South Florida Stroke Coalition Meeting (9/29/2022)

All right, Austin, whenever you're ready, you want to kick off the meeting.

As people come in? I will, I will admit them in. And we are recording, just FYI everybody. And thanks for everyone for coming today.

All right, thanks Peter. Hi everyone. Welcome to our quarterly or biannual South Florida coalition meeting. Hope everyone and their families have been safe over the past week with the hurricane and the after effects and sending well wishes to everybody, especially on the Gulf Coast.

I'd like to wait a couple of minutes just to allow more people to log on. The agenda for today's meeting, as you all may have seen in the Zoom invite, is to learn more about some of the prehospital technologies. Specifically, we're fortunate to have some excellent and innovative companies present. One from viz, AI Daniel d' Amore is going to present on some of the pre hospital features that VIZ is working on.

And for those of you, I'm sure all of you are familiar, but just in case, VIZ is a artificial intelligence software company for automatic automated detection. Initially they start out for LVO detection, large vessel occlusions and have expanded their feature set since then. And we also have.

From Mind Rhythm, which is a pre hospital.

Technology company that is going to be presented by Robert Dunn on a innovative technology around LVO detection using eeg. So our goal with the SFSC is to continue to learn about new technologies as they come to the horizon and see how we can, you know, use our tri county.

Sort of consortium to implement these technologies in the field with buy in from ems, especially if there is potential impact to improve stroke care and timeliness of stroke care due to the nature of the disease and achieve better and better outcomes.

So.

I think if everyone feels comfortable starting we looks like have about 34, 35 people and then Peter, you can certainly send out the video recording for anyone who didn't get a chance to join. So we'll go ahead and start with Daniel and then Carolina Gutierrez from University of Miami after we learn about some of the prehospital technologies is going to present the progress on the data transparency with the regional dashboards and some other projects that our EMS coalition has been working on with their team.

So Daniel, I'll pass it to you.

Great.

Thank you so much and thanks for giving us the opportunity to chat with you guys today. It's very important for us obviously not just with stroke but with every hyper acute disease state. We focusing on stroke right now because it's a stroke meeting, but recognizing that EMS has way more to do than just stroke. So the goal is Always to make things easier for them, not more difficult. So we'll show you some of the things that we're working on right now. I'm going to give you a quick demo. So if you have no idea what what we do at Viz, it's just going to give kind of like a little bit of an overview. So what you should be able to see is my phone. Everybody see my phone. I think you should be in the app store. I'm going to go right here and then this is really nice. You can just plug in vis AI. And this is like a tutorial. It is a couple of years old. So you know, we don't have all our best trade secrets in there to show everybody. But it does give you an opportunity to kind of pop in and really look at the dicom view and the some of the communication things that we have. So you'll see that when I got mine, I'm going to open mine up right there at this training. And again it's like a 30,000 foot view of what we do and how we do it. We're going to demonstrate a couple of things with LVO intracranial hemorrhage and I'm going to click into any one of those. And again this is something you'll be able to download and walk through yourselves. When you have a little bit more time. I'm going to view that case and they're going to cut into a couple of things. Very important. Right, so we work with the CT scanners directly. For us it's the more the merrier. The more scanners you have, the more users, the better, the more engagement your programs are going to be being able to connect directly to your scanner and then map those images to us. We'll be able to run through AWS cloud based service looking for large vessel occlusion, intracranial hemorrhage and as I'll show you a few other disease states as well. So again this is really, it's that point of contact right at the very beginning and then being able to send out alerts to all viewers. Right. So you're going to get transparency of imaging and transparency of communication all at once. When I click in here, you're going to see the demonstration of how I get information. My scans are coming through. I look at that, click into this one. Any ones that come in I want to take a look at. So obviously I'm very important, very interested in the large vessel occlusion. And then over here you're going to see the effects of the DICOM viewer and I'm going to jump out of this one right away and go into my demo one here. So in my demo one you can see me see my demo. Of course I timed out right.

Real life zooming.

Biometric scans pretty quick once it did get get back in. And that would be that case of that patient coming in with a large vessel occlusion. Just real quickly I wanted to show you the dynamic DICOM view that we have. Number one, I'm going to be able to get any information about that patient that anybody has put in. So I can see already somebody's put in an NH of 22. But more importantly, clinical presentation obviously looks like a big bad stroke either ischemic hemorrhagic as soon as we rule that out. Right. So in my thumbnails I'm going to have everything I want to look at but obviously I want to focus into this thing that's highlighted large vessel occlusion. And then you'll see here now I'm going to have a real packs in the pocket. I have the full, full capability of a DICOM view, being able to slide across all of my images in my axial view with a differentiator going all the way to the aortic arch which is very important for us being able to reset this and pan in, zoom in, pan out, change the mips, all those things that are important for decision makers. I've got my non contrast all of that information as well with hyper dense vessels you'll see in a couple of slides and then in my CT perfusion. So I really just kind of wanted to show you the viewer. But all of this is really is just stepping up to the toolbox. So in my three dots up here you're going to see I've got full communication panel as well as the ability to be proactive and do things I can one button touch and activate teams. So this obviously comes becomes very important when with the hyper acute phase and being able to activate things. I've got a view patient log that I can see an audit trail of everything that has happened but more importantly what has not happened yet. So now I can look at that and say oh my God, Dr. Antavia has not seen this yet. I need to reach out and touch him. Right. Being able to see that and looking through all of the audit trail like say I absolutely have to make sure that Jamie Strauss sees this patient right now. I can go in here.

