ARTICLE IN BRIEF
The story about the launch of a dedicated emergency neurology department at a community-based hospital prompts discussion about the growth of the specialty of neurocritical care — with both training and research opportunities.
When Khamal Brown, a sophomore on Princeton University's football team, began acting erratic and confused at practice one afternoon in October 2012, team physician Margot Putukian, MD, logically suspected a concussion. The local New Jersey ambulance service wanted to take Brown to a community hospital with no in-house neurologists, but Dr. Putukian insisted that they rush him instead to Capital Health Regional Medical Center in Trenton, home of the nation's first dedicated neurology emergency department.
At the Center for Neurologic Emergency Medicine, Brown was rushed past standard emergency-room admitting procedures and was in a CT scanner within ten minutes. There, neurosurgeon Mandy Binning, MD, saw that the young man did not have a concussion — instead, a congenital arteriovenous malformation (AVM) had ruptured and hemorrhaged into his brain.
Brown was immediately transferred to the hospital's neurological intensive care unit, where Dr. Binning performed a ventriculostomy to drain the fluid. Later, he underwent open surgery to repair the AVM. Today, Brown has only a small scar to remind him of the experience; he will probably return to playing football in 2014.
Capital Health does appear to be the only hospital in the nation with an entire emergency department dedicated specifically to neurologic emergencies such as stroke, aneurysm, and brain trauma, according to Jin-Moo Lee, MD, PhD, director of the cerebrovascular disease section of the department of neurology at Washington University in St. Louis.
“Similar models have been employed in Europe — for example, in Germany and Finland — where they have achieved impressive door-to-needle times for ischemic stroke patients of 30 minutes or less,” he said. “But I'm not aware of anything else like this in the United States.”
“We have things such as chest pain centers within EDs, but as far as I know, this would be the only dedicated neurologic ED,” agreed Opeolu Adeoye, MD, a neurocritical care specialist at the University of Cincinnati. “This is a potentially big advantage, inasmuch as patients with neurologic conditions sometimes have an impairment, and if you're impaired to the point that you can't make much noise, you may fall through the cracks in a busy emergency department. A section dedicated to triaging, identifying, and treating these patients could potentially advance care.”
“Broadly speaking, the whole area of so-called ‘emergency neurology’ is becoming increasingly important,” said Kevin N. Sheth, MD, chief of the Division of Neurocritical Care and Emergency Neurology and director of the Neurosciences Intensive Care Unit at Yale New Haven Hospital. Dr. Sheth serves on the editorial advisory board of Neurology Today.
“This parallels a broader trend in the acute neurosciences and acute neurocritical care. While other institutions may not have dedicated neurologic EDs, there are several other programs led by physicians who are dually certified in neurology and emergency medicine — such as Ed Jauch, MD, who directs the Division of Emergency Medicine at the Medical University of South Carolina [MUSC]. A few years ago, this would have been incredibly rare, but now it's really in the vanguard.”
One driver of the growth in emergency neurology has been the creation of the Neurological Emergencies Treatment Trials (NETT) Network, a hub-and-spoke network involving 22 “hub” institutions each linked with at least three “spoke” hospitals.
Launched by the NIH in 2007, NETT conducts large, simple multicenter clinical trials focused on the emergent phase of patient care, aimed at improving outcomes of patients with acute neurologic problems. “They're focused on acute trials in things like stroke, head trauma and seizures,” said J. Claude Hemphill III, MD, professor of clinical neurology and neurological surgery and Kenneth Rainin chair in neurocritical care at the University of California, San Francisco.
In parallel, fellowships in neurocritical care have become a growth field. After he completed fellowship training in 2006, Dr. Adeoye was one of the first emergency physicians to become certified as a neurocritical care specialist by the United Council for Neurologic Subspecialties. Since then, more than 40 neurocritical care fellowships have become available, including the one in the Division of Neurocritical Care at the University of Cincinnati, which Dr. Adeoye directs.
