as proof of attendance.
All slides,
handouts,
and participation certificates will be sent to attendees
within one week of today's call.
We're happy to have two guest speakers today.
Dr. Margaret Tremwel and Renee Joiner.
Dr. Tremwel is a stroke neurologist
and the medical director
of Washington Regional Medical Center's stroke program
in Fayetteville, Arkansas.
She is also the chair of the American Heart Association
Southwest Affiliate Stroke Committee.
Renee is the director of operations for Arkansas Saves,
a Medicaid funded statewide telestroke program
operating through the center of distance learning
at University of Arkansas medical sciences.
At this time, I'll turn it over to them.
- [Renee] Good afternoon, this is Renee.
And I think that Dr. Tremwel
is gonna join in as we go through the slides.
I'm very excited to be here today to talk about
AR Saves which is a unique telestroke program
that we have in Arkansas.
And...
Let's see, Larissa.
Okay, there it goes.
So I have nothing to display.
Our objectives for today's presentation
is one, to describe why a coordinated system of care
is needed for stroke patients.
That includes the telemedicine component.
To describe how the Arkansas Stroke Assistance
through Virtual Emergency Support which is AR SAVES
is providing access to vascular neurologists
and evidence-based treatment
of Acute Ischemic Stroke
in Arkansas' most rural communities.
To present the impact of a comprehensive telestroke program
on patient outcomes over time
and to discuss the cost savings
of a statewide telestroke program.
Our motto here at UAMS
with the centers for distance health
is one we kind of stole from Bono.
And it is, where you live should not determine
whether you live, or whether you die.
And you'll understand why we're saying that
more here in just a moment.
So it's important to know what telemedicine is,
particularly from a Medicaid perspective
in order to be reimbursed.
So the Medicaid definition is
it's a two way, realtime,
interactive communication between the patient
and the physician,
or the practitioner at the distant site.
The electronic communication means
the use of interactive telecommunications equipment
that includes, at a minimum,
audio and video equipment.
It does not mean,
Larissa if you could do the next one please.
It does not include email or web page data collection.
So we've got a question for the audience.
Have you ever used telemedicine in your practice?
Yes or no.
I'm not seeing any responses but
we'll go onto the next slide.
- [Larissa] So, 14 out of the 43 people attending
said yes.
10 said no.
And about two were not sure.
- [Renee] Okay great, thank you.
- [Larissa] Let me close the polls.
All right.
- [Renee] So the reason why telemedicine is important
in a rural state is this.
Access to subspecialty health care.
And telemedicine can actually enhance
the rural economic development
by being able to provide the providers at the ED
in the home hospital and the community hospital.
It also allows for patients to remain in their community.
And then the community receives
the market share of resources.
So there's a lot of different advantages
to having a telemedicine program statewide,
both for the providers and for the patient.
And also for the community
and for those that reimburse,
the third party reimbursers.
There's several different kinds of models
of a telemedicine program.
One is a closed system but open to all hospital networks.
That's AR Saves.
We operate out of UAMS.
But because we're Medicaid funded,
then we're considered a gap-filling program.
And so any hospital that doesn't have access
to vascular neurologists can join our program,
no matter if bound to Saint Vincent,
whatever network they're in.
And within a closed system,
there are two different types of telemedicine.
With AR Saves we have the type
whether it's a physician patient relationship,
which means that all of our physicians
do have to be credentialed in each hospital
where they provide a consult.
Or we have the Arkansas Trauma Hand and Burn
telemedicine program.
That's a physician to physician consult
where there's no patient relationship.
And therefore, they do not have to be credentialed
in every single hospital.
There's a closed system within a hospital network.
Our Mercy Health System here in Arkansas
is an example of that.
And it's pretty much state,
and the VA system too.
They kind of take care of their own.
So they have a telemedicine program.
But it's within their own system.
They use their own providers.
And if a hospital, a smaller hospital,
cannot take care of a post-TPA Patient,
then they transfer within their health system.
And it works beautifully.
And then there's another kind
that's really coming on the scene right now
which is where rural hospitals can contract directly
with sub-specialty providers.
The University of Mississippi Medical Center
is an example of that.
Their ED physicians train nurse practitioners
in about five or six very rural hospitals
in order to provide emergency care in those facilities.
Otherwise those facilities were gonna have to close down.
So that's kind of a unique model.
And then there is the model where
a hospital can contract directly
with a group of sub-specialists,
such as neuro on call.
It's a group of specialists.
And that they do is provide the consult.