I think we'll get some hurricane effect with our wi fi here. I get my, my being able to reach out directly. So Jamie Schross has not seen that yet. I can go into her and look for her directly.

And then when, as soon as I find her, there she is now, you'll notice I could text her directly or call directly. So this is a very important case. I want to be able to call and talk to her about it. And as I call, sorry Jamie, expose your phone number there. The everybody in your directory is going to have the ability to reach out. We want to. My, my goal in life has always been to, to eliminate badge buddies. So this is the way to do that. Being able to build your directory for whatever you need to have. You want to make sure that all of your stations are online, your, your EMS captains for everybody. You can have them all built in there. And then being able to share cases, not just call and text, but actually be able to hold share whole series. Right. So that obviously be very important to be able to share that large vessel occlusion. Again, I'm going to pick on Jamie. Since you already saw her phone number. She's going to be in there. I'm going to search her and then as soon as I find her, I can share that whole case to her. And then that way she gets, as soon as she logs in, she can jump right into that case. So all of these things that we built are really built to coordinate care.

I don't have a whole lot of time, so I really don't want to spend too much time in here because I have a PowerPoint. But I would go back to this. I'm going to take this over here.

And going to share now this guy right here. So this is going to, we're going to talk specifically about the.

Cases that we have and do full screen.

Okay. So viz AI right. So we're, we're a mobile platform, but we also have a web base and we're also integrated into radiology work list, which is very important. And again, as we mentioned, we have more than large vessel occlusion. We have lvo ich aneurysm now subdural pe aortic and many other right around the corner for FDA approval. Being a system of action is the way I described that in the demo.

Right.

The delivery. We're pre PACs. That means that we're getting, you're going to get those images on your phone faster than you'll even get them mounted to your pack station for reading. Very important. We're packs free or independent of packs, which means a PACS crashes. And we know it happens sometimes you'll still have those images for decision making processes and you won't skip a beat. Being that we're cloud based, detect, alert and engage very quickly. And our action is to be proactive versus reactive. So we want to get away from that complete linear process that is so prevalent in treatment decisions currently in hospitals. We want to make sure we have transparency of the imaging as well as communication. And of course, we have validated data, clinical studies that show reduction in treatment times, increased treatment rates, improved health economics, as well as a lot of research. Now we're talking about pre PACs. Jamie's on the call with me and then. Oh, I see Dr. Felipe de los Rios. Very important. We work with those two people very closely. And EMS was really our number one focus at Baptist Health South Florida when we were there. Dr. Bella Sch is still there fighting the fight. So what we wanted to do is to be able to get a platform in the hands of people that are making those decisions or asking to make those decisions right up front. So we're looking at a couple of different things here. Number one, we're in 1200 hospitals already and you can see the saturation that we have in not just Florida, but specifically in South Florida. So I think it's very important that we're kind of congregating on a platform that works very well. Right now we're in 70 hubs and spokes compared to 22 in a competition. And there's still white space opportunities for 60 more. So it just gives you that geography thing. Now what our problem is and why do we need to visit ems? Why do we need help with a paging system? Even when we started looking at ems, I started thinking back as a stroke responder and it's even earlier than EMS or it's right after EMS is that whole process of getting the information to the stroke team can be challenging and again, very linear. You know, the EMS to the radio, to the charge nurse, to PBX to the stroke alert. This could have been an amazing report. And what you end up on your pager or your cell phone is stroke alert ETA five minutes. So it really doesn't, a lot of times, doesn't help. South Florida is way better than most parts of the country. I can tell you that right now. I have not just national experience, but now we're in six different countries and sites in Europe and I see a little bit of everything. Right? So. But there is a resounding message, and that is EMS is limited. The information that a hospital gets is limited. Communication is Often disjointed and siloed. And there is certainly not enough EMS outreach and collaboration. So what we're doing right away is helping out with that front end paging thing, right? So now we can communicate directly. Now I can get my stroke page. Picture that Stroke alert. Whatever you're getting on your cell phone pager can now actually be presented as a patient jacket in your app. So now you can again have expanded participation because everybody in the app is going to be in there. You can have templated information for your, for your reporting. It is one platform instead of pulling out two or three different ones. And it's pre imaging. Now what we're really excited about is that true EMS part of it, right? So this is an ongoing thing that we're doing where we're using EMS to enter the pre hospital information in the field. So that means that patient jacket, that alert that I'm getting as a user on the phone is actually initiated by a paramedic or a flight nurse or whatever have you EMS out in the field that enables bidirectional communication. Destination triage. Obviously, if there's a question of whether it should go to a capable psc, a TSC or a csc, right? Making sure that the right patient gets to the right place. So this is an example. So this would be the advantage for, for ems, right? Recipient of the current stroke paging. Everyone aware of inbound strokes users get context and early communication. And you'll see we see great examples of that, of asking leading questions like, is there a witness? Can you give me their cell phone number? Have they had anticoagulants in the last 48 hours? All of that kind of communication can now happen before the patient ever gets here. Parallel processes begin earlier and more people are engaged. This is an example of how that looks. So that patient jacket comes in, it says stroke alert. I click into my stroke alert. Now I'm getting the information about the stroke alert. And then immediately now we have communication within the teams, within hospitals about that inbound patient, which is very important. And you'll notice here that you can actually add pictures and things like that directly in the app. Everything is hipaa compliant and 100 protected and 100% communication. Okay, so that missing link to really truly make this is that EMS integration, right? Being able to get everything started earlier benefits everybody. So again, destination triage, improved lead time. So now I can, I can, I can activate teams that are. That looks like a large versus inclusion. I can go ahead and talk about, hey, let's call in The IR team to make sure they're on standby or whatever that process. You have valuable information flow. Again, leading questions that you can ask about. You'll be able to maintain that sphere of influence that you have within your. Your outreach group. Decreased treatment times, better outcomes. Right. Viz, ems. So getting the app in the hands of the providers is going to give that opportunity for. For EMS to really activate. So this was a mock stroke we did with a flight crew in Phoenix, and they immediately wanted to adopt that. That's like an example of some of that communication being able to add that context. Right. So the son's name is Daniel. Here's his phone number. That actually creates a link, as you can see, it's underlined, clicking in there. I'd be able to call Daniel directly and say, hey, Daniel, this is St. Joe's Hospital. We understand that your dad looks like maybe having a stroke coming in. Blah, blah, blah. No anticoagulation. Because they just told me, you know, he's on. He's on Plavix, but he hasn't taken it in three weeks. So now we're getting some history and stuff like that. So, again, very proactive bidirectional communication. Okay. This is a great case from. From Piedmont. And Jamie can chime in if she wants to add a little context as well. But a very aggressive neurosurgeon, and he is using this with his air crews in. In the Atlanta area. And not only activating from their point of view, but you'll see by some of that communication, it's definitely two way. Like, he'll. He'll tell them, no, go straight. Make sure that when you land on the helipad that you go straight to the cath lab. So a lot of very proactive things going on. Right. So this case that he posted, I believe it was in LinkedIn, and I just took some snippets of it. But this is, you know, this is that kind of real communication that happens. Right. And then again, being able to plug in. Here's your pre. Nice post. All that stuff for feedback with ems, which we know is very important. EMS does a great job bringing the patient. We don't always do a great job of letting them know what we did with the patient. How did the patient do all that kind of stuff? My son's a paramedic. I hear it all the time.

