MANAGEMENT ACUTE ISCHEMIC STROKE

(FOCUS ON ALTEPLASE ADMINISTRATION AND PREPARATION)

Lisda Amalia
Cerebrovascular Subdivision
Department of Neurology Medical Faculty Padjadjaran University
RSUP dr. Hasan Sadikin Bandung
INTRODUCTION
• The committees of the American Heart Association (AHA) and the American Academy of
Neurology (AAN) then published guidelines endorsing the use of ALTEPLASE t-PA for
acute ischemic stroke under strict inclusion and exclusion criteria.

• The use of ALTEPLASE (t-PA) for acute ischemic stroke resulted in a significant
improvement in NIH Stoke Scale within the first 24 hours as well as neurologic and
functional outcomes at three months if administered within 3 hours of stroke onset.
 Significantly more patients had complete recovery at three months who were
treated with t-PA than placebo  mortality dan morbidity

TIME IS BRAIN
OUTLINE
• Stroke epidemiology
• Why rTPA or trombolysis?
• Guideline management acute ischemic stroke
• What is alteplase ?
• Preparation before rTPA administration
• Stroke network
• Management complication
WHAT IS A STROKE?
A STROKE IS A MEDICAL EMERGENCY!

• A stroke occurs when the blood flow to

a part of the brain is interrupted
• Lack of blood supply means that not
enough oxygen or nutrients reach the
brain and the brain cells become
damaged or permanently destroyed
• Depending on which part of the brain is
affected, different symptoms can occur
• If not treated in time, a stroke can have
emotional, physical or even fatal
consequences
STROKE TYPES AND INCIDENCE

Haemorrhagic
Other
12%
5%

Cryptogenic Atherosclerotic
30% cerebrovascular
disease
20%

Small vessel
Cardiac disease
embolism “lacunes”
20% 25%

ALBERS G, ET AL. CHEST 2004;126 (3 SUPPL):438S-512S.

5
WHY R TPA OR TROMBOLYSIS ?
• IV thrombolytic therapy remains the cornerstone of evidence-based acute ischemic stroke
therapy (Class I; level A)
• IV rt-PA is efficacious and cost-effective for patients with acute ischemic stroke treated
within 3 hours of symptom onset
• 6.6% complication of symptomatic intracranial hemorrhage (sICH)
• iv rt-PA Number Needed to Treat (NNT) :
• 4.5 for 0 -90 minutes
• 9.0 for 91-180 minutes
• 14.1 for 181-270 minutes
• 21.4 for 271-360 minutes
THROMBOLYSIS:
NUMBER OF PATIENTS NEEDED TO
TREAT (NNT) TO ACHIEVE EXCELLENT RECOVERY (MRS 0-1)

≤ 90 mins NNT=4 to 5

90 min - 3 h NNT=9

3 - 4.5 h NNT=14

mRS, modified Rankin Scale

Lees et al. Lancet 2010;375:1695-1703.

RT-PA EFFECTS ARE TIME DEPENDENT
18
Only 11% of all thrombolysed
16 15.3
AIS patients receive rt-PA within 13.9
14 90 min of symptom onset
% patients treated

12 10.6 10.7
10.2
10 11% 9.2
8.5
7.8
8
6 4.7

4 2.9 3.2

1.6
2 0.8
0.2 0.3
0
90 180
OTT (min)

AIS, acute ischaemic stroke

Wahlgren et al. Lancet 2008;372:1303-1309.
Lees et al. Lancet 2010;375:1695-1703.
The above figure demonstrates that the likelihood of
a favorable clinical outcome diminishes as time to
the initiation of IV rt-PA initiation increases.
GUIDELINES
ESO GUIDELINES FOR THE MANAGEMENT
OF ISCHAEMIC STROKE AND TRANSIENT ISCHAEMIC ATTACK

In patients admitted within 3 hours of stroke onset brain CT should be obtained

to guide routine thrombolysis treatment with rt-PA (Class I, Level A)

I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose given as a
bolus followed by a 60-minute infusion, is recommended within 4.5 hours of
onset of ischaemic stroke (Class I, Level A)

The use of multimodal imaging may be useful for patient selection for
thrombolysis but is not recommended for routine clinical practice (Class III,
Level C)