But outside of that,
I mean that's really the only piece that they provide.
And then there are companies that provide a turn key service
such as OneTouch or Reach.
And that's a company where they provide
the connectivity, the equipment,
the specialists,
the software for the data analysis,
the entire piece of it.
But what we're gonna talk about today
is AR Saves, the number one,
closed system but open to all hospitals
and how that works.
So Arkansas, you guys may know this by now,
but Arkansas was number one in stroke mortality.
We're in what's called the stroke belt.
We were first in 2011.
We're excited to say that
we're now sixth in the nation
in terms of stroke mortality.
And we're hoping to move further down the line on that, so.
Arkansas is, let's see.
It's a beautiful state to live in.
But it is a difficult state to get from area to area.
And so you can see that
we've got 2.9 million in terms of
the population who lives here.
Of that 2.9, 50% of our population
lives in what is defined as a rural area.
And 54 of our 75 counties
are considered rural,
which means that they have less than 50,000 population.
In addition to that we have
the 12th largest road system in the nation.
And very few of that is actually interstate.
So to get from one location to another,
it can be difficult.
Also, Arkansas has
73 of 75 of our counties
are considered MUAs.
And so there's no access to primary care either.
So the way that this all started, AR Saves started is,
back in 2002,
the Department of Human Services,
the Medicaid division,
approached UAMS with a High-Risk OB support concept.
And this was an initiative.
This was an initiative to look at
high-risk infant mortality.
And we were one of the highest at the time.
And so the centers for distance health
developed a concept for telemedicine.
And Medicaid was able to leverage federal dollars
to increase access to care.
UAMS actually provides a state match to that.
So there's really no state funding
that goes into the program.
This is the model that AR Saves is built on.
It's 100% Medicaid funded.
Medicaid pays for the on-call cost
of our vascular neurologist.
It also pays for connectivity to maintain connections
and equipment.
And we also are able to offer to the hospitals in the system
FTE support for a part-time nurse
and a part-time IT support person.
So connectivity is a big issue with telemedicine.
Back in 2006 actually,
the Department of Health had volunteered some funding
that they used to put T1 lines
connecting every hospital in the state,
and to put han-bergs in every emergency department
so that in the event of a mass casualty or
any other kind of disaster,
if there is a need,
hospitals could communicate to each other
and then back to the Department of Health.
This was built on and this infrastructure
was used to leverage additional monies
from the FCC Rural Health Care Pilot Program.
And you can see on this slide that
in 2007 they were able to get
a $4.8 million dollar grant award.
And then 2010, an additional $102 million grant award.
And so now what we have
is an incredibly connected state
as a result of the grant funding
that we were able to get.
If we'll go to the next slide.
So you can see on the left,
this is how Arkansas is connected before 2010.
And now you can see how we're connected today.
There's over 625 sites connected.
We've had over 160,000 hours of video calls.
So we know that it works.
We do it all day every day.
We do it for a lot of different reasons.
These connections here,
the dots,
represent our critical access hospitals,
our acute care hospitals across the state,
all the hospitals that would otherwise not have access
to a vascular neurologist.
Next slide please.
So does it work in terms of the money
that's being spent on it?
We had experts take a look
at how much Medicaid was paying,
and the cost savings of the program
in calendar year 16.
So in calendar year 16 we had 247 patients treated
within three hours of their Last Known Well Time.
115 of those patients made a complete recovery.
Which I think if you do the math,
that's like 46% I think.
You all may have to help me with that.
But anyway,
so if you look at the projected savings
in healthcare costs as a result of those 115 patients
making a full recovery,
the net savings for the state was $27 million dollars,
over $27 million dollars.
I feel like that's a very conservative estimate.
It doesn't really include
long-term care for patients
had they had that outcome.
And as you can see,
our annual budget is $9 million dollars.
Next slide please.
So in order to make this successful,
there are lots of different components to the program.
So we talked about the connectivity and the equipment.
We have a 24/7 call center.
And all of this is funded through the Medicaid contract.
We have a 24/7 call center so that
once a stroke patient enters the ED
of a rural hospital and they suspect stroke,
they immediately call our call center.
We take a limited amount of information
from the ED staff.
And then we connect with the vascular neurologist
to complete an assessment.
So that 24/7 call center
is an important component to the program.
And it's a component that I've not found
in other telestroke programs.
And I think it's one of the reasons
why we're as successful as we are with our program.
The second reason I think we're so successful
that I've not found in other telestroke programs
is the video support.