Yeah, I can chime in there, too, Daniel, about Piedmont and kind of the structure of why when I was at Piedmont, we really were looking at, you know, transporting across wide geographies but also really just with traffic, which you all are very familiar with. And in Florida and South Florida, being able to get patients to where they need to be quickly. And we had a lot of challenges. So that was implemented with all of the AIR methods team and has been really successful and they're working on publication, but has really cut the transport time and the ability to activate immediately to start pulling that patient into the comprehensive center for treatment and giving the field back the ability to connect directly with the physician to make those treatment decisions.

Yeah, some of those hospitals in that region in Atlanta are really very rural. So we saw immediate impact on those hospitals. Their door indoor out time literally plummeted because of the additional communication tool that goes along with. And basically, basically being able to have a hubby think of like a military operation almost. It's like oversight or overview.

Right.

They're the snipers in the tower looking down and saying, oh, look, I think I have a target over there. And that target happens to be an LV alert that pops up or another kind of stroke patient that is definitely going to require tertiary care, that kind of thing. So again, we're in. Yes, we're.

A question, Daniel. Thank you. Just a quick. I have a few comments, but I mean, again, I'd like to take this offline if it's too long, but first of all, we appreciate that you're considering ems, which is obviously the reason that we started this coalition and connected with the stroke registry. My question for you is, is there a way to reduce the duplication of input of information? Your son's a paramedic, so you could ask him that. What we try to avoid is having them put information in one app and then go to their, you know, their EPCR and have to retype everything in. Are you working with any of the other vendors out there to reduce the need for duplication? Because if that happens, you'll get more buy in. It's tough to. You know, our EMS folks do a lot of hard work and they don't want to go from one app to the other to the other.

Yeah, no, that's a great question. And Jamie is going to chime in, I'm sure about this as well. But I will say one thing right away. We. We do integrate with, I want to say two of these ones that she'll tell you, we do have integration. The reality is we think that, you know, once, once this is cooked, it's going to be better than that. We have EHR integration with EPIC in a couple of sites. We're looking at safety pad, A couple of things like that. I've got a great conversation going on with a, with a new EMS captain. Well, he's not a new captain, but he's new in the EMS role. Just finished his EMS captain course and is super excited about getting his station to pilot this. So we're looking at hopefully making something that won't require integrating three and four software packages as is, but with the ability to do that if it's needed. You, like you rely on one, for instance. We wouldn't want you to kick out those other ones. We want to be able to integrate. So I guess the short slash, long answer is there is integration, but we really want to make this something that you won't feel you need to integrate anybody else with. Right. So that makes sense. So just.

Well, are you, are you with eso? Because eso is, I would say 90% of South Florida. Well, I should say Broward county uses eso.

They're a big national provider for ecr. Are you guys integrated with them?

We have not yet. We haven't yet. But Jamie, you want to add to that?