CREATING A PROGRAM
Erol Veznedaroglu, MD, left Thomas Jefferson University Hospital in Philadelphia several years ago to help found Capital Health's Institute for Neurosciences, which includes the neurology ED. He said he conceived of the idea of a dedicated neurologic ED while at Thomas Jefferson University, but said that in many major academic health centers, turf wars between departments would have made the concept impossible to execute. Capital Health, a good community hospital with a large surplus, wanted to build new programs of excellence and saw the neurosciences as a big area of opportunity.
“In Jefferson, we got probably 60 percent of the volume of neuroscience cases from New Jersey — even emergency stroke patients.”
The Institute for Neurosciences at Capital Health — which in itself is somewhat unusual, combining neurologists, neurosurgeons, neurocognitive specialists, pain specialists, and rehabilitation medicine in one common department — opened in January 2009.
Dr. Veznedaroglu recruited Michael D'Ambrosio, DO, then the director of the stroke program at South Jersey's Kennedy Health System and, like MUSC's Dr. Jauch, one of the few physicians in the nation to be board certified in both emergency medicine and neurology, to direct the new neurologic emergency department. It officially opened in January 2011; in 2012, the department treated more than 4,500 patients, approximately 47 percent of whom were admitted (compared with 10-15 percent of patients admitted from standard emergency departments).
“In this ED, neurology patients have two 256-slice CD scanners and a bedside CT dedicated to them.”
When a patient with signs of stroke, head injury, or other neurologic problems — the triage list includes symptoms such as altered mental status, blurred speech, seizure, traumatic head injury, and one-sided pain or numbness and weakness — arrives at Capital Health, he or she is immediately sent to the neurologic ED section, which has six dedicated beds (and will likely soon expand to include more). All of the physicians assigned to that department have undergone specialized “mini-fellowship” training: four weeks of neuroradiology, two weeks in the interventional suite, and two weeks in the neuro-intensive care unit.
“If you walk in the door with stroke-like symptoms, you're in the CT scanner within less than 20 minutes. If you arrive in an ambulance, you go straight to the CT scanner,” Dr. Veznedaroglu said. (The hospital has done extensive training with the region's EMS teams.) “We've dramatically cut down our patients' time-to-treatment, whether that's tPA [tissue plasminogen activator an interventional procedure.”
In an ongoing study — not yet submitted for publication — Dr. Veznedaroglu said that the door-to-needle time for the neurologic ED, when its pre-hospital alert protocol for paramedics is used, is 43 minutes. That's not unique — Dr. Lee noted that his own institution reports a door-to-needle time of 38 minutes — but it is a more than 42 percent reduction compared with the national median of 75 minutes among hospitals participating in the American Stroke Association's Get With the Guidelines Program in 2009.
“I think that there is a lot of promise in programs such as these,” said Washington University's Dr. Lee. “Their response times look great, and they do very well with neurologic emergencies.”
Of course, the department has been open for less than two years and the data are still developing. “I would like to see data on how well they deal with multiple comorbidities happening at the same time. It's not rare for stroke patients to have a concurrent heart attack, for example,” Dr. Lee observed. “In order to truly evaluate the utility of a neuroscience ED, we'd want to look beyond just door-to-needle times and evaluate how well all patients seen in that ED do, compared with patients seen in a standard ED.”
“While not everybody will be able to have a dedicated new center attached to the main ED, every ED in the country can have a heavy focus and emphasis on rapid assessment and rapid triage of patients with neurologic emergencies,” said Dr. Adeoye.
To that end, the Neurocritical Care Society last year launched Emergency Neurological Life Support (ENLS), a collection of protocols for the management of common neurological emergencies within the first hour of onset. Created by both neurointensivists and emergency physicians, ENLS aims to standardize emergency neurologic care, covering topics ranging from acute and ischemic stroke and intracerebral hemorrhage to status epilepticus, meningitis, and traumatic spine injury. It's backed up by CME-certified online training; the first wave of students was certified at the October 2012 Neurocritical Care Society meeting.