Small hospital launches high-tech stroke solution

Program includes specialists via Internet

If administered within three hours of a stroke, the drug t-PA (tissue plasminogen activator) can reverse stroke damage that would turn an active person into an invalid. But success depends on speed and teamwork of the caliber you might expect in an Olympic relay race. "Time is brain," says John Hartness, MD, chairman of the stroke treatment improvement committee at Union Regional Medical Center (URMC) in Monroe, NC.

T-PA assessment and therapy is a process in which minutes count and handoffs are numerous. "I can’t emphasize the team effort enough," Hartness explains. "If any one person is not there to do his job, it breaks down.

"The sooner t-PA starts, the greater the benefits. But after three hours [from the time of the stroke], there’s more harm than good," he stresses.

That time frame is a distinct challenge for URMC. The 160-bed hospital’s catchment area is largely rural. When specialists are needed, URMC’s clinicians usually turn to the larger medical centers in Charlotte, 30 miles away. Monroe isn’t a place where you’d look for adoption of a revolutionary and highly complicated therapy within months of its introduction.

But URMC was upgrading its stroke care procedures in 1995 as Hartness kept one eye on the t-PA clinical trials. When the guidelines emerged in December that year,1 the hospital was positioned to consider them.

Candidates for treatment are people who sustain an ischemic stroke caused by a blood clot that becomes lodged in the brain or in an artery supplying blood to the brain. Administered intravenously, t-PA dissolves clots that block blood flow. It does not work for hemorrhagic strokes, which are caused by a ruptured blood vessel in the brain.

Country cousins’ teach city docs

An interdisciplinary committee included members from the area’s stroke care network. Repre-sented were radiology; lab; surgery; physical, occupational, and speech therapy; nursing; social services; intensive care; and the emergency department (ED), as well as the local family practitioners. The committee created technological links with the offsite specialists. "We had to tweak our processes so we wouldn’t lose patients to the time barrier," Hartness recalls. The t-PA protocol went into use in June 1996.

The ED orchestrates the moves:

• Paramedics make a heads-up call to the ED when they are dispatched to a possible stroke episode. In transit, they assess the patient for signs such as facial paralysis, general weakness, and impaired speech skills. If possible, they draw a blood sample to shave minutes off procedures in the ED.

• ED staff, meanwhile, clear a large front room to accommodate the stroke care team.

• Upon receiving a call from the paramedics, ED staff telephone or page the radiologists, neurologists, and neurosurgeons, alerting them to watch for X-rays and CT scans transmitted electronically, usually over the Internet.

• Word goes out to URMC’s lab and radiology technicians to stand by for tests.

• If a blood sample is not ready upon arrival, the ED nurse draws it within 10 minutes, or calls a physician if it has to be drawn from a large blood vessel. Testing rules out hypoglycemia.

• A nurse administers a stroke scale to determine the extent of brain injury.

As the specialists in Charlotte learned more about t-PA through their consultation on URMC’s cases, they spread the word to their peers. Soon, Hartness and his team received invitations to come to Charlotte and tell their story.

"Here we were, the country cousins, telling the city doctors about our new stroke treatment program! It was a surprise to all of us that we were using t-PA before the centers in Charlotte. We usually expect it to be the other way around," he says.

URMC takes care of about 150 stroke episodes each year. Here are a few of their t-PA statistics:

• The therapy has been administered 11 or 12 times, according to Hartness.

• Average arrival-to-CT-read cycle is under 45 minutes.

• T-PA starts in less than 60 minutes.

• More than 50% of the t-PA recipients experience complete, or nearly complete prevention of long-term brain damage. In the clinical trials,1 patients treated with intravenous t-PA were at least 30% more likely to have minimal to zero disability three months later.

Treatment costs are low

Recently, in a new URMC record of 25 minutes for arrival-to-CT-read, t-PA spared a 91-year-old man from spending the rest of his life paralyzed and bedridden. It saved his family the ordeal and expense of moving him to a nursing home. He didn’t even need rehab after he left the hospital.

Economically, t-PA is a bargain when compared to the cost of long-term disability, Hartness explains. His point is clear in the case of another URMC stroke patient.