Yeah. So from an integration perspective, you know, the way that our platform and ecosystem is built, since we're cloud based, the integrations can happen from each L7 and they can be bi directional. Right. So we can, we have to set up the work stream and the mapping to those discrete fields. But what we are able to do is really take any of the inputs that you would be putting in and push over and seen from viz, anything that's being pushed in there can push over to yours. So that's just working through discovery to understand what is the exact integration we want to look at. But we're able to integrate, integrate pretty seamlessly with anything, especially if it's cloud based.

Yeah. So, yeah. So in other words, maybe, maybe we ought to take this offline because with another hat that I have in the world, I do have multiple integrations. So I know how those agents, how those companies work. But back to our paramedics who are, we're trying to have them be on scene for as short of a time as possible, get all the right information, treat the patient appropriately, go to the right facility and then communicate with the hospital.

We went through this process, Prijesh has to remind me, years ago we tried this and it was a failure.

2017, for a number of reasons.

It was 2017 a long time ago. It was a failure because of the fact that one of the reasons is that it's hard to get them to adopt Something that they don't see value in on their part of the world. And maybe I see Chief Papa, he and I are going to present here in a minute. But I'd love to hear any more EMS leaders on here talk about or maybe give the viz folks some insight into what would work for ems. It's a great start, don't get me wrong.

Yeah, well, and to your point, that's exactly what we want to happen, right? We want to make something that, and I said it earlier, I want to make it easier for you, not harder. It is going to be easier for us. I don't want it to be easier just for us. It has to be easier for everybody and being able to integrate early on. And my initial thought when I had the conversation with that EMS captain was all right, so where do you enter that information? Oh, we enter into the safety pad. Bam. That's an integration point for us or a possibility whether it's eso safety pad or all of them. We do have different systems in our, in our South Florida counties.

Chief Papa Gasaka. Go ahead, Chief.

Yeah, that if you've got to keep it on as most simplistic platform possible, that they're not triplicating or quadrupling the volume of work documentation, etc. Pre hospital doesn't like documentation. I don't know many people that really do love documentation.

The easiest approach, the easiest way to, if I've got to fill this out, it's phenomenal information. I clearly understand where you're going with it and I think it definitely has a place, especially stroke care or mimics. But somehow if I'm filling this out and then you have chief officers because the system has no available units, etc. And the turnaround times need to be quick. It needs to be something that they can tap on, be a component of the overall epcr, whatever the platform is that they're using and then be able to integrate that. Whether it's coming, going into a cloud and then being downloaded from a cloud like we use other apps. But there's only so many people on scene that can, that can function doing and filling out this information. Especially if you've got a critical patient, then you know the focus is going to be on, on the patient stabilization and supporting their, you know, end organ perfusion, etc. So it's got to be some type of a very simplistic approach for them. I would make the analogy that it's like asking them to perform an NIH stroke scale.

Yeah, exactly.

Not practical for pre hospital.

Right. For sure. And we're 100% with you. That's exactly what we're looking for. Is really thought leaders like yourselves to say, hey, this is what will work. This will not work that way. We don't spend time on something that's not going to work. We want to make it again, easier for you, not more difficult. I just wanted to point out a couple of things. Obviously it's not just stroke. I want to hammer that home. It's not just stroke. We are getting into all these other things. We already have a trauma platform. We are using this with ER physicians that are using it as a dicom view viewer and communication tool. STEMI Cardiac is right around the corner that we're working on right now. Jamie's teams have that. Okay. So I, I did want to pander to you all because I, this is one of my favorite publications, right. EMS World. I actually have seen these episodes or the, the journals. Right. So this is something that is very important. This, if you look at what I'm trying, the message I'm trying to get here is that we want to collaborate, we want to partner with you. All right. Partnering for projects. Some of those potential things that, that you know, I've heard kicked around pre hospital stroke scale correlation with CTA results, for instance, that's something that we could easily dig into. Based on those results, would we look to unify an advanced stroke scale in South Florida instead of having the two major ones or three of them that we use or whatever. Or maybe there's time for a new one that actually could, could work to cover that. Dido, we know that the, the are, we are decreasing in the Atlanta region already this door indoor out decrease for spokes and hubs. And then I don't know if this is trademarked yet. If it's not, I want to trademark it. But we want to decrease in the street to treat time. Right. So that's your on scene time to the treatment time. I don't know, I don't know if it's trademarked, but I'm going to claim it if it's not. And basically we are in South Florida. Jamie just recently moved to Atlanta. She was here for a long time. Lisa Guillen on the call is here. Brian Redmond, I see on the call is here. So our team is in South Florida. And when I say this is made in South Florida, it really is because we're the ones pushing our company to say, hey, we need a viz EMS platform because how important it is to work in that, in that pre hospital field And I think that this would be great opportunity to partner with you all to see, can you help us make this a reality, to make that the platform that it is the way you want to, want to make it the way you want to design it. When we turned around and recognized that we needed a web based, for instance, our engineers never thought we would need a web based app because it's a mobile device. Why would I need that? We gave them the story. Radiologists want to see this next to their, their, their big monitors that are reading scans. So great, we build a web. But what we did is we got radiologists, neuroradiologists and interventionalists and asked us, do you want to replicate this or do you want this to look more like a pack station? They all said we wanted to make it look like a pack station. So we, we, you know, we, we work with people to make sure that it's. You want to use and not just something that we're going to sell you. We're not selling you subscriptions. We want to sell partnerships. Right.

