In 1996, when the Food and Drug Administration approved tissue plasminogen activator (tPA) as a therapy for ischemic stroke, neurologists had new hope for a condition once thought all-but-impossible to treat. Today, experts contend that despite some progress in use of the drug, two major impediments to combat stroke remain: Community hospitals have been slow to adopt thrombolytic therapies, and minorities continue to be at historically high risk for developing stroke.
Two new programs in New York City – at Harlem Hospital Center in Central Harlem and Lincoln Medical and Mental Health Center in the South Bronx – aim to address those issues. Both hospitals are located in communities with a large population of African-American and Hispanic residents and with higher-than-average stroke rates. According to the New York City health department, the number of people who die from stroke in Central Harlem is 90 percent higher than it is for the rest of the city. In the South Bronx, that figure is 30 percent. The strategies adopted by these programs – and others throughout the country – may serve as a blueprint for how community hospitals can improve their stroke response.
STROKE AWARENESS IN HARLEM
Harlem Hospital Center, a 286-bed facility working toward recognition as a National Stroke Center, implemented a public awareness campaign in February to educate local health care professionals and Harlem residents about the risks and symptoms of stroke.
Along with colleagues Olajide Williams, MD, Assistant Professor of Neurology at Columbia University, who has directed the hospital's in-patient stroke program since 2002, convened a task force comprising stroke experts, as well as local clergy, pharmacists, community board members, and community activists. The group sponsored a free CME conference in February to educate primary care physicians, physician assistants, nurses, and emergency medical staff about treatment and prevention of stroke in African-Americans and Hispanics. About 300 professionals attended the event, surpassing organizers' expectations, he said.
The task force is specifically interested in educating Harlem's children, Dr. Williams said, because “we are seeing a wave of obesity and diabetes in children that will translate into earlier cardiovascular disease.” He noted that increasing numbers of stroke victims in their 20s and early 30s are admitted to Harlem Hospital.
Through a program sponsored by the American Stroke Association that uses hip-hop music as a motivational teaching tool, Dr. Williams's team has been visiting public schools to teach students about stroke. The goal is to modify behavior in future generations by educating 4th, 5th, and 6th graders. He noted that studies have shown these are ideal ages during which to change behavior – specifically, eating habits and lifestyle choices that can lead to blocked arteries.
“In one of the schools, 75 of about 220 children told us that they had a first-degree family member who had had a stroke,” he said. The program also found that children are sometimes the ones to call 911 when their parents or grandparents fall ill, so they are teaching students how to recognize symptoms of stroke. So far, the program has reached about 500 children, he said.
Harlem Hospital has also been targeting the community's adult and elderly populations, primarily through free health screenings. At an event held in February attended by 139 people, the hospital checked blood pressure, diabetes, heart disease, and cholesterol, and offered individualized nutrition and physical activity assessments.
Although the hospital is also working to develop evidence-based stroke protocols, Dr. Williams said its main focus is public education. “If people in these communities aren't educated about diseases that we have these great treatments for – and that are often time-dependent – then we are just shooting blanks.” At Harlem Hospital, only about 2.5 percent of patients eligible for tPA are receiving it, mostly because they do not get to the hospital within the three-hour window required, he said.
Ralph Sacco, MD, is hoping to answer the million-dollar question of whether patient education changes behavior. He and Dr. Bernadette Boden-Albala are currently working on an NIH-funded study, SWIFT (Stroke Warning Information and Faster Treatment), which is trying to establish whether people arrive earlier at the ER when they are educated about stroke symptoms. They want to enroll about 1,400 stroke and transient ischemic attack survivors, he said. Dr. Sacco, Director of the Stroke and Critical Care Division at Columbia University, is one of several psychologists and researchers who have been involved in developing the Harlem education program. Since 1990, he also has led the NINDS-funded Northern Manhattan study on stroke incidence and risk-factors within the New York City neighborhood of Washington Heights. The study found that African-Americans have twice the risk of stroke than whites.
MORE TPA IN THE SOUTH BRONX
Like Harlem, the health care system in the South Bronx is also known for low tPA utilization. This may change now that the area received its first state-designated stroke center in February at Lincoln Hospital.
About 18 months ago Sindhaghatta Venkatram, MD, Director of the new stroke center, and colleagues sought to overcome some of the delays that prevent patients from receiving tPA. The group put together a seven-member, 24-hour on-call stroke team, and developed protocols that require the hospital to complete and review CT scans and laboratory tests within 45 minutes from the time that a patient first arrives in the emergency room (ER). While he admits that at first this goal “raised a few eyebrows,” since being implemented over a year ago, the protocols are achieved 95 percent of the time, he said. At press time, he said the average door-to-CT read time was 37 minutes.
The hospital also holds classes for paramedics twice a year to teach them about recognition of strokes so that they get patients into hospitals as quickly as possible. As is done in Harlem, Dr. Venkatram talks to community leaders about why Bronx residents need to call 911 as soon as they notice stroke symptoms in order to have access to thrombolytic therapies
As a result of these initiatives, the tPA rate at Lincoln increased by 20 percent in the last six months, he said. “This has really resulted in wonders. I can think of numerous examples where patients walked home afterwards and felt happy,” he said.
LESSONS FROM HOUSTON AND KANSAS CITY
These initiatives stem in large part from the fact that New York State has mandated the development of stroke centers, but other regions have also embarked on such projects, and with great success.
James C. Grotta, MD, helped establish the University of Texas Houston Stroke Team in 1988 – one of the first in the country. He said that when developing stroke centers, hospitals should probably not focus most of their attention on community education. “I would say that if you have $100,000 to spend on your stroke program you should focus on streamlining your ER and working with paramedics. Education is a bigger problem – $100,000 would just be a drop in the bucket.”
Dr. Grotta said things that might seem like minor inefficiencies, such as waiting for the attending physician to order a CT scan, taking an elevator to the CT scan, and taking patients' blood to a distant lab, can add up to major time gaps that can prevent a patient from receiving tPA. In response to these delays, he and his team developed protocols so that in Houston, triage nurses order the CT scans; blood tests are conducted and sent to the lab upon arrival of a patient; two IV lines and a Foley catheter are placed immediately; and all stroke patients are sent to treatment rooms that are stocked with tPA and appropriate forms, orders, and flow sheets. All tests must be completed within 60 minutes, although Dr. Grotta said he would like to get that down to 45 minutes.
The best way to improve stroke response is probably through a region's emergency medical service (EMS) system, he said. In Houston, Dr. Grotta worked with the city's EMS director to educate paramedics about stroke recognition. The paramedics were told that when they pick up a stroke patient, they should call the hospital's ER so that it can mobilize its stroke team to respond the second the patient arrives.
Dr. Grotta pointed out that organizing paramedics in Houston was a relatively smooth process because the city has a centralized emergency response system. This means that when someone calls 911, the Houston fire department always responds, unlike other cities where the call would be answered by the ambulatory service of the nearest hospital.
Marilyn M. Rymer, MD, who helped develop the stroke center at St. Luke's Hospital in Kansas City, MO, emphasized the importance of organizing emergency providers so that they route patients to hospitals that can administer stroke therapies.
“Many states, cities, regions, don't have any sort of policy for stroke patients to be routed to a center of excellence,” she said. States should organize their community hospital systems so that when possible, patients are referred to hospitals with a stroke center rather than those that are closest in proximity. The program in Kansas City, established in 1993, was the first acute intervention center in the area. It currently administers intervention in up to 30 percent of its ischemic patients, she said. The hospital caters to a 100-mile radius, although Dr. Rymer said patients sometimes come from even further for the hospital's stroke services. The program's slogan, “Just get here,” says a lot about its reach: Last year, 61 different hospitals referred patients to St. Luke's.
“We consult with the referring hospital by phone and often direct bridging dose IV tPA be given in the referring emergency department before transport,” she said. “We only do this if we can be sure the time of onset was less than three hours and the CT findings and the other important NINDS criteria are met. If we are not sure of those then we ask that the patient be transported. If they are outside the IV tPA window on arrival, we evaluate them for intra-arterial thrombolysis or mechanical thrombectomy.”
IT TAKES A VILLAGE
Dr. Grotta said the process of establishing stroke centers should be approached as a community initiative, not a competition. “My advice is to be collaborative. Try to help other hospitals in your area so that they can be stroke centers also.”
ARTICLE IN BRIEF
✓ Hospitals in urban and rural areas are conducting extensive outreach to patients, paramedics, and emergency room staff to improve the detection of stroke and timely treatments.