ESO Guidelines 2009 Update. www.eso-stroke.org

ESO GUIDELINES:
RECOMMENDATIONS FOR STROKE SERVICES
AND STROKE UNITS

All stroke patients should be treated in a stroke unit

(Class I, Level A)

Acute stroke patients should have access to high technology medical and
surgical stroke care when required
(Class III, Level B)

The development of clinical networks, including telemedicine, is recommended

to expand access to high technology specialist stroke care (Class II, Level B)

ESO Guidelines 2009 Update. www.eso-stroke.org

AHA GUIDELINES FOR THE EARLY MANAGEMENT
OF ADULTS WITH ISCHAEMIC STROKE
• I.V. rt-PA (0.9 mg/kg, maximum 90 mg) with 10% of the dose given
as a bolus followed by an infusion over 60 minutes for selected
patients within 3 hours of onset of ischaemic stroke (Class I, Level A)
• I.V. administration of streptokinase is not recommended for
management of ischaemic stroke (Class III, Level A)
• Brain imaging (either CT or MRI) should be interpreted by an
experienced clinician (Class I, Level C) before starting thrombolytic
therapy (Class I, Level A)
• Additional information in the diagnosis of ischaemic stroke may be
provided by multimodal CT or MRI (Class I, Level A)
 ACCP GUIDELINES: RECOMMENDATIONS
FOR ACUTE ISCHAEMIC STROKE TREATMENT
• I.V. rt-PA is recommended for acute ischaemic stroke (AIS) over no I.V. rt-PA if treatment
can be initiated:
• Within 3 h of symptom onset (Grade 1A)
• Within 4.5 h but not within 3 h of symptom onset (Grade 2C)
• If AIS treatment cannot be initiated within 4.5 h of symptom onset, I.V. r-tPA is not
recommended (Grade 1B)
• In patients with AIS due to proximal cerebral artery occlusions who do not meet eligibility
criteria for treatment with I.V. rt-PA, intra-arterial (IA) rt-PA should be initiated within 6 h of
symptom onset over no IA rt-PA (Grade 2C)
• I.V. rt-PA is recommended over the combination I.V./I.A. rt-PA in patients with AIS (Grade
2C)
• In patients with AIS or TIA, early (within 48 h) aspirin therapy at a dose of 160 to 325 mg is
recommended over no aspirin therapy (Grade 1A) and over therapeutic parental
anticoagulation (Grade 1A)
NICE GUIDELINES: RECOMMENDATIONS ON THE USE
OF ALTEPLASE FOR TREATING ACUTE ISCHAEMIC STROKE

Alteplase is recommended within its marketing

authorisation for treating AIS in adults if:

Treatment is started as early as possible within 4.5 hours of onset of

stroke symptoms, and

Intracranial haemorrhage has been excluded by appropriate imaging

techniques

AIS, acute ischaemic stroke

NICE technology appraisal guidance 264, September 2012. guidance.org.uk/ta264

WHAT IS ALTEPLASE (ACTILYSE ®)?
…alteplase or recombinant tissue plasminogen activator (rt-PA)
Actilyse® is...
...a fibrinolytic agent that acts
to dissolve blood clots
(thrombi) in a blocked vessel,
restoring blood flow to the
tissue beyond
Actilyse® is…
Actilyse® is... Actilyse® molecule
… indicated for the
thrombolytic treatment of:
› acute ischaemic stroke
› acute myocardial
infarction
› acute pulmonary
embolism
 ACTILYSE® - MODE OF ACTION

Actilyse® (rt-PA) is a fibrinolytic agent that activates plasminogen to form plasmin. Plasmin, in turn, degrades fibrin, a
component of blood clots. So Actilyse® stimulates the release of plasmin, which breaks up the clots in a blocked
vessel, limiting the tissue damage caused by ischaemia.
MODE OF ACTION
Actilyse® is relatively inactive when infused into the
systemic circulation:

• Low affinity for circulating plasminogen

• High affinity for fibrin-bound plasminogen

Actilyse® rapidly converts fibrin-bound plasminogen

to plasmin resulting in:

• Highly effective local fibrinolysis

• Limited systemic effects

EVERY SECOND COUNTS 1
Cerebral blood flow pattern after middle cerebral artery occlusion