So we have IT specialists who are on every single live call
to make sure that there's no issues with connectivity.
And if there are,
then they're on the phone with AT&T, or Windstream,
or whoever happens to be the provider for that hospital
to make sure that we get that connection back.
They also kind of watch the carts 24/7.
So they know if the cart has been unplugged,
if it's online.
If it's not, they'll make a phone call to the hospital
to say if you need to do a live call,
it's not gonna work.
You're gonna have to get your cart plugged in,
whatever the issue is.
But they troubleshoot those sorts of issues.
We also have an image repository.
This is where the CT scan that's done
at the originating site
can be immediately uploaded into a repository
so that our neurologist can have immediate access.
So we're not having to wait for their radiology department
or whoever reads their CTs to make a read
and then get that information to a neurologist.
Our neurologist can do that themselves.
And it's immediate.
And then we have our contract neurologist.
We're bringing all of that into the state.
There for a while we had to have a few
that were out of state.
But now, we've got enough where
we're gonna have Arkansans taking care of Arkansans
which we feel like is real important.
And like I said we've got 24/7 call list.
We have a backup neurologist
in case we have more than one call at a time.
I talked a little bit about the funding
for the hospital participation earlier.
That funding also includes workforce development funds.
So we provide funding for each hospital
so that they can attend any trainings that we do
or any other trainings that would support their staff in
providing better stroke care.
And then we also do data,
which we're gonna look at here real quick in a minute
for quality assurance.
We do a QA on every live call
that's conducted through AR Saves.
And we provide an email, a friendly email back to
the ED to say,
you all did great here.
Here are your opportunities for improvement.
And here's some training that's available to you
to improve for the next time you have a call.
Some of these small hospitals may get one call a year.
And so we make sure that they're kept,
you know, their skillsets kept up.
They're required to do at least a mock a month.
And that helps.
And then we do on-site visits
where we can provide training,
we can look at their time targets.
We make sure that they've got the evidence-based protocols
in place for their facility, those sorts of things.
The other thing that's really important about AR Saves
is community outreach.
You know, we know that you can have the program,
you can have the best care available.
But if the community doesn't know that it's there
and in their local hospital
and what to look for in terms of signs and symptoms,
they're not gonna be able to get to the ED
in time for treatment.
So we spend a lot of time and effort.
Each hospital is required to do at least two
community outreach events a month
through the Medicaid contract.
Next slide please.
Okay so this is Saint Mary's,
which is an acute care hospital.
And this is Tim Tanner who is the nurse facilitator
for that program.
And he's actually conducting a mock right now
with our call center.
And so if you're in the ED in one of our facilities,
this is what you see.
There's our cart.
And who you see on that other screen,
if they weren't doing a mock and it was a live call,
could be Dr. Tremwel instead of Calvin.
But that's what it looks like
from the patient's perspective.
Next slide please.
And then this is what the vascular neurologist will see
on the other end.
It's important to be able to make sure
that we're giving the right medication,
that we're giving the right dose,
that the dose amount is correct.
And so all of that is shown to the vascular neurologist
as a confirmation.
And it's as clear as that.
That's what they see.
Next slide please.
This slide has a lot of information on it.
But it shows Arkansas
and our 75 counties.
And each red flag represents an AR Saves hospital.
We've got 54 hospitals across the state
that participate in the program.
We're hoping to bring another six hospitals on
this next year.
And once that happens,
every ED in the state
will be a stroke-ready hospital.
And so we're so excited about that.
When we combined our efforts
with the Mercy Health Stroke Program
with what's happening with the VA and Saint Vincent,
then every single ED in the state can provide treatment,
on-site treatment to stroke patients.
You can see that in calendar year 2017,
we had a total of 102, I mean 1,002 consults.
We gave TPA to 340 patients.
And so our percentage of patients
treated with TPA is 34%,
which is very high considering some other programs.
And then we did a total of 1,004 mocks.
With our communities events last year,
we did over 1,700 events.
And we were able to reach out to over 289,000 Arkansans.
And then you can also see that
out of the 54 sites,
20 of those are critical access hospitals.
That's the whole reason the program was developed
was for those sites.
And then by December 2018,
we're looking to have 23 critical access hospitals.
We're doing right now three to four live calls a day.
What's on the bottom is also important.
We're not bringing every post-TPA patient,
or patient that needs interventional radiology to UAMS.
That's not what the program is about.
And so what we've done is to identify
the hospitals across the state
that have neuro ICU capability
that can take a post-TPA patient,
and those that also have interventional radiology.