The age 40-something truck mechanic suffered a severe ischemic stroke but arrived in time for t-PA. He was able to walk out of the hospital and go back to work after a brief recovery period. "In that case, we saved two breadwinners — the mechanic and his wife, who would have had to quit working to take care of her husband," Hartness notes.

Hartness credits part of URMC’s complication-free track record to conservative adherence to the time and patient profile guidelines. "About 80% of the hemorrhaging from the drug comes in cases where it is given outside of the guidelines. But we’ve also been very fortunate," he concedes. "Sooner or later, we will experience complications." Even with timely administration, the drug can cause cerebral hemorrhaging for some patients.

In the clinical trials, 6.4% of the t-PA recipients had brain hemorrhage; only 0.6% of the placebo recipients had similar problems. Three months post-stroke, mortality was 17% in the t-PA group and 21% in the placebo group. Hartness emphasizes the cerebral hemorrhage risks from using the drug more than three hours after the stroke usually outweigh potential therapeutic benefits.

Early in the stroke care initiative, the emphasis was on coordination of the clinical response, he says. "Now we’re ready to get the information to the community that there is something we can do for strokes, if they can get in here fast enough." The local news media have cooperated by running newspaper, radio, and television stories. Community groups sponsor educational programs. "People are starting to get the point that they should act fast when they see the symptoms in themselves or in their loved ones," Hartness notes.

Eventually, URMC will work with the schools to introduce stroke symptom recognition into the science curricula. The goal is for children to carry the message home. With that goes the never-ending emphasis on prevention. According to Hartness, smoking is quite prevalent in the area. His observation is confirmed by a recent study2 conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention in Atlanta. Hypertension is disproportionately high among residents of southern states, especially middle-aged, non-Hispanic white men living in nonmetropolitan regions.

Doing what works locally

The stroke treatment program at URMC grew out of the VHA’s Clinical Advantage initiative. VHA is a nationwide network, based in Irving, TX, whose membership comprises community-owned health care organizations and physicians. Clinical Advantage is a member resource for converting clinical knowledge into patient care practices.

The hallmark of the effort, according to VHA vice president for clinical affairs, Stacy Cinatl, is the interplay between standardization and flexibility. One set of practices or objectives cannot work for all VHA organizations, as the membership runs the gamut from academic medical centers to rural clinics.

Available care improvement programs include: Acute myocardial infarction, medical error reduction, and congestive heart failure. The theme is "Here’s the science, find ways to make it work in your organization."

The Clinical Advantage stroke care program involves five domains:

1. Coordination of care

2. Saving brain

3. Preventing complications

4. Secondary stroke prevention

5. Restoration of function

Participating institutions learn how to apply proven change methodologies like rapid-cycle change as taught by the Institute for Healthcare Improvement in Boston, and PICOS, the QI improvement process introduced by General Motors in Detroit, as applied in the manufacturing world. Collaboration and information-sharing take place through VHA-sponsored chat rooms monitored by experts, and shared literature reviews, case studies, and care techniques.

Are primary care facilities next?

The experience at URMC makes a strong case for the potential of applying complex medical processes in primary care facilities. The keys are strict adherence to proven guidelines and creative partnering of human and technical resources.

"Everybody has to look at how resources are being used in their institutions. Start asking Who could learn new skills? How can we find the consultants to fill in for our knowledge limitations?’" Hartness suggests. "At first people here didn’t think they could learn what they needed to know to use t-PA, but the enthusiasm grew when they saw that we got good results from tweaking our work processes and applying the drug protocol. Now, everyone is very proud of our success and nobody wants to be the reason it doesn’t work."

Cinatl predicts that consumer demand will grow as people learn about t-PA through local media and articles like the one in a recent issue of Good Housekeeping.3

References

1. National Institute of Neurological Disorders and Stroke RT-PA Stroke Study Group (John Marler, MD, project officer). Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1,581-1,587.

2. Obisesan TO, Vargas CM, Gillum RF. Geographic variation in stroke risk in the United States: Region, urbanization, and hypertension in the third national health and nutrition examination survey. Stroke 2000; 31:19-25.

3. Cool LC. Brain attack! Good Housekeeping, December 1999:64-66.