The penumbra is
Infarct
moderately
Penumbra ischaemic tissue that
may remain
salvageable for
several hours if
reperfusion
takes place1,2
Onset of stroke:
death of brain cells within minutes1

Thrombolysis needs to be given as early as possible to prevent the

conversion of potentially viable brain tissue in the penumbra from
becoming completely ischaemic and dying

1. SAVER J. STROKE 2006;37:263-266.

2. MOUSTAFA RR, BARON JC. BR J PHARMACOL 2008;153:S44-S54.
EVERY SECOND COUNTS 1
Cerebral blood flow pattern after middle cerebral artery occlusion

The area of infarct

Infarct
represents severe
Penumbra ischaemia2

6 hours after stroke onset

Thrombolysis needs to be given as early as possible to prevent the

conversion of potentially viable brain tissue in the penumbra from
becoming completely ischaemic and dying

1. SAVER J. STROKE 2006;37:263-266.

2. MOUSTAFA RR, BARON JC. BR J PHARMACOL 2008;153:S44-S54.
EVERY SECOND COUNTS 1
Cerebral blood flow pattern after middle cerebral artery occlusion

The area of infarct

Infarct
represents severe
Penumbra ischaemia2

24 hours after stroke onset

Thrombolysis needs to be given as early as possible to prevent the

conversion of potentially viable brain tissue in the penumbra from
becoming completely ischaemic and dying

1. SAVER J. STROKE 2006;37:263-266.

2. MOUSTAFA RR, BARON JC. BR J PHARMACOL 2008;153:S44-S54.
TIME IS BRAIN TISSUE1
Areas of ischaemia following middle cerebral artery occlusion before (left) and after (right) reperfusion

Ischaemic core
(brain tissue
destined to die)2

Penumbra
(salvageable
brain area)2

An untreated patient loses approximately

Reperfusion offers the potential
1.9 million neurons every minute in the
to reduce the extent of ischaemic injury3
ischaemic area1
Adapted from:
1. Saver J. Stroke 2006;37:263-266.
2. González RG. Am J Neuroradiol 2006;27:728-735.
3. Donnan G, Davis S. Lancet 2002;1:417-425.
INCLUSION CRITERIA
• symptom onset less than 180 minutes
• patient is > 18 years of age
• clinical diagnosis of ischemic stroke causing a measurable neurological deficit (NIHSS)
• patient/family are informed of possible benefits and risk of t-PA.
 4-STEP PROCESS:
SELECTION FOR ACTILYSE® TREATMENT

4
3
Contra-indications
2
Severity of stroke
1
Diagnosis

Exclude bleeding
STEP 1
EXCLUDING BLEEDING
Intra-cerebral haemorrhage Sub-arachnoid haemorrhage

1. Rule out blood or other mass effect

STEP 2
DIAGNOSIS

1. Rule out Intracranial bleed

2. Stroke mimics, e.g. tumour
3. Extensive ischaemic damage
 STEP 3
STROKE SEVERITY
The ASPECTS score NIHSS score
Score Stroke Severity
0 No Stroke Symptoms
1-4 Minor Stroke
5-15 Moderate Stroke
16-20 Moderate to Severe Stroke
21-42 Severe Stroke

A score of zero indicates diffuse ischaemic damage Contraindications for rt-PA

A score of ten indicates a normal CT scan
Minor neurological deficit or symptoms rapidly
Clinical
studies1
have demonstrated that patients with an improving before start of infusion
ASPECTS score of >7 were most likely to benefit from
treatment
Severe stroke as assessed clinically (e.g.
NIHSS >25) and/or by appropriate imaging
Those with an ASPECTS score of <5 were unlikely to see
techniques
any improved outcome and were exposed to a significantly
higher risk of haemorrhage following thrombolysis
STEP 4
EXCLUDE CONTRAINDICATIONS
Contraindications fall under the following broad categories1, 2