'Cause we want the patient to go to the closest,
most capable hospital possible.
It's important to us
to be able to keep the patient as close to home as possible.
Next slide please.
We're really excited about this one.
This is a 30 minute drive time
to a stroke-ready hospital
once we get all the EDs in place.
The blue circles are what's currently in place.
And then the yellow circles are the ones
that we're gonna bring on during this next year.
The green circles that you see on here are the Mercy sites.
And that's the best that we can do.
We've got a few holes there.
But there are no hospitals in those counties
for us to bring on.
Next slide please.
So question for the audience.
Do your pre-hospital providers know the location
of their closest stroke-ready hospitals?
Yes or no.
Okay so it's showing that 27 out of 47 do.
None out of 47, no.
And then not sure, 19 out of 47.
This is an important question.
Next slide please, Larissa.
For this reason.
Since 2009, we've been collecting data.
And so we're data-rich right now.
And we're really trying to drill down
to see how we can improve the program
and what we really need to be focusing on.
And so we've been looking at patients
that arrived to our stroke-ready hospitals by EMS
or by POV.
And for those that did arrive by EMS,
did EMS pre-notify
that they were headed to that facility
with a potential stroke patient.
And so in 2017,
we had 1,002 stroke patients.
At the time we had 48 hospitals.
We've brought some on since then.
Those arriving by EMS decreased the door to CT time
by 4.7 minutes,
versus those that came in by POV.
That really kind of surprises me.
I expected that to be a little bit better.
But still, 4.7 minutes.
And then EMS alerted ED with Code Strokes,
those that did decreased the door to CT time
by 11 minutes and four seconds.
That's huge.
But those that arrived by EMS with pre-notification,
we saw a 29 minute reduction in Door To Needle time.
So what we're trying to do
is to get the word out to everybody.
Call 911.
Here are the symptoms of stroke.
And then call 911.
Do not bring your family member or your friend in
by your car.
Call 911.
And then we spend a lot of time training our EMS providers
signs and symptoms of stroke,
where their stroke-ready hospital is at,
and to be sure to pre-notify Code Stroke
before they get there.
That way, if there is a patient in the CT,
they can take that patient,
remove that patient out
and have the CT ready for the potential stroke patient
that's coming in by EMS.
Next slide please.
So what is the average?
Whoop.
What is the average drive time for EMS
to reach a stroke-ready hospital from a rural area
in your state?
A is less than 30 minutes.
B, 30 to 60 minutes.
C, 60 to 120 minutes.
And then D, more than 120 minutes.
Okay, so we got the results.
So, A, less than 30 minutes.
15 out of our 46 participants.
60 to 90 is three.
90 to 120 minutes is four.
And then not sure is 20 out of 46.
So, this is kind of our dashboard that we look at.
So 37% of our patients had a Door To Needle time
within 60 minutes.
Of course, that's our target.
We try to meet the HA targets and guidelines for our care.
Last year, or for FY16, it was 26.
So we have improved quite a bit this past year.
This compares to 26.6% of hospitals
with a neurologist on-site.
And it's better than other large telestroke programs at 13%.
So not only do we compare ourselves against ourselves,
but we also try to look at the research that shows
some data on a national level.
The two charts below shows
the number of consults,
and then the number of patients that received treatment
throughout our time.
And then the percentage of patients that received treatment
is the one on the right at 34%.
Next slide please.
So this really says it all.
This is a case study of a patient that
came into one of our hospitals in Searcy,
and had a complete basilar artery occlusion,
a brain stem stroke.
A brain stem stroke, as you guys know,
is difficult to identify.
You don't see the usual FAST signs and symptoms.
But we'd been really educating EMS on BE-FAST.
We've added the balance and the eyes
to the list of signs and symptoms.
And EMS arrived on scene.
This was a 49 year old fireman
with a history of A-fib,
not on anticoagulation.
The patient became ataxic, drowsy,
speech heavily impaired,
vomiting, severe nausea.
Northstar EMS brought the patient from home
to White County Hospital in Searcy in Arkansas.
So his initial NI stroke scale was 11.
His time of onset was 1155.
The case conclusion is
he left the hospital in four days
with an NI stroke scale of zero.
The cool thing about this is,
this patient one,
when EMS arrived on scene,
they knew what they were looking at.
And then they pre-notified and got the patient
to the closest stroke-ready hospital available to them.
They arrived on scene at White County.
So Last Known Well Time to the ED was 37 minutes.
