2018 MEDICAL DIRECTORSHIPS AT THE WILLIAM W.
BACKUS HOSPITAL
David Tinklepaugh, MD.
Director of the Primary Stroke Center
SCOPE OF SERVICES
As medical director of the Primary Stroke Center at the William W.
Backus Hospital, my responsibilities encompass the development
and continuous improvement of our inpatient and outpatient stroke
services as well as stroke education. This includes:
• Developing stroke care protocols and evidence based care
• Partnering with the Ayer Neuroscience Institute Stroke Council
to integrate Backus Hospital into the Hartford HealthCare
stroke system of care
• Working with the Stroke Coordinator to track stroke outcomes
and care metrics
• Managing data collection alongside the Stroke Coordinator for
the “Get With the Guidelines” (GWtG) stroke registry
• Serving as liaison between various other stroke services
such as tertiary vascular neurology at Hartford Hospital and
interventional services
• Developing strategies, action plans and measurement for
improvements, and the allocation of resources regarding quality,
safety and education
• Providing ongoing stroke education to staff including providers,
nursing, rehabilitation personnel
• Advising on community education and outreach
After receiving my training in general neurology and fellowship
training in Neuromuscular Disease at Yale-New Haven Hospital, I
joined Neurology Associates in private practice in 2003. I served
as Chief of Neurology for a year at Backus Hospital and have
provided in-patient consultative services, along with my colleagues,
since 2003. Recently I completed Hartford HealthCare’s Provider
Leadership Development Institute (PLDI) course.
I was appointed as Medical Director of Stroke Services at Backus
in 2017 and charged with building a stroke program to meet the
objectives of the Joint Commission for Primary Stroke Center. In
conjunction with Rebecca Durham RN, Regional Institute Director,
and the diligent work of Melissa Lawson RN, our Stroke Coordinator,
the stroke program was certified as a Primary Stroke Center by the
joint commission in April 2018.
16 THE OPEN JOURNAL
CURRENT STATE OF
PRIMARY STROKE CENTER
Our goal as a primary stroke center is to provide exceptional,
evidence based care for patients with cerebrovascular disease and
stroke. There are many ideologies for stroke which differ for stroke
which differ in prognosis and treatment.
Snapshot of Backus Stroke Population (April-July 2018)
All Strokes and TIAs 62 in 13 Months
Ischemic Strokes 34 (53% of Stroke Admissions)
TIA’s 29 (47% of Stroke Admissions)
No Hemorrhagic Strokes
TPA and endovascular thrombectomy are well established
treatments for acute, large vessel thrombotic stroke presenting
within 4.5-6 hours. The DAWN trial, published in 2018, was a
pivotal study in treatment of large vessel thrombotic stroke. The
DAWN trial (NEJM 2018; 378:11-21) randomized 206 patients
with ischemic stroke involving the intracranial ICA or MCA at 6-24
hours to thrombectomy or standard medical therapy (tPA within
4.5 hours of stroke symptoms and antiplatelet medication after
imaging studies to exclude hemorrhage at 6-24 hours). The study
showed an improved rate of functional independence (49% vs 13%)
at 3 months. The rate of intracranial bleeding (6% vs 3%) and the
3-month mortality (19% vs 18%) were not significantly different in
the treatment arms.
CT perfusion with RAPID software represented a major leap
forward in acute stroke care when rolled out at Backus Hospital
earlier this year. CT image processing software, RAPID, allows
the identification of at risk ischemic tissue up to 24 hours after
stroke onset. Appropriately identified patients are candidates
for endovascular thrombectomy at Hartford Hospital. Prior to
publication of the DAWN trial, which demonstrated the benefit of
this technology, the Stroke Council worked diligently to decide on
the appropriate utilization of this anticipated technology across the
network of Hartford HealthCare hospitals.
We considered the various ways to deploy RAPID, ultimately
choosing to distribute this capability to each of the hospitals.
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
Continued on page 17
 2018 MEDICAL DIRECTORSHIPS AT THE WILLIAM W. BACKUS HOSPITAL

iterated multiple protocols from identification of large vessel strokes
to transportation logistics, settling on our current approach. Now in
place, these protocols allow Backus to identify patients with large
vessel strokes who would benefit from thrombectomy and quickly fly
them to Hartford Hospital for intervention.
Both Melissa Lawson RN and I have been involved with the Hartford
HealthCare Ayer Neuroscience Institute Stroke Council which meets
monthly to develop protocols, service lines and performance metrics.
From these councils we design the most appropriate services at
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
families.
[1]1 IV t-PA arrive by 2 hours, treat by 3 hours
[2]
2 Early antithrombotics; % with therapy CHALLENGES
by end of hospital day 2 Any time a hospital makes a major commitment to new evidence
[3]
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]
4 Antithrombotics; % with therapy at discharge.
protocols based on up to date review of our metrics and outcomes.
[5]
5 Anticoagulation for Afib; % discharged on therapy
[6]
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]
7 Statin on discharge only those requiring higher levels of care to the larger hospitals
[8]
8 Dysphagia screen in the Hartford HealthCare system. This will include achieving
[9]
9 Door-to-needle time ≤ 60 min Stroke Ready Hospital status for Windham and Joint Commission
designation in the near future. n
[10]
10 IV t-PA arrive by 3.5 hours, treat by 4.5 hours
[11]
11 NIHSS reported
[12]
12 Stroke education
[13]
13 Rehabilitation considered; % assessed
for rehabilitation services
[14]
14 LDL documented
[15]
15 Intensive statin therapy

FALL 2018 17