Onset of symptoms
Increased bleeding risk more than 4.5 hours
ago

Severity

Aged
Unstable patient
18 – 80 years

1. NINDS RT-PA STROKE STUDY GROUP. N ENGL J MED 1995;333:1581-1587.

2. BOEHRINGER INGELHEIM. ACTILYSE ® SUMMARY OF PRODUCT CHARACTERISTICS.
CONTRAINDICATIONS
• Paediatric patients <18 years and adults
>80 years of age
• Symptoms of ischaemic attack beginning
>4.5 hours prior to infusion start or time of
symptom onset is unknown
• Very mild strokes, as the risks outweigh the
benefit1
• Minor neurological deficit or symptoms
rapidly improving before start of infusion
• Severe stroke as assessed clinically (e.g.
NIHSS >25) and/or by appropriate imaging
techniques
• Seizure at onset of stroke
• Evidence of intracranial haemorrhage (ICH)
on the CT-scan
FULL DETAILS OF ALL WARNINGS AND PRECAUTIONS CAN BE FOUND IN THE ACTILYSE ® SUMMARY OF PRODUCT
CHARACTERISTICS
BOEHRINGER INGELHEIM. ACTILYSE ® SUMMARY OF PRODUCT CHARACTERISTICS
› Symptoms suggestive of subarachnoid
haemorrhage, even if CT-scan is normal
Increased
bleeding risk
› Administration of heparin within the previous 48
hours and a thromboplastin time exceeding the
upper limit of normal for laboratory
Aged
› Any history of prior stroke and concomitant 18 – 80 years
diabetes
› Prior stroke within the last 3 months Severity
› A platelet count of below 100,000/mm3
› Systolic blood pressure >185 or diastolic BP Onset of
>110 mmHg, or aggressive management symptoms more
than 4.5 hours
necessary to reduce BP to these limits ago
› Blood glucose <50 or >400 mg/dl
Unstable patient
 REVIEW ADDITIONAL WARNINGS
• Thrombolytic/fibrinolytic treatment requires adequate monitoring.
• Actilyse® should only be used by physicians trained and experienced in
the use of thrombolytic treatments and with the facilities to monitor that
use.
• It is recommended that when Actilyse® is administered standard
resuscitation equipment and pharmacotherapy be available in all
circumstances.

• Please see full prescribing information for more details.

BOEHRINGER INGELHEIM. ACTILYSE® SUMMARY OF PRODUCT CHARACTERISTICS

STEP 4
TREAT THE PATIENT WITH ACTILYSE®

In acute ischaemic stroke, the recommended dose of Actilyse®

is 0.9 mg/kg body weight (maximum 90 mg)1
• 10% of the 0.9 mg/kg dose is given as an initial intravenous bolus
• The remaining 90% are infused intravenously over 60 minutes

BOEHRINGER INGELHEIM. ACTILYSE® SUMMARY OF PRODUCT CHARACTERISTICS

STEP 4 (CONT)
ADMINISTRATION OF ACTILYSE®
Remove Actilyse vial,
sterile water for injection
and transfer device from
box (please note there is
no transfer device in the
10 mg pack).
INSPECT SOLUTION
for particulate matter
and discolouration.
Transfer device not provided with 10 mg vial
BOEHRINGER INGELHEIM. ACTILYSE® SUMMARY OF PRODUCT CHARACTERISTICS
Remove cap from one Remove cap from other INVERT BOTH VIALS Swirl gently to dissolve
end of transfer device. end of transfer device. so Actilyse is on bottom. Actilyse. DO NOT
Insert piercing pin into Push inverted Actilyse SHAKE.
Allow ALL water to flow
upright vial of sterile vial down so that piercing
WFI. KEEP WATER VIAL pin passes through into Actilyse vial.
UPRIGHT. centre of Actilyse vial Remove transfer device.
stopper.
Withdraw BOLUS DOSE Administer Withdraw remaining 90% INFUSE remaining 90%
(10% of total dose) INTRAVENOUS BOLUS of dose. DISCARD of dose over 60 minutes
using a syringe and dose over 1 minute. EXCESS quantity of drug using infusion pump. At
needle. over that required for the end of treatment
treatment. FLUSH tubing with
15-20 ml of Normal
Saline.
WHEN & HOW TO USE ACTILYSE®
Take every effort to shorten time to treatment!

• Thrombolytic treatment requires adequate

monitoring
Treatment must be performed under the responsibility
and follow up of a physician trained and experienced
in neurovascular care and the use of thrombolytic
treatments.