They were seen by the ED medical director
within seven minutes of the time that they got there.
We got the neurologist connected within 33 minutes.
This happens to be one of Dr. Tremwel's patients.
And then we were able to give Alteplase
within 46 minutes from arrival into the ED.
This patient was transported by air to UAMS
and arrived at UAMS at 1420,
and coded almost as soon as they got into the ED, he coded,
and was intubated at 1425.
They were able to revive him and remove the clot.
He went to interventional radiology.
They removed the clot at 1518.
And so from the time that he had his first symptom
to the time that he left,
or was cared for at UAMS with interventional radiology
was less than four hours.
And before we had this program,
there is no way that that could have happened.
And I believe that this patient would not be alive today.
I don't know, Dr. Tremwel,
if you want to make any comments about that.
Okay, well we'll go on.
You'll see on the care team we've got
Northstar EMS ground ambulance.
We've got the White County Emergency Department staff.
We've got AR Saves who has to do the connections
between the ED and our neurologist.
Survival Flight Air Ambulance then arrived
at the White County Emergency Department
to then air lift them to UAMS.
And so there was a lot of things happening
in order to take care of this patient.
And it just went very smoothly.
- [Dr. Tremwel] I'm sorry.
I had trouble getting my mute button to work right.
This is Tremwel.
And yeah, I just want to emphasize that
when you look at this case,
this is not just a one person in 10 years.
This is a routine phenomenon that we find.
And also to emphasize that stroke does occur in the young.
And my personal experience is
a young person in a rural area
has a good chance of doing well
if we can just support the blood vessel circulation
that they have that's patent.
You know, try to dissolve the clot as much as we can.
But more importantly is the TPA keeps the collaterals open
so that we give the TPA,
they're getting the helicopter at the same time,
the patient's taken into a place where they can
pull out a clot,
that they have an excellent chance of doing very well
with a full recovery,
or a near full recovery.
And the other thing is is that...
The thing is, it's not like you have to do
every single component of this.
That once EMS sees what their impact is on a patient,
and all of a sudden they're asking for education,
they're bringing questions,
they're actively involved.
And the same thing with the nursing and physician staff.
Always in the beginning,
there's always a little bit of fear of a change.
But once they start seeing that the impact
that they're changing their practice has on their community,
then everybody's all in.
I think Arkansas Saves is probably the most popular
program in the ERs across the state.
The ER physicians would say that
when a stroke patient comes in,
that's the easiest thing that they do
because they know they've got expert care
that's gonna take care of this patient.
They got a system of care within the state
that's gonna make sure that they're in the best spot
that they need to be to make a full recovery.
I can't recommend a program any more highly than this.
It's worth the effort of organizing people
because they're gonna organize themselves as you go along.
- [Renee] And that's exactly what we're seeing.
So I think that when we first started,
we were begging hospitals to come on board.
And now we've got hospitals begging us
to get on board.
And so we've had to go back to Medicaid
to ask for additional funding
in order to bring on additional sites.
Like I said,
initially it was for critical access hospitals.
But now what we're trying to do
is make sure every ED in the state
is stroke-ready.
And we do.
Tim Vandiver is one of our outreach nurses.
He's also a paramedic.
And he does all of the training with EMS.
And his calendar is booked with EMS agents
who's calling him and asking him to come out
and train their medics.
And Dr. Tremwel, that's exactly right.
On the next slide you'll see
how we've done since 2008
in terms of our time targets.
And so we're steadily trying to improve.
We're really trying to get down to that
60 minute Door To Needle time.
And like I said,
we do on-site visits to every hospital
that participates with us.
And we really look at how they can shave off a minute here
and how we can help them do that.
So that kind of shows the improvement over time.
The next slide shows kind of how we do our on-site training.
Like I said,
we train, we retrain,
and we train again.
It's important for the nurses and the physicians,
the ED physicians to be comfortable with the equipment,
with being comfortable being on video,
and then being comfortable with
helping the neurologist do the
NI stroke assessment to scale.
And so we do mocks
and make it very, very interactive for those sites.
- [Dr. Tremwel] There was the annual,
oh you're gonna do that one now, I'm sorry.
- [Renee] And then here's our annual training or convention.
Did you want to say something about that?
- [Dr. Tremwel] Well what I would say
is with the annual training that we even...
It's a stereotyped exam that the nurses are taught for
evaluating the stroke patient.
But at the meeting we interact with one another
and present different cases which required
different types of evaluation,
and we can all learn at that meeting
so that like the basilar stroke patient
requires a little bit of a different exam
to be able to get the data,
you know, what's wrong with 'em.