And I think we, we really appreciate that. You know, I know that the idea that Brijesh and I had was to bring, bring in all the different options to, to the group to get all the opinions, you know, that are on the table and look at all the options. You guys have done great work, definitely moving in the right direction. And I would love to speak to you guys offline as well if you had the time. But Brijesh, I know we have. Should we open it up for.

Can I add one more thing, Peter? Sorry, just, you know, from my perspective, I oversee clinical affairs, and my team's role is really to partner and have partnerships, whether it's with hospitals or organizations where we really want to do meaningful research. And on my team, there's scientists that can write the IRBs and we have coordinators and research support. So I would really, really like to use, you know, South Florida and because of the dynamic EMS work that you've all done to show value. So I wanted to put that out on the table as well, that we do have that internal team support. I have a team of about 10 clinical affairs that do different research and clinops work.

All right, excellent. Thank you, Jamie. I want to let Brijesh come and make a couple of comments, but what I would say to that is the following is that whenever we introduce something big, a big change into South Florida into the EMS system, we typically do it in one pocket. We validate it. Does it work or not work? It doesn't work, we move on. If it works, then we'll continue to spread it out just like whole blood. What you're seeing now is expanding across and that's the great work of Jim Roach and Heath Clark and Charlie Coyle and so forth.

But.

So we're definitely interested in that. But Brigitte, she wanted to make a few comments. Go ahead.

Sure. Thanks Peter, and excellent presentation, Daniel. Really appreciate all the information.

I agree wholeheartedly with Peter. Given our past experience with some of the other technologies, we want to get this right this time around. Given that we're now more than five, eight years from the time mechanical thrombectomy has become a standard of care. I think our collective experience, we, as he said, want to learn from all the available technology vendors out there and make an informed decision in terms of what makes sense for our region. Given that we have a multitude of fragmented EMS agencies working across county lines sometimes. And it's not as simple as just implementing within one healthcare system. Ideally this should be county wide and hopefully tri county. And that way we can also scale this up with data collection and do meaningful research. It's not a, you know, just improving patient and catchment area within one healthcare system or having any competitive advantage, you know, be great if or any other technology that we aim to utilize pre hospital can be implemented in hospital as well. So that way funding is not an issue either. Because you know, the challenge with a lot of the technologies is who pays for it. Right. And so these things can become very expensive very quickly. And ultimately if the hospitals are willing to support a product like this and I think there's inherent value, then pre hospital should come at no charge. And that way all the great work paramedics are doing, we can utilize that information also have it connected to, as you will see in a second, through the Florida Stroke Registry to the databases that exist and as Peter said, not duplicate the work that we're doing or the work that paramedics are doing pre hospital, we want them to focus on the patients, use the existing ESO platforms or whichever EPCRs exist so that they don't have to take out their smartphones and use a second app. So I think I would encourage any vendor out there to use APIs, connect to existing platforms and then be able to connect to the in hospital platform such as Epic, Cerner, et cetera, so that all of this data is invaluable. And if you have just like you showed the entire spectrum of stroke care from on scene to arrival to reperfusion, nicely packaged Being able to share with ems, but also through the databases so that we can turn this around in real time and share it with EMS on a quarterly basis. Right. And so there's so much opportunity here for game mechanics and saying, okay, look, which county is better? You know, door to reperfusion, door to needle. And allow all of us to improve. That has been our overarching goal for the last seven, eight years, is let the data do the talking.

Transparency of data. Exactly.

Yeah. And so we're excited about this. And like Peter said, you know, we can follow up offline.

Yeah, thanks for that, Prijesh. And we can set up an additional call and we can highlight for. We have what's viz. Community, where we do inter facility connections and inter community connections, so. So we can talk through that as well. I know we're at time.

Yeah.

And.

And we are local, so we could also get together. Right. So.

Awesome. So I just want to know how.

I just want to know how you. You look younger today than you do in that picture. Haven't figured that out yet.

Peter. You look exactly the same, Peter. So I wouldn't say anything. Maybe just the glass.

My wife doesn't think so. But.

You want to move on to. I think instead of going with Dr. Dunn, who. I don't see him on the call just yet. You want to go with Carolina, Dr. Gutierrez?

Yeah, that would be great. We have Carolina joining us to represent the Florida Stroke registry team from University of Miami. And Carolina has done some amazing work for our South Florida Stroke Coalition, so we're grateful to have you join us. Carolina. She has some excellent updates that will be useful for EMS and the stroke centers.

Thanks. You want me to share the slides or. I know you have them as well. We're gonna.

Yeah, if you. If you have them, Carolina, that'd be great. Thank you. And thanks, Daniel.

No worries. Hi, Daniel. Nice to see you.

Hi, Carolina.

I haven't seen you in a while.

I see a lot of friendly faces here.