• The treatment effect is time-dependent: The

earlier the treatment with thrombolysis, the
greater the benefit
Give Actilyse® as soon as possible after symptom
onset and within 4.5* hours of stroke symptom onset

*IN SOME COUNTRIES, ACTILYSE ® IS ONLY LICENSED FOR USE W ITHIN THE FIRST 3 HOURS
OF STROKE SYMPTOM ONSET. PLEASE CHECK YOUR LOCAL LICENSING REGUL ATIONS FOR
ACTILYSE ® .
COMPLICATIONS OF
TREATMENT WITH ACTILYSE®
The most frequent adverse reactions associated with Actilyse® are:

• Bleeding associated with thrombolytic therapy:

• Symptomatic ICH (up to 10% of patients)
• Superficial bleeding, normally from punctures or damaged blood vessels
• Internal bleeding into the gastrointestinal or urogenital tract, retroperitoneum or CNS or
bleeding of parenchymatous organs
• Respiratory tract haemorrhage
• Other bleeds

If a potentially dangerous haemorrhage occurs,

treatment with Actilyse® must be discontinued1
• Hypertension (>185/110 mmHg)
• Anaphylaxis
DETAILS OF ALL ADVERSE EVENTS CAN BE FOUND IN THE ACTILYSE® SUMMARY OF PRODUCT CHARACTERISTICS.

BOEHRINGER INGELHEIM. ACTILYSE® SUMMARY OF PRODUCT CHARACTERISTICS

RELATIVE CONTRAINDICATION
• Age > 85 years
• Severe neurologic deficit (e.g., National Institutes of Health Stroke Scale Score > 20).
• Baseline CT scan evidence of extensive ischemic changes. This includes early evidence
of sulcal effacement, herniation, mass effect, or edema.
• Recent myocardial infarction (given risk of post-myocardial infarction pericarditis and LV
thromboembolism), recent dysfunctional uterine bleeding, or active menstruation.
 Activate Stroke Blood test & CT scan Vital sign
STROKE alert w/o contrast & NIHSS

Do not give aspirin, ticlopidine, clopidogrel, glycoprotein IIB/IIIA agents, heparin in

Review any
patient
form or warfarin for 24 CT scan : haemorrhage (-)
hours.
inclusion and Labthe
: normal
• Monitor the patient carefully, especially bloodplatelet count, PT,
pressure.
exclusion criteria aPTT, blood glucose
• Monitor neurological status (NIHSS)

ALTEPLASE (tPA) 0.9 mg/kg (maximum of

90 mg) infused over 60 minutes with 10%
of the total dose administered as an initial
intravenous bolus over 1 minute
Stroke circle management
BENEFITS OF INTEGRATED STROKE NETWORKS
Ongoing coordination of
multiple clinical services
throughout stroke care
Ensure the right care Centralised emergency
for the right patient at the number ensures one stop
right time access to stroke care
Stroke
Networks
24/7 acute specialty cover Call centre triages patients
within a region prior to dispatch of
emergency team
Transport patient
to a stroke centre as quickly
as possible after symptom
onset
Direct transport to
stroke centre Telemedicine
Rapid transfer from
non-stroke
centre
Carr et al. Acad Emerg Med 2010;17:1354-1358.
Rymer. OMAG Mar-Apr 2010, available online.
PREPARATION ALTEPLASE ADMINISTRATION
• Stroke tim :
• Neurologist
• Radiologist Emergency Room/ER
• Clinical pathologist department staff
• Neurosurgeon
• Medical rehabilitation
• Anesthesiologist
• Internist/hematologist

