thank you very much dr. Mayer this is
being a long day for all of us and it
has been with a lot of energy and just
sitting around all day I have been
thinking about what brings this energy
and I think it is primarily two things
one is that we are all here with a
common mindset the mindset that we do
what is the best for our patients and
the goddess of politics or specific
interests the second is that we are sort
of I was thinking of the words of kids
were standing upon the forehead of the
age to come
so we've seen great developments we are
waiting many more to come
and this is an era of enlightenment that
comes in contradiction with a long
period of darkness and this was a time
that even somebody as great as John
shillings action would say that he who
is trading by drugs human Lydia
owing to softening on a cloth is
treating a whole of the brain and if we
hit drugs which could dissipate the plug
in the vessel I know of none they would
have to do it with marvellous quickness
or the nerve tissue would be dead by
starvation before circulation was
reestablished and here we are we have
the drugs we have the devices of the
methods and what we have been talking
all this how to get that marvellous
quickness and this is part of what
qualities about so interestingly about a
year after John feelings Jackson died
Richard Stewart Stephens was born and
Richard Stevens hid the relatively
conventional career he started as a
cardiologist he did Theory attrex until
in his retirement his wife died of a
stroke and that he decided to dedicate
the last 15 years of his life to
improving the outcomes of stroke
patients so he was the first one to
conduct a well-designed
randomized control trial about stroke
unit care and he was also the first
to understand that each one of us needs
to study the incidence and outcomes of
stroke in the community that we live in
so he was the first one to design and
conduct a stroke registry and I would
like to make the following points one is
that quality presupposes effective
treatment if we do not have effective
treatment we cannot have quality efforts
but effective treatment is a moving
target it's time there is another layer
of new treatment superimposed in the
previous one so at any given time
quality involves setting standards the
best science and the best practice as
dr. yog said and then implementing the
standards and finally maintaining them
because sometimes it's easy to implement
but difficult to maintain and if we are
to sort of divide the course of human
civilization by the breakthroughs of
stroke care we start from the beginning
to the mid nineteen eighties where there
was nothing maybe heparin or
endarterectomy two months after the
stroke and then from the mid 1980s as we
said to 1996 we have the stroke unit
care era 1996 to 2015 IV TPA and
initially three hours and then four and
a half hours after 2008 and then 2015 we
see the fab 5 trials that dr. Mayer
mentioned and this is the early
endovascular from back Tamara
why is it early because it's only six
hours now we have the dawn trial results
and hopefully in January in the stroke
conference we will have the diffuse
three trial results well we will have
the error of late image based
endovascular thrombectomy after 24 hours
and maybe the next one is just wishful
thinking but in a few years after the
eye witness trial comes out the ekeus
for extent consortium from Germany and
Australia come out with their child then
maybe we will have the late image based
IV TPA so lots of exciting things to
come in stroke research and subsequently
quality so we're going to talk about
these three
proven treatments for stroke stroke unit
kill IV thermolysis and thrombectomy and
even though we saw that come back to me
is a new exciting development with a
number needed to treat less than three
when we talk about all stroke patients
the impact on stroke outcomes comes
primarily from stroke unit care so going
through those three points which also
reflect the cause that we have taken as
a comparisons to extent over the last 20
years we have been trying to treat
outpatients while in the stroke unit and
this typically means preventing blood
clots putting them on oil antiplatelet
and anticoagulants starting educating
them assessing them for rehabilitation
but there is a lot of other intangible
measures control of blood pressure
control of hypoglycemia is dr. verella
said early nutrition assessment with
dysphagia screens early IV hydration
lots of things that we do in a stroke
unit or now in the critical care setting
that cannot be done in the general flow
and one of the great projects that has
happened over the last few years
nationally is the get with the
guidelines project for the American
Heart Association which have been
participating in it for the last ten
years and the time is not enough to show
all the measures certainly everybody in
this hospital has played a great effort
into getting our numbers up and our
quality improvement project running but
in this defect-free composite stroke
measure we have been getting
consistently up over the last few years
this is a chart that was made with the
help of Don scores aerial informatics
East so we thank very much and that was
top unit care second is IV TPA as we
have heard we were the coordinating
Center in the Imaging Center for DNA MDS
trial that establish TPA within three
hours so together with IV TPA came a new
number of quality metrics the goal now
is
to treat people as fast as possible as
many people as possible and also as well
as possible because we know that
protocol violations are well associated
with intracranial hemorrhage so we
measure door to needle time doll to
lapse dough to City and at the same time
we have been trying to improve our
within the world's efforts of what makes
systems and processes faster is it
parallel processing is a TMS to
notification and a great number of
things that were said early on
and nationally the same has been done
with the target stroke project with dr.