And so we can learn that as a big group together.
So everybody has skills are lifted up at this meeting.
- [Renee] We're having our annual conference this week
as a matter of fact.
It starts tomorrow.
And we have nearly 300 physicians,
ED nurses,
and EMS practitioners coming to the conference this year.
And so it's just an incredible time
to bring everybody together,
let them learn from each other.
We are gonna be doing hands-on skill stations
with difficult patients,
the scenarios from the ASLS class.
So we're looking forward to that.
Next slide is do your stroke ready hospitals
conduct community educational activities
on the signs and symptoms of stroke
and to call 911, yes or no?
And while we're getting answers to this,
I'll just say, like I said before,
we believe community outreach is
as important as clinical excellence in the program.
And so we spend a lot of time and effort
working with our hospitals on how to do
outreach in their community,
how to identify high-risk communities
within their community,
and how to reach out to them
in order to get patients into the ED in time for treatment.
And we've seen,
we've gotten some evidence that shows
that with community outreach,
with large groups and it's interactive,
we do see within a time period
patients coming into the ED in time for treatment.
So we know that it works.
So on the poll,
do your stroke ready hospitals conduct community
educational activities,
18 out of 47 said yes.
Three said no.
And then 26 we've got no answer for.
The next slide shows
the largest brain in Arkansas.
And it's the only.
There's not anybody else in Arkansas that has this.
And it's beautiful because
it's a great tool to start the conversation.
And so we take this to community events.
And as you can see here,
this is a elementary school.
We've really started trying to get into the schools
because you know,
many of these kids go home to their grandparents
and the person who's having the stroke
is not gonna necessarily know
that's what's happening to them.
So it's important for those around
to understand the signs and symptoms.
So we've been spending a lot of time and effort with
elementary, junior high, and high school.
We actually won the RAISE Award.
It's the National Stroke Associations RAISE Award
for our community outreach last year.
So we were excited about that.
- [Dr. Tremwel] One example of that in a local area
was getting health teachers on one specific day,
I think it was the fourth of May.
And they called it may the fourth be with you
to end stroke.
And the health teachers taught their students.
I think it was two grades,
sixth and seventh grade,
and then charged those students to go home
and teach their parents the signs and symptoms of stroke.
And programs like that really get the kids enthused.
They love teaching people things.
And it's a good way to get the word out.
- [Renee] So the slide that you're seeing now,
we do a big strikeout stroke
as a community outreach event.
Those in Northwest Arkansas
and in the Little Rock area.
And so this is our strikeout strike for this year
here in Little Rock.
And you can see,
we recognize our strike survivors at these events.
And so everyone that's on the screen,
except for Olivia to the far left,
are stroke survivors
that were taken care of in our program.
The gentleman that's on the mound raising the ball,
and who threw the very first pitch
is the 49 year old fireman that we just talked about.
And it was really incredible to watch him
be able to throw the ball.
He didn't quite make it over the base,
but he did a good job with that first pitch.
So that just kind of brings everything back around to
this is why we do what we do.
Saving patients one patient at a time.
Next slide please.
And then this is why it works.
These are our nurse facilitators from across the state.
There are 54 hospitals represented in that group.
We have a nurse facilitators retreat
in addition to the annual conference where
we just bring them in,
and we do round table discussions
on what works in different sites,
and what they need from us
that's different than from what they're getting,
and what our goals need to be for the next year.
And then the next slide.
So this is one of our stroke survivors.
And I'm showing him 'cause I'd like to read a quote.
He's Tom Berryhill,
and he was taken care of at Saint Mary's.
He should have gone to Dardanelle,
but at the time,
Dardanelle was not one of our hospitals.
Now it is.
Because of him,
Dardanelle reached out to us
and we've been able to bring them on as one of the sites.
But I called Tom and asked if I could talk about him
in my presentations.
And this is kinda what he said back to me.
He sent me an email.
And he said, I'm curious,
do you ever do anything to recognize the various
members that play a part in AR Saves.
Let me see if I can find this, okay.
All I did was refuse to die until the doctor's intervened.
What about the paramedics,
the ER staff,
the nurses, flight crew,
the ICU staff and everyone else?
Those men and women are the rock stars of the program.
I'm just the lucky recipient of their talents.
I would hate for those people to ever be taken for granted.
They're very special to me,
and they're the reason that I can say thank you
and Merry Christmas,
Tom Berryhill.