Coordination of acute stroke respon team  critical to

success
BLEEDING PRECAUTIONS
• No concomitant antithrombotic or antiplatelet therapy during the first 24 hours after
symptom onset. If heparin or any other anticoagulant is indicated after 24 hours, consider
performing a non-contrast CT scan or other sensitive diagnostic imaging method to rule
out any hemorrhage before starting an anticoagulant.
• Restrict central venous access and arterial punctures during first 24 hours.
• Avoid inserting indwelling bladder catheter during infusion and for 30 minutes after
ALTEPLASE (t-PA) infusion ends.
BLOOD PRESSURE CONTROL
• Pretreatment
Monitor blood pressure every 15 minutes. It should be below 185/110 mm/hg before
initiating t-PA.
• During and after treatment: Monitor blood pressure for the first 24 hours after starting
treatment:
Suspect the occurrence of intracranial hemorrhage following the start of
every 15 minutes
ALTEPLASEfor 2 (t-PA)
hours infusion
after starting
if therethe infusion,
is any then
subsequent
neurological
every deterioration,
30 minutes for 6 hours,change in seizure
then every hour for pattern, newand
18 hours, or severe
then q 4 hours for 24
hours, exacerbation of headache, brady- or tachycardia, acute
then per routine.
hypertension or other sudden change in vital signs including
• If systolic BP is persistently > 180 mm Hg, start an intravenous infusion of Nicardipine,. Start
respiratory
at 5mg/hour pattern,
and titrate muscle SBP
to maintain tone,less
decerebrate/decorticate
than 180 and DPB less posturing,
than 105orby increasing
onset of nausea and vomiting.
infusion rate by 2.5 mg/hour every 5 minutes to a maximum of 15 mg/hour.
• Frequent BP measurements (every 15 minutes) are recommended for 1 hour after initiation
of the Nicardipine infusion and after a dose change, then every 30 minutes.
• Monitor for hypotension.
MANAGEMENT COMPLICATION
• If hemorrhage is suspected:
• Discontinue ALTEPLSAE (t-PA) infusion
• Immediate CT scan to check for presence of hemorrhage.
• Draw blood for Hct/Hgb, PT, aPTT, platelet count, fibrinogen and type and cross.
• Prepare for administration of plasma and/or cryoprecipitate
(if clinically significant abnormalities in coagulation screening tests are found)

Start to consult neurosurgeon or

hematologist
BIAYA PASIEN STROKE/EPISODE PESERTA
JKN
25/11/2018 45
 TARIF RS :
CONTOH KASUS PASIEN STROKE ISKEMIK
(Severity Level 2) LOS 5 hari Rp 9.869.280,-

TARIF INACBG’s :
Rp 13.017.600,-

25/11/2018 46
Regional 1, RS Tipe A, Kelas rawat : Kelas 1
CONTOH KASUS PASIEN STROKE
ISKEMIK DENGAN rTPA (Severity
Level 2) TARIF RS :
LOS 7 hari Rp 26.215.960,-
TOTAL BIAYA OBAT, ALAT, MAKANAN FT
3,875,984
TOTAL BIAYA LAB PENUNJANG::
3,926,000
TOTAL BIAYA RUANGAN:
1,095,000
TOTAL BIAYA JASA:
2,149,000
TOTAL BIAYA PENUNJANG LAIN :
1,316,776
r-TPA (Alteplase) 5,225,000 / ampul (x2 ): 10,
450,000
Insulin Sliding scale/skala luncur : TARIF INACBG’s
2,233,000 Antihipertensi : Nicardipin :
1,155,000
:
Anti koagulan oral: 8x1900 :
Rp 13.017.600,-
15,200

25/11/2018 47
Regional 1, RS Tipe A, Kelas rawat : Kelas 1
CONTOH KASUS PASIEN STROKE
HEMORAGIK
(Severity Level 2)LOS 10 hari TARIF RS :
Rp
20.851.047,-

TARIF INACBG’s
:
Rp
10.009.100,-
25/11/2018 48
Regional 1, RS Tipe A, Kelas rawat : Kelas 1
3 CARA MANAJEMEN STROKE
YANG BERPELUANG DAPAT
MENGUNTUNGKAN UNTUK
RUMAH SAKIT

25/11/2018 49
A. Aspek
3 CARA Finansial
MANAJEMEN dari manajemen
STROKE YANG
BERPELUANG DAPAT MENGUNTUNGKAN UNTUK
INA-CBG yang Benar
RUMAH SAKIT

Hal-hal yang
1 perlu diperhatikan
3 :
 Pencatatan Diagnosa (Diagnosa utama, Diagnosa
Manajemen INACBG & Peningkatan reputasi RS
sekunder), Faktor Penyulit, Prosedur, Serta Layanan
Upaya Efisiensi
Penunjang pada RM secara tepat
 Entry kode ICD X dan2ICD 9 menghasilkan tarif INA-
CBGs yang tepat
Meningkatkan
 Utilisasi Top-Up pelayanan
pemeriksaan penunjang pada keadaan
tertentu Post-Stroke-Care