So just a quick update on my end about the Florida Stroke Registry, and I'm going to have Dr. Mehta and Dr. Anteby join me in on some parts as we update you all on our regional dashboards and some of the new things that we have with regard to data transparency that you just mentioned. The quick overview that we usually bring to you all is about how many hospitals we have in the stroke registry. Now it's 100. We have still pending about another 10 to 15. It depends on the day because hospitals get purchased and then they also go away, names change and it seems to be always a moving target. But we're pretty close to accomplishing having most of the hospitals, the majority of the hospitals, stroke centers in the Florida Stroke Registry. And we still continue to monitor. Obviously at this point we would hope that all hospitals would be nationally certified, but there's still a few that are probably in the process of becoming nationally certified. So we've caught them, as we've monitored, in a time where they're not quite there yet. And that's what we show here. Majority, again, CSCs are nationally certified. Here's the outlay of the layout of the different kinds of national certifications for csc, the thrombectomy, stroke capable primary stroke centers, and then the ASRs and then the nuns. Again, there's some what's happening with the nuns, I think is again, there's some transitioning happening, but we're also beginning to capture some rural sites, which is a little bit interesting and very exciting for us because we, we never had those in the past. I think we're beginning to get them because the American Heart association is offering rural sites free, free use of the get with the guidelines stroke tool for five years. So I think that's how we're beginning to get that data and we'll begin to, to document that and lay that out a little bit better for you all, for, for our stakeholders to see what that's about. With regard to your counties with Broward, Miami Dade and Palm beach, these are the most recent numbers in terms of stroke, in terms of the certifications and in terms of the national certified centers. Again, I'm showing you what we have seen after a laborious process of going through each of the national certifying sites and through the state website to see how hospitals lay out in some cases, the ones that I'm showing you where there's I'm calling them Primary Stroke center ahca. So self certified, they could be on the verge of becoming. So you know, we're showing you as it is. But again, we're very hopeful that these are all becoming nationally certified.

These are also for those of you who look at your regional dashboard, the hospitals that you're going to see in the regional dashboard for Browers, in the regional dashboard for Miami Dade county and then in the regional dashboard for Palm Beach. So that's the current status of your hospitals and for the stroke coalition, I think what we want to talk a little bit about for you all next. And I'm going to hand the mic to Brijesh to talk about this is basically our regional dashboard updates, the format. We've been working on this for several months now, maybe a year, but we're finally there in terms of showing you this data, in terms of trends, and I think that'll be really useful to you all. We can still tweak things to improve so that the reports are better and easier for you to read. But of course, we also have. We also. I wanted to mention real quickly, before I stop talking, you all talked about the Dorian Doral measures. That's something that we want to incorporate in these dashboards as well. So in the near future, we'll be reaching out to you for more suggestions, advice, feedback, and potentially ask some of you to be on subcommittee to help us make this happen. So, Brijesh, do you have access to this or do you want me to show my screen?

Yeah, if you don't mind sharing your screen. And thanks very much for that update.

So, Carolina, you know, the team at, um, led by Dr. Sacco as well, they've done a fantastic job of pulling together all this data, which, as you can imagine, is fairly cumbersome. But to be able to do it consistently quarter after quarter, you know, year over year, for the last, you know, at least few years that we've begun this effort and then share it with EMS is invaluable. And the hospitals, you know, have all of this data that they can now benchmark. And the FSR team has updated each of these modules, so I'll go through them one at a time. So up at the very top, you can see there's two categories. So there's IV TPA and endovascular thrombectomy. And so it's easy to just now see kind of big picture how patients, you know, sorry, how hospitals are doing from a quality standpoint by treatment modality. And so you have the overall percentage of IV TPA given at each of the hospitals. And so this is just in Broward, and they're benchmarked against other.

Regions throughout the state. And we're also looking at whether it's possible to benchmark at a national level to see how counties and at a state level were performing compared to the US.

The median door to needle time, I know that's of, you know, probably most significance in terms of a proxy for quality and efficiency. So that you can see, you know, most of the hospitals. The green are those that are high volume centers, the blue are medium volume, and then the orange are the low volume centers. And within the appendix, the definition for how those are Labeled are further explained. So, you know, all of this is fairly objective based on existing literature of how they're, you know, sort of labeled as high, medium and low. And overall the trend you can see is that the high volume centers do better than the overall sort of median for low volume centers. Experience matters and the 90 day Mrs. At discharge.

You know, at discharge and at 90 days are resulted there. We have a lot of gaps there and that's something we've discussed over the years. And you know, you can see that the high volume centers have done a better job than the low volume in terms of follow up. It's not just important to provide, you know, these time sensitive treatments, but to also measure how these patients do in terms of their functional independence at the time of discharge in 90 days. And that requires, you know, staffing and personnel making phone calls at, you know, 30 days, 90 days to, you know, the impact of the care that we provide. So definitely want to encourage, you know, where there are gaps to do everything possible, you know, among the stroke coordinators and C suite personnel to, you know, ensure that the follow up data is collected as much as possible symptomatic ich. Again, similar trends where the high volume centers are providing this data and you can also see it's based on the higher overall percentage of treatments and you know, overall the denominator of stroke patients that come in and then get treated, that understandably the higher volume centers, you know, will have more realistic sort of symptomatic ICH rates. It's, you know, overall more reliable given the higher power in the number.

And if you can switch over Carolina to the EVT dashboard and again, this is for all of 2021, quarter one through four. They are working on the FSR team on, you know, year to date data. And so that will be accessible I believe by end of this year, if not sooner.

Sorry, sorry, having trouble getting it in here. But to your response, when it'll be available, we're working on quarter one, 2022 and hopefully that'll be out by mid November, if not sooner. And I apologize, this doesn't seem to be working.

Again.