He's gonna be at our conference this week,
and we've got a survivor panel that kinda tells their story.
And it's an opportunity for him to kinda say
what it's like being on the other side,
and to be able to say thank you to the group
that took care of him.
And then we were gonna try to do a video,
but I'm not sure Larissa if that's gonna work.
- [Larissa] Let's give it a shot, one sec.
- [Renee] Okay.
- [Larissa] You able to see my screen?
- [Renee] Yes.
- [James] I was in my yard
putting some flowers in the ground.
(man murmuring)
I had a video conference with a neurologist from UAMS.
- [Neurologist] Mr. Owens, can you raise your left leg?
- I told him I couldn't lift my left leg or
not too many left side functions were working very good.
- [Woman] Hold this leg up.
- From what I can remember I had a droopy face
on my left side,
I was slurred speech. - Good, good, good.
- [Neurologist] Okay there is left facial droop, okay.
- [James] Instructed me on TPA.
- He has a blocked clot in his brain
and this medication may dissolve this blocked clot.
- It was a shot, apparently to help my symptoms.
At the time I didn't know it was a stroke,
but apparently I had a stroke.
- [Neurologist] If you get this medication,
you have one out of three chances
for complete recovery or major improvement.
- Whatever that medicine was,
it worked very, very good on me.
- [Renee] Okay great so,
that was one of our very first patients
who received TPA.
And what you could see on the screen at one point,
you could see him,
but you could also see our call center in the bottom corner,
our video support person,
and our vascular neurologist.
And so it takes all of them
to make a live call possible.
And I'm happy to take any questions.
Or Dr. Tremwel, if you want to add anything.
- [Dr. Tremwel] Thank you for covering it all.
Any questions from the participants?
- [Larissa] Yeah, so there's one in the polling,
and the Q&A section.
Does AR Saves coordinate all the community and outreach
events and education?
- [Renee] No, we don't.
It's actually the responsibility
of each hospital to do that.
But we provide,
we're able to use our funding to purchase swag.
So we have magnets,
and fans,
and pens,
and brain erasers,
and everything else you can think of.
And so we provide those free of charge.
And we use BE-FAST.
That's the term that we use.
We provide those free of charge to all the hospitals.
Now we do often go out and assist with those events.
'Cause like I said,
many of them are so large
that they can't really do that on their own.
If they use the mega-brain,
then we are there with the mega-brain.
We have to bring that to 'em,
set it up,
and then bring it back.
- [Dr. Tremwel] And the information
is in multiple languages.
We even have up here
information in Marshallese from Arkansas State.
- [Larissa] Wow that's great.
That's the only other question I have in the Q&A section.
Would anyone like to come off mute with star six
to ask a question?
As everyone gets up the courage,
I'll also just put out a few reminders.
A copy of the presentation,
and then the recording,
and the certificate of participation
will be ready for everyone in about a week.
And that'll be emailed to everyone
who's attended and registered.
Any questions with star six?
Anyone would like to come off mute?
We did have another one come in through the Q&A section.
Do you have competition in your state
with comprehensive stroke centers?
We currently have three different systems
providing comprehensive treatments.
All systems obtain rural transfers,
and this is a large portion of the stroke patients treated.
- [Dr. Tremwel] Well currently, we don't have any
comprehensive stroke centers in the state of Arkansas.
And I wouldn't call it competition.
We have a lot of cooperation.
Arkansas Saves helps determine where the patient should go.
And it's based on the shortest time
to get the appropriate care.
- [Renee] And that builds on a trauma system of care
that we were able to get funding
back in, oh gosh,
2011 I think,
I can't remember exactly,
from the Department of Health to set up a trauma system.
And you know,
we only have one adult level one trauma system in the state
and that's in Central Arkansas.
And so,
there's a call center that's been formed for EMS
to call when they get on scene of a trauma patient
and call this call center to say
these are the injuries.
Where's the closest place for me to go?
In order for that to happen,
we had to bring all the hospitals together to work together.
And we had AR Saves already in place when that started.
And so like Dr. Tremwell said,
there's just an incredible amount of cooperation
across the state
to get the patient to the closest place
that can take care of them.
It's really an incredible system.
- [Larissa] Well you've inspired several other states.
I'm seeing comments of people who are wanting
to get this built in their state.
And we did get a question.
I mean, do you mind sharing
where you got the big brain from?
There's a question on that.
(laughing)
- [Renee] Let me send you that information.
It's somewhere in Texas.
But yeah, I will send you that information.