25/11/2018 50
 Pemeriksaan
penunjang
Terapi selama
Pemeriksaan
perawatan
fisik
(Prosedur)

Hasil
Anamnesis Diagnosa konsultasi

WAJIB TERCATAT DALAM REKAM

MEDIS 25/11/2018 51
 25/11/2018 52
Agusniadi G (2017)
 25/11/2018 53
Agusniadi G (2017)
 25/11/2018 54
Agusniadi G
 Beberapa Contoh Kode ICD terkait stroke iskemik yang
dapat dimasukan ke Grouper untuk menghasilkan Tarif
CBGs yang lebih tepat :
Kode Keterangan
Kategori Deskripsi
ICD Tambahan
ICD 10 I63 Cerebral infarction

ICD 10 I69.3 Sequelae of

cerebral infarction
ICD 10 Y44.5 Thrombolytic
drugs
ICD 9 92.12 Scan of other Termasuk dalam
sites of head - Top Up Special
Nuclear Medicine CMG

ICD 9 88.91 MRI of brain and Termasuk dalam

brain stem Top Up Special
CMG
Source:
http://apps.who.int/classifications/icd10/browse/2016/en#I69.3 25/11/2018 55
http://icd9.chrisendres.com/index.php?action=procrec&recordid=3568
Contoh Besaran Tarif Pada Regional 1 Rumah Sakit Kelas A Pemerintah
Contoh Tarif Rawat Inap :

Kode INA- Tarif Kelas Tarif Kelas

Deskripsi Kode INA-CBG Tarif Kelas 3
CBG 2 1
Kecederaan pembuluh darah
G-4-14-I 6,955,000 8,346,000 9,737,000
otak dengan Infark (ringan)
Kecederaan pembuluh darah
G-4-14-II 9,298,300 11,157,900 13,017,600
otak dengan Infark (sedang)
Kecederaan pembuluh darah
G-4-14-III 11,670,400 14,004,500 16,338,600
otak dengan Infark (berat)

Kode INA- Tarif RS Tipe

Deskripsi Kode INA-CBG
CBG A
Nuclear Medicine (CT-Scan
Contoh Top up Special CMG : Z-3-17-0 2,342,700
Termasuk)
Z-3-16-0 MRI 1,959,200

Hasil akhir perhitungan klaim pada Grouper bisa lebih rendah atau
lebih tinggi dari standar tarif yang tertera di PMK 64, Tergantung
pada entry kode ICD X dan ICD 9 yang dilakukan RS
Source:
• Peraturan Menterl Kesehatan RI Nomor 64 Tahun 2016
• Peraturan Menteri Kesehatan RI no. 76 Tahun 2016 tentang Pedoman Indonesian Case Base 25/11/2018 56
Groups (Ina-cbg)
Contoh Besaran Tarif Pada Regional 1 Rumah Sakit Kelas A Pemerintah
Contoh Tarif Rawat Inap :

Kode INA- Tarif Kelas Tarif Kelas

Deskripsi Kode INA-CBG Tarif Kelas 3
CBG 2 1
Kecederaan pembuluh darah
G-4-14-I 6,955,000 8,346,000 9,737,000
otak dengan Infark (ringan)
Kecederaan pembuluh darah
G-4-14-II 9,298,300 11,157,900 13,017,600
otak dengan Infark (sedang)
Kecederaan pembuluh darah
G-4-14-III 11,670,400 14,004,500 16,338,600
otak dengan Infark (berat)

Kode INA- Tarif RS Tipe

Deskripsi Kode INA-CBG
CBG A
Nuclear Medicine (CT-Scan
Contoh Top up Special CMG : Z-3-17-0 2,342,700
Termasuk)
Z-3-16-0 MRI 1,959,200