That'S okay. If it loads, great. The main point of the EBT dashboard, similar to IV tpa, it shows the percentage of eligible patients that receive the therapy. You know, those patients that come in with large vessel occlusion are the ones that are tracked. And then what is the door to puncture time? The benchmark that you know, we're aiming for is ideally less than 60 minutes and then reperfusion at least by AHA ASA standards is 120 minutes within some of our individual health systems. We've, you know, raised the bar even more, if you will, and we've made our internal benchmarks 90 minutes. So door to vessel open, 90 minutes. And.

In terms of symptomatic ICH rates, those are also reported as part of joint commission and DNV criteria. And, you know, as we also discuss in a second, you know, greater number of the previously PSCs or TSEs going comprehensive, our hope is to also.

Send to EMS some meaningful information and reports on how hemorrhagic patients are doing, you know, specifically those with ruptured aneurysm, intracerebral hemorrhages, and be able to better understand the impact of the care provided at tscs and cscs for hemorrhagic patients.

Carolina, you want me to, you want me to convert over now to the EMS medical director view? Carolina?

Yeah, and I can show it either on these slides or if you have your own.

I have it.

Yeah, I have it.

Maybe it'll be easier for me to navigate it this way.

Let me just share my screen. So just as a setup for what you're going to see next. And this is really a lot of work.

Let me just mute that person.

Sorry.

There's been a lot of work done by Dr. Gutierrez and the entire Florist Stroke Registry team. What I'm about to show you, and it's really meant for EMS for the medical director to be able to partner up with their local hospital that they transfer to and start to understand what the data looks like and how they can collaborate better. So let me share my screen.

What you're going to see here now is only going to be available to medical directors with a password.

You see, I'm logged in as me here at the top, and as I go down, what Carolina and the team have done is just incredible. What they've done here is they've said, okay, for this particular county, we're going to use Broward County. On the left hand column, you see the EMS system name the medical director. And then if I just click on this stroke center, I open it up, and now you can see that a single agency, Coral Springs, as an example, we transport to lots of different facilities. We have the potential to do that. And what was always very difficult is trying to keep track of did that hospital allow the medical director to see what letter they were on the dashboard. So we're calling that a transparency column here. And if that's the case, I would just click A yes or no. And the only people who could see this particular page are the medical directors. And we also have in here the name of the hospital, what their certification is, and then the stroke coordinator. And all this is information that we're kind of pulling from different sources. So if you see something on the screen here that's not correct, just speak to Dr. Gutierrez and it'll be corrected. This is not available to anyone just yet. This is, you know, the work that's been done up until this point. And then up here, we'll be able to see the dashboards themselves. And then if there's any texting between medical directors, they've given us like a internal texting capability so we can discuss with each other. So, Carolyn, is there anything else that I missed or that you wanted to mention?

Sure. So just basically that, you know, the idea behind this is to. To begin to follow the collaboration between the hospitals and the EMS directors. And so in the back end, what we're planning on doing is that as the EMS directors have access to this and they indicate, yes, I got the. I wish the hospital shared the code with me and they collaborated with me. I think on every quarterly basis, what FSR will do is capture that information and let you all know. So then in this forum you'll be able to talk about it. Oh, you know, we're so happy that our entire Miami Dade county sharing the dashboards with their EMS directors or not, and understand potentially why that collaboration is not happening. So that's the kind of leaning forward that we're trying to do with regard to data sharing. And that's what this accomplishes. Hopefully at some point we can get rid of this because you all will be sharing data and we won't need this kind of a chart to track. I think the other thing we weren't able to show you, because we're still trying to perfect it, is the chat that we have set up for you all on this platform. It'll be a little bit. I know, Peter, you showed it to me before. It's a kind of a social media ish type of format. We're trying to establish that on that platform that Peter just showed you. What we're hoping is that whatever conversations you all have between you, that that will be a foundation for more things that we can do, the Florida Stroke Registry or EMS and hospital. So I think a lot of gold can come out of this if you use it. And let me just show you the last slide, if you don't mind, as we end this section that's what I wanted to mention. That's all. Peter, if you want to continue.

Yes, great.

I think I just wanted to just let you guys know, again, these are the last steps. So we've been talking about this for a little while now and it really has been laborious and we apologize, but it's hard to set up the programming on how to do this stuff without it being a Frankenstein chart. So. So hopefully it's going to be user friendly and it'll be something that you guys can use comfortably. So what's left to do here is we're planning on, as I said, accomplishing the quarter 1, 20, 22 FSR regional dashboards. It's a quarter of data from that time period. If we can, we'll try to bring in more real time data, but at this point, this is how slow it is. It's about six months behind. Right. So that will be available hopefully by June, by November. At that same point, what we're going to do is we need to notify the hospitals and let them know we're doing this. So we have to let them know this is a new initiative, nothing different. We're not unblinding any data. We're just strongly encouraging that you collaborate with your EMS director through this particular initiative. And so this is how it's going to work. We're also going to get the email addresses from bmo, who's been collaborating with us to get us all the EMS directors in this, at least we use in the regional. Who should be using the regional dashboards, their associated hospitals, et cetera. Once we get that, then we'll create an account for you all so that you don't have to create it. We may reach out to you in case we have a wrong email address and, or as Peter said, if some of the information that we have associated is incorrect, maybe we don't have all the hospitals that you're, that you're sending your patients to or there's some small hiccup that we can. And then finally we should schedule some time to train you, the EMS directors. I know the audience is not full of EMS directors, but those who are on show you how to use these dashboards, you know, to read them. They're somewhat self descriptive, but possibly you could use a quick little tip. And I know Peter and Brijesh actually have a video that's, that's great. That we have on our website that you all can use. I think that's really all I wanted to update you all on. We want to thank you all, of course, Peter and Brijesh are part of our advisory committee, so they know a lot about the stuff that we do in the fsr, and I'm grateful that they contribute. They're part of this presentation. And this is all of us from um, and of course, we have our Department of Health, who is also heavily involved in the stuff that we do. So thank you all.