- [Larissa] We have another question.
What's the optimal timeframe
for thrombectomy post-TPA?
- [Dr. Tremwel] Well now the time window extends
out to 24 hours for the possible time window.
The optimal time window
is certainly within the first four and a half hours.
Any measure you can use to improve the patient's
perfusion of their brain is acceptable
in the first four and a half hours.
Beyond that time window,
there's a few studies that are out there.
One of them looks at CT and geography,
and then CT perfusion
to determine if there's an area of brain that
is at risk of being lost,
but is not yet lost.
It's just ah-ske-nah but not deceased.
And so if you pull out the clot,
there's a good chance that there could be a good recovery.
And then another study that just looks at
the size of what we call the core impart.
And that's the area of brain that
by CT perfusion looks to be already lost,
that there's no recovery.
And if that is small enough,
then the idea is,
and you have a NI scale that's greater than six,
then pulling out the clot,
there's a good chance that you can have improvement
in the patient's outcome.
And that extends out to, in one study,
out to 16 hours,
and the other study out to 24 hours.
So currently, in the state of Arkansas,
we're looking at 24 hours out for thrombectomy.
But the issue is
there's only a few thrombectomy centers in Arkansas.
So we also have to take into account
the length of time it would take
for the patient to get to a thrombectomy center,
and how the severe the stroke,
and their age.
You know, greater than 90 the chances of doing well
are of course less.
So we look at multiple factors in this.
- [Larissa] What data do you require when a patient
has been treated at a facility with TPA?
- [Dr. Tremwel] I'm sorry, I didn't hear what you said.
- [Larissa] What data do you require when a TPA patient
has been treated at a facility?
I guess when they're transferring.
- [Dr. Tremwel] Well a nurse report,
and then a physician report is given.
And what I'd like to know is just
when the Last Known Well Time was,
what the symptoms are,
what their NI stroke scale score was
before they got TPA,
what time they got the TPA and what the dose was,
and then how their vital signs,
blood pressure,
and that sort of thing are doing,
and if they've made any improvements.
Then also, questions about blood thinners
and things like that,
Aspirin, Plavix, you know,
what kinds of medications
and what their past medical history is
to try to get an idea of what the cause of the stroke was.
Now some hospitals in our state
actually have CT angiography
and we'll go ahead and get a CT angiogram
of the neck and the brain
so we can say where the blood clot is,
if there is a blood clot there.
Because if they don't see a blood clot,
then they could go to a hospital
that treats post-TPA
but doesn't have a thrombectomy capability.
But if they have a large clot
in a major artery of their brain,
then they should go to a thrombectomy center.
Those types of questions that we ask.
And then also when they're transferred,
there's a report of the nurse
to the transferring nurse if it's by helicopter,
or the EMS if it's by ground.
- [Larissa] Are any of your pre-hospital providers
using any of the available scales
to evaluate for LVOs?
- [Dr. Tremwel] There are a number of scales
that can be used
and the data's really out at this point
as what is the best scale.
I think the best thing is is if there is a positive sign,
that is you see a hyperdense middle cerebral artery,
or a basilar artery,
or vertebral artery sign,
and you have an NI stroke scale score
that's greater than six.
And then I also, personally,
will look at their cortical findings
that makes me think it could be an embolic stroke
or a large vessel stroke.
But right now,
there's a variety of scales that are out there.
But none of them really have the sensitivity
and specificity that I can recommend on a webinar to units.
- [Larissa] I think that's all the questions
that I have in the Q&A section, go ahead.
- [Renee] I was just gonna say,
we're getting read to pilot doing
telemedicine in the back of an ambulance.
And we're doing it in Southwest Arkansas
so that we can connect our neurologist
into the back of the ambulance with the paramedic
and the patient.
And so we're really hoping that if this does work
that that will really help us
with the issue that you just described.
Right now, we're really recommending for
all of our patients to go to
the closest stroke-ready hospital
and then be assisted by a neurologist,
and then go from there,
rather than trying to identify an LVO on their own.
- [Larissa] Would anybody like to come off mute
with star six to ask a question?
I think we're coming to the end of our time.
Dr. Tremwell and Renee,
I just want to thank you guys.
Hot that you have your conference this week.
So I appreciate you taking the time to do this webinar
as you're probably also preparing for that.
So we really appreciate that.
And thank you everyone who attended.
Again, look for an email in about a week from today
with slides,
a link to the recording,
and your participation certificate.
Thank you so much.
Have a great week.
- Thank you. - Thank you.
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