Hasil akhir perhitungan klaim pada Grouper bisa lebih rendah atau
lebih tinggi dari standar tarif yang tertera di PMK 64, Tergantung
pada entry kode ICD X dan ICD 9 yang dilakukan RS
Source:
• Peraturan Menterl Kesehatan RI Nomor 64 Tahun 2016
• Peraturan Menteri Kesehatan RI no. 76 Tahun 2016 tentang Pedoman Indonesian Case Base 25/11/2018 57
Groups (Ina-cbg)
 PENGARUH KODING KOMPLIKASI DAN KOMORBID
Classifications :
Principal Diagnosis : Ischemic Stroke (I63.9)
ICD-10 WHO -
Diagnosis
ICD-9-CM - Posedur Case - A Case - B Case - C
INA-CBG
Principal Diagnosis Ischemic Stroke (I63.9) Ischemic Stroke (I63.9) Ischemic Stroke (I63.9)
Secondary Diagnosis Hypertension (I10) Hypertension (I10) Hypertension (I10)
Hemiparesis (G81.9) Hemiparesis (G81.9)
Pneumonia (J18.9)
Procedure Head CT Scan (87.03) Head CT Scan (87.03) Head CT Scan (87.03)
Fisioterapi (Assisting Fisioterapi (Assisting
exercise) (93.11) exercise) (93.11)
Thorax X-Ray (87.44)
KODE INA-CBG G-4-14-I G-4-14-II G-4-14-III
Kecederaan pembuluh Kecederaan pembuluh Kecederaan pembuluh
Deskripsi kode INA-
darah otak dengan infark darah otak dengan infark darah otak dengan infark
CBG
(ringan) (sedang) (berat)
RS Tipe A Pemerintah
TARIF KELAS 3 6,955,000 9,298,300 11,670,400
TARIF KELAS 2 8,346,000 11,157,900 14,004,500
TARIF KELAS
PMK1 64/2016 9,737,000 13,017,600 25/11/2018
16,338,600 58
B. Aspek Finansial dari Peluang Efisiensi

REFORMASI IT REFORMASI AKSELERASI PPK KENDALI LOS

• CPOE(Computer TARIF • Akselerasi • Bed
ized Physician • Revisi Tarif Paket pembuatan PPK Management
Order Entry), agar rasional dan • Akselerasi yang efektif dan
konsul online, kompetitif penggunaan efisien berbasis
CTTP online • Penyeragaman PPK IT
• Kendali e- tarif untuk • Patuh PPK/CP
prescribing tindakan yang • Optimalisasi
Fornas sama Case
• Sistem perjanjian • Input tagihan real • Manager/Care
dan antrian time Manager
• Resume Medik • Peningkatan
Online kompetensi
• Medical Record penata rekening
Elektronic

Agusniadi G (2017) 25/11/2018 59

B. Aspek Finansial dari Peluang Efisiensi

GERAKAN SADAR GERAKAN EFISIENSI KENDALI OBAT DAN

BIAYA • Efisiensi Proses ALKES
• Diseminasi berulang Pelayanan • Prescribing FORNAS
KMKB • Efisiensi Utilitas (93%) dan Kendali
• Supervisi proses (listrik,AC, Air) ANTIBIOTIK
pelayanan oleh DPJP • Efisiensi ATK • Kendali penggunaan
• Pelayanan Palliative • Implementasi e-Office BMHP & Alkes
dan Interdisipline • Purchasing Strategy
yang terkendali

60
Agusniadi G (2017) 25/11/2018
TAKE HOME MESSAGE
• The use of ALTEPLASE t-PA for acute ischemic stroke under strict inclusion and
exclusion criteria resulted in a significant improvement in NIH Stoke Scale within the first
24 hours as well as neurologic and functional outcomes at three months if administered
within 3 hours of stroke onset, significantly more patients had complete recovery at
three months who were treated with t-PA than placebo  morbidity ↓
• Coordination of the acute stroke response team is critical to success and each team
member is responsible for a designated component of care including management
complication after rTPA administration

TIME IS STILL BRAIN

REFERENCES
• The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke. The New England Journal of Medicine. 1995;
333:1581-7.

• Adams HP Jr, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A
supplement to the guidelines for the management of patients with acute ischemic stroke: A
statement for healthcare professionals from a special writing group of the Stroke Council,
American Heart Association Stroke. 1996; 27:1711-8.

• Practice advisory: Thrombolytic therapy for acute ischemic stroke - Summary statement: Report
of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.
1996; 47:835-9.

• Adams, HP Jr, Adams RJ, Brott T, et al. Guidelines for the Early Management of Patients With
Ischemic Stroke. A Scientific Statement From the Stroke Council of the American Stroke
Association. Stroke 2003; 34:1056-1083.
Thank You