Yahoo phase one and two phase one
started in 2010 and it resulted in a
significant improvement in increase in
the number of hospitals that give TPA
with doll to knit in less than 60
minutes and now we participate in the
Phase two which tries to bring the time
down to 40 minute 45 minutes we have
been increasing the number of patients
that get TPA within four and a half
hours and this is not easy it has
required a lot of team effort our
brainstorming quality improvement
projects over the years were proud to
say that we have been increasing our
would have been decrease in our door to
needle time so that the great number of
patients get it within 60 minutes and
now that we started participating in the
phase two already our median time is
below 45 minutes out dot needle time for
IV patients so now we we go to the third
aspect of quality efforts in the
vascular Anatomy we saw the five trials
that established in the vascular some
back to me and with them we now have
another whole set of measures so how can
we make that process faster we have to
break the time of onset to reckon all
ization to a number of other times so
onset to doll of the emergency
department
emergency dole to picture or city area
now picture to punctual puncture to
first pass first bus to eternal ization
and each one is a target for quality
efforts we're doing excellently at that
and we have more quality projects coming
up in the very near future the
establishment of endovascular
thrombectomy not only increased the
complexity of our efforts within the
hospital but also the quality that is
needed in the Intel hospital transfer
and development of regional calcium
systems so when we hit the IV TPA only
it was a relatively homogeneous
population of stroke centers that would
give IV TPA and provide stroke unit care
now we have tiers of care we have the
acute stroke ready centers and for
example in our system we have three
first ending emergency departments that
are essentially stroke ready centers
that give the TPA and then transfer the
patient we have the primary stroke
centers that can give the IV TPA
improvised stroke here and the advanced
comprehensive stroke centers as we have
been for almost the last two years that
can provide care with IV endovascular
but also hemorrhages now we are seeing
the development of the concept of from
back to me capable stroke centers that
provide the whole scheme extract care
including come back to me but excluding
hemorrhages and also we have now the
different approaches does the patient
with the loud special operations to go
to the primary center get the IV TPA and
from there to the comprehensive which
means that you will get he or she will
get faster
IV but maybe a little bit later in the
vascular treatment or do they go
directly to the mothership the
comprehensive Stroke Center and it
appears that we may have to rely on
geospatial information advanced software
so that we can develop a policy for each
individual region so one
sniffing concept is very Dido has dr.
yog said that darling go out but
depending on that we have to make
quality decisions and quality
improvement projects as to whether
patients will go directly to the
comprehensive or will go first to the
Primary Stroke Center we have seen a
significant increase in the volume so we
have to be very fast and very efficient
about how we improve those things so
overall we have seen a movement of the
pendulum towards comprehensive stroke
centers over the last few years we
suspect that he once laid image-based
into vascular son back to me is going
also to be announced and established
this will require new quality efforts
and will further move towards
comprehensive stroke centers but if you
know this is a projection
even when late IV TPA implemented then
this will take things back to the
primary stroke center so instead of
doing the scoop and run approach of
trauma to do sort of a scan and land
approach especially for late appearing
patients and this is all quality for
acute treatment we are happy these days
if we have a good outcome in 40 60 % of
patients the question is what happens to
our the other half of patients and we do
not have in that research or much
quality efforts yet on recovery and
rehabilitation I suspect that this will
be the next and final frontier of stroke
treatment dr. Howell will speak about
that thank you very much
[Applause]