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Brain Trust: The Brains Behind a Neurologic ED

Marcolini, Evie, MD

doi: 10.1097/01.EEM.0000531132.54497.b7
Brain Trust

Dr. Marcolini is an assistant professor of emergency medicine and neurology in the department of emergency medicine and the division of neurocritical care and emergency neurology and the medical director of SkyHealth Critical Care Air Medical Transport at Yale University School of Medicine. Follow her on Twitter @eviemarcolini. Read her past columns at http://bit.ly/EMN-BrainTrust.

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I had the privilege recently to interview Karen Greenberg, DO, who holds a unique position as the director of the neurologic emergency department at the Global Neurosciences Institute of Crozer-Chester Medical Center in Chester, PA. She is one of a kind, but we may be seeing more in her position with the recent progress in stroke and neurology and the collaboration of the two fields in primary and comprehensive stroke centers.

EM: What is your training?

KG: I did one year of internship and three years of residency with the University of Medicine and Dentistry of New Jersey with Kennedy Health System. One of our attendings, Michael D'Ambrosio, DO, was board certified in emergency medicine and neurology. He won numerous teaching awards, so I really had a lot of training with neurologic complaints in the ED.

EM: What inspired you to pursue neurology within emergency medicine?

KG: My mom fell from a golf cart going 20 mph in 2008. She sustained a skull fracture through the foramen magnum; subdural, subarachnoid, and cerebellar hemorrhage; and bilateral frontal contusions. She made a remarkable recovery with only mild cognitive deficits. I never thought neurologic emergencies would become my niche, but I figured it was meant to be when this neuro ED opportunity came about back in 2011. It was my way to give back.

EM: What is the structure of your department?

KG: We have a dedicated space with four beds within the ED itself, and it can expand into two resuscitation bays for critical cases. I work with a dedicated ED nurse and ED tech. We see patients with any type of neurologic complaint: headache, seizure, dizziness, altered mental status, head injury, and, of course, stroke. I work closely with CT, MRI, and our neuroradiologists to obtain the studies we need.

EM: How did this department come to be?

KG: Erol Veznedaroglu, MD, recognized the benefits of a multidisciplinary team working in a focused model for neurologic ED patients. He created the Global Neurosciences Institute (www.gnineuro.org) that includes the Neuro ED, neurologists, neurosurgeons, neuroradiologists, pain specialists, neurocognitive specialists, and rehabilitation specialists. The ability for EPs to focus on neurologic complaints and not have to worry about chest pain or abdominal pain waiting to be seen is unique but not dissimilar to pediatric, trauma, and geriatric EDs.

EM: The neurologic patient takes longer to evaluate, and what are the benefits to having the time to do that?

KG: The greatest by far is giving these patients the time they deserve. I recently spent a significant amount of time doing a detailed neuro exam on a 78-year-old with pain behind her right eye and mild headache. I had the luxury of time to spend focusing just on her neuro exam, which helped to accurately and expediently arrive at her diagnosis.

Our neurosurgeons also have a number I call with any neurosurgical emergency, including acute ischemic stroke. When I call their 800 number, I speak directly to a neurosurgeon or the fellow. If I need help ordering the correct imaging (CTP/CTA vs MRI/MRA) or whether to give alteplase, we work together. It is a unique relationship between EPs and neurosurgeons.

We also published an article that showed door-to-needle (DTN) time was 35 minutes in an acute ischemic stroke patient seen in the Neuro ED compared with 83 minutes in the main ED. (Am J Emerg Med 2015;33[2]:234; http://bit.ly/2Dg6y67.) Eighty-nine percent had DTN under 60 minutes if seen in a Neuro ED compared with 31 percent in the main ED. Average discharge NIH stroke score was 2 for Neuro ED patients and 6 for main ED patients. Significantly more patients were ultimately discharged home after their hospitalization if evaluated in the Neuro ED vs. the main ED.

EM: Do you think this model is appropriate for every ED?

KG: It's not for everyone. Credit goes to Crozer for recognizing the specialized resources that go into creating this. I think EDs that would benefit most are the hub hospitals that have a lot of spokes.

Primary and comprehensive stroke centers have a lot of pressure to stay certified and to meet the standards from the Centers for Medicare and Medicaid Services, the Joint Commission, and the American Heart Association. Most EPs don't know the stroke metrics. I've sent out surveys, and only 20 percent of EPs knew what the CMS STK-4 metric was that is specific to ED care and tied to reimbursement. The Neuro ED staff knows what these core stroke metrics are to meet the goals.

EM: How does the Neuro ED affect EM practice and residency training? Did EPs push back about giving up part of their practice to a subspecialist?

KG: There was initial resistance from the main EPs. As EPs, we are proud and confident that we can handle everything coming through the doors without knowing anything about a patient. It is difficult for EPs to hear that a Neuro ED “specialist” will see the neuro complaints exclusively, but eventually it worked out.

We became very popular when we told EPs that someone else would see all the headache, dizzy, weakness, and stroke patients. Neuro complaints aren't always fun or easy. My team and I became a resource to them. I have shared my knowledge of how to get better DTNs, how to order advanced imaging, and when to consult neurology vs neurosