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

NNT 2 NNT 7 (3,1) NNT 14 Saver JL. Stroke 2006;37(1): Hacke W et al. NEJMN 2008;359:1317­29. Every 1 minute will die: neurons synapses 12 km myelinated nerve fibres 90 minutes 180 minutes 270 minutes

 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 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):CD

 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 (3):

 Before 2001 – without central accreditation of SC  – Stroke centers accredited only by scientific society  2010 – New system of SC/CSC – accredited by Ministry of Health + scientific societies, operational from  11 comprehensive stroke centers  34 stroke centers  From  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  inhabitants COMPREHENSIVE STROKE CENTER (KOMPLEXNÍ CEREBROVASKULÁRNÍ CENTRUM)  NICU – 13 beds  Neurology – 30 beds  Neurosurgery – 20 beds  Early PT – 20 beds  Catchment area  inhabitants

Soláň Ústecký kraj Ústí n. Labem Chomutov Děčín Teplice Nem. Litoměřice Liberecký kraj KN Liberec Česká Lípa Jihočeský kraj I. Nemocnice Č. Budějovice II. Nemocnice Písek Královéhradecký kraj FN Hradec Králové Obl.nem.Trutnov Obl. Nem. Náchod Jihomoravský kraj FNUSA + FN Brno Břeclav Znojmo Vyškov Moravskoslezský kraj FN Ostrava MN Ostrava Vítkovická nemocnice Krnov Třinec Karviná Olomoucký kraj IFN Olomouc Prostějov Hl. m. Praha Nemocnice Na Homolce ÚVN FN Motol VFN FNKV + FTNsP Plzeňský kraj I. FN Plzeň Karlovarský kraj Nem. Sokolov Nem. Karlovy Vary Zlínský kraj Zlín (T. Bati) Uh. Hradiště Kraj Vysočina Jihlava Nové Město na Moravě Středočeský kraj Kolín Kladno Mladá Boleslav Příbram Pardubický kraj Pardubice Litomyšl Situation 2014

 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

I. – VI VII. – XII. 2013

I. – VI. 2013VII. – XII. 2013

Mean I.-VI ,54%... Mean VII.-XII ,86% PA BV KL BK MB LTMš

I. – VI VII. – XII. 2013

Orange – 1 st half 2013Blue – 2 nd half 2013

I. – VI. 2013VII. – XII. 2013

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