Thank you, Carolina. I just want to thank you. I don't think people recognize how much work you guys do behind the scenes to make these dashboards come to life and then in turn, improve the care that our patients are receiving. And to the hospitals who are providing the data and who come to these meetings, we really appreciate that we finally have kind of full 360 collaboration with EMS, the hospitals, and Florida Stroke Registry, so from the state level as well. So thank you so much.

Thank you all.

All right, Brijette, you want to move on to Dr. Dunn. I can introduce Rob.

Yes, that'll be great. Thanks, Peter.

All right, so I have the pleasure to introduce a good friend of mine. He's an EMS medical director in the great state of Michigan in Detroit. And Rob is part of a group that I'm in where we have kind of like 50 EMS medical directors from the 50 most populated portions of the United States. And I heard about this last year where he is now the principal investigator on a very neat tool, if you will, that could potentially help evaluate LVO without using, like, a race or the fast ED or van, but just by putting a headband that. That. That functions as an EEG, if you will, to detect LVO. So. So there's Dr. Dunn. Rob, thanks for joining us and appreciate you making this presentation for us here on the webinar. Feel free to share your screen at any time.

Yeah, I'll share my screen in just a second. I just want to say hello. I've been listening for a little bit. We have.

Some similar collaborations going on in my state, although not. I don't think we're at the level of sophistication yet. I actually co chair our State Systems of Care Task Force, which is trying to create some administrative rules to create much more integrated stroke data system and actually get some funding for it, which is always a challenge, as well as, you know, kind of codify some of our destination protocols. So always interesting to hear what's going on in other states. And. And it's. And it's great. And I always appreciate Peter. We've had him up here giving some talks. And, you know, I think, frankly, like a Lot of. A lot of things in medicine and ems. It's, you know, it's all R D, rip off and duplicate. So I've. I've definitely taken some of Peter's stuff.

So.

Yeah, I want to talk a little bit about a clinical trial that we're doing. So let me share this. I promise not to kill you with, with PowerPoint. And let's see. That looks like it's going to work.

You guys seeing a slide?

Yep.

Perfect.

All right, so it's called the Episode Trial. It is a device trial, as Peter was talking about it. It's actually, it's not quite.

It's not quite an eeg.

It's actually a very sensitive accelerometer that can sense the pulsation of blood flow in the brain. Right. We all know we've got accelerometers all over the place now. There's one in your laptop, there's a whole bunch of them in your phone. They've gotten very sensitive. So this was some of the initial work done on this.

And this was what I'd call a fixed base deployment. They were testing this out in triage at hospitals. It's nice, it's quiet. The patients are sitting down. And the picture that you see next to this headband, and this is one of the early prototypes, that's actually the headband that we started this trial. And I'll show you the updated one that looks a bit more like a finished product and less like something made in someone's garage. And you can see the different kinds of blood flow that it detects. You can see a normal. You can see.

A stroke kind of an evolution where you see that little fuzzier thing. And then you see a middle cerebral artery occlusion there where you see this very kind of fuzzy. You know, it almost would be like the equivalent of static because it's not getting. It's not sensing a clear pulsation from that part of the brain. It does. It reads this in about 80 seconds. And the, the company, this is not yet FDA approved. It's still experimental, but it's a minimal risk diagnostic device. The company was interested in trying this out in ems. As many of you know, there has been a bunch of work pre hospital kind of looking for, if you will, like the holy grail of pre hospital stroke research. Something that's the equivalent to an ekg, the way an EKG is for stemi. And this is one of many devices that are out there. You guys may have participated in some trials of this device, but in their initial fixed base deployment. They.

Found that in the. So the first.

This first line on this is the device. The first line is the device. And then these of course are all kinds of other stroke scales and physical exam assessments for stroke. You know, they found it to have a fairly good. This is just crude accuracy. Again, this is in a fixed population that's sitting still in the hospital and a fairly low false negative rate. And again, this is on that initial device. So they approached us and then we actually worked with a number of other EMS systems around the country to deploy this in kind of a two phase clinical trial. There's the initial phase of about 150 patients which were just finishing up, and the second phase which we hope to be starting soon. And I've actually spoken at least to some of you in Florida about potentially being sites and connecting you with the sponsor. So in our state to do pre hospital research.

Has a pretty clear path. We actually have a state law that includes EMS studies in the state law. So it creates a path to do EMS research. There's a couple steps that are different, of course, than doing in hospital research. One is you have to create a pre hospital protocol as if you were going to be using this device in a kind of straightforward, regular fashion. So we created a protocol that basically, and that's right here on the screen, this looks just like our other local protocols or guidelines. And it basically says if you have, you know, any suspicion of stroke or someone who has altered mental status, you're going to apply this device. And that's kind of the field part of it that has to get approved by our irb. We use our Wayne State IRB to approve that kind of thing.