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David Tinklepaugh, MD.

Director of the Primary Stroke Center


As medical director of the Primary Stroke Center at the William W. PRIMARY STROKE CENTER
Backus Hospital, my responsibilities encompass the development Our goal as a primary stroke center is to provide exceptional,
and continuous improvement of our inpatient and outpatient stroke evidence based care for patients with cerebrovascular disease and
services as well as stroke education. This includes: stroke. There are many ideologies for stroke which differ for stroke
which differ in prognosis and treatment.
• Developing stroke care protocols and evidence based care
Snapshot of Backus Stroke Population (April-July 2018)
• Partnering with the Ayer Neuroscience Institute Stroke Council
to integrate Backus Hospital into the Hartford HealthCare All Strokes and TIAs 62 in 13 Months
stroke system of care Ischemic Strokes 34 (53% of Stroke Admissions)
• Working with the Stroke Coordinator to track stroke outcomes TIA’s 29 (47% of Stroke Admissions)
and care metrics No Hemorrhagic Strokes
• Managing data collection alongside the Stroke Coordinator for TPA and endovascular thrombectomy are well established
the “Get With the Guidelines” (GWtG) stroke registry treatments for acute, large vessel thrombotic stroke presenting
• Serving as liaison between various other stroke services within 4.5-6 hours. The DAWN trial, published in 2018, was a
such as tertiary vascular neurology at Hartford Hospital and pivotal study in treatment of large vessel thrombotic stroke. The
interventional services DAWN trial (NEJM 2018; 378:11-21) randomized 206 patients
• Developing strategies, action plans and measurement for with ischemic stroke involving the intracranial ICA or MCA at 6-24
improvements, and the allocation of resources regarding quality, hours to thrombectomy or standard medical therapy (tPA within
safety and education 4.5 hours of stroke symptoms and antiplatelet medication after
imaging studies to exclude hemorrhage at 6-24 hours). The study
• Providing ongoing stroke education to staff including providers, showed an improved rate of functional independence (49% vs 13%)
nursing, rehabilitation personnel at 3 months. The rate of intracranial bleeding (6% vs 3%) and the
• Advising on community education and outreach 3-month mortality (19% vs 18%) were not significantly different in
the treatment arms.
After receiving my training in general neurology and fellowship
training in Neuromuscular Disease at Yale-New Haven Hospital, I CT perfusion with RAPID software represented a major leap
joined Neurology Associates in private practice in 2003. I served forward in acute stroke care when rolled out at Backus Hospital
as Chief of Neurology for a year at Backus Hospital and have earlier this year. CT image processing software, RAPID, allows
provided in-patient consultative services, along with my colleagues, the identification of at risk ischemic tissue up to 24 hours after
since 2003. Recently I completed Hartford HealthCare’s Provider stroke onset. Appropriately identified patients are candidates
Leadership Development Institute (PLDI) course. for endovascular thrombectomy at Hartford Hospital. Prior to
publication of the DAWN trial, which demonstrated the benefit of
I was appointed as Medical Director of Stroke Services at Backus this technology, the Stroke Council worked diligently to decide on
in 2017 and charged with building a stroke program to meet the the appropriate utilization of this anticipated technology across the
objectives of the Joint Commission for Primary Stroke Center. In network of Hartford HealthCare hospitals.
conjunction with Rebecca Durham RN, Regional Institute Director,
and the diligent work of Melissa Lawson RN, our Stroke Coordinator, We considered the various ways to deploy RAPID, ultimately
the stroke program was certified as a Primary Stroke Center by the choosing to distribute this capability to each of the hospitals.
joint commission in April 2018. Hartford HealthCare then purchased CT hardware upgrades and
the RAPID software for each hospital, a significant financial
commitment to stroke patients in the network. The council also
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iterated multiple protocols from identification of large vessel strokes Both Melissa Lawson RN and I have been involved with the Hartford
to transportation logistics, settling on our current approach. Now in HealthCare Ayer Neuroscience Institute Stroke Council which meets
place, these protocols allow Backus to identify patients with large monthly to develop protocols, service lines and performance metrics.
vessel strokes who would benefit from thrombectomy and quickly fly From these councils we design the most appropriate services at
them to Hartford Hospital for intervention. Backus Hospital.

Previously, all tPA treated patients were sent reflexively to Hartford In August of 2018 Dr. Priya Narwal, MD joined the Backus Hospital
Hospital. Protocols were developed to treat acute stroke patients as a full-time neuro-hospitalist. She was fellowship trained in
with tPA in the emergency department, and the hospitalist team vascular neurology. In addition to providing inpatient neurological
made an enormous commitment to manage the post-tPA patients at consultative services, she maintains an outpatient stroke follow-up
Backus Hospital. clinic for patients discharged from the Hartford HealthCare family
of hospitals with stroke or cerebrovascular disease. She provides
Our current quality metrics include “Get With the Guidelines” (GWTG): stroke education for hospital staff in addition to patients and their
[1]1 IV t-PA arrive by 2 hours, treat by 3 hours
2 Early antithrombotics; % with therapy CHALLENGES
by end of hospital day 2 Any time a hospital makes a major commitment to new evidence
3 VTE prophylaxis; % receiving prophylaxis based care protocols, there are growing pains. We have been
on day of or day after admission able to make huge gains in hitting our metrics just months after
qualifying as a Primary Stroke Center. We continue to refine our
4 Antithrombotics; % with therapy at discharge.
protocols based on up to date review of our metrics and outcomes.
5 Anticoagulation for Afib; % discharged on therapy
6 Smoking cessation; % receiving counseling during admission Another challenge for us is to collaborate with Windham Hospital,
keeping appropriate patients in the East Region, and sending
7 Statin on discharge only those requiring higher levels of care to the larger hospitals
8 Dysphagia screen in the Hartford HealthCare system. This will include achieving
9 Door-to-needle time ≤ 60 min Stroke Ready Hospital status for Windham and Joint Commission
designation in the near future. n
10 IV t-PA arrive by 3.5 hours, treat by 4.5 hours
11 NIHSS reported
12 Stroke education
13 Rehabilitation considered; % assessed
for rehabilitation services
14 LDL documented
15 Intensive statin therapy

FALL 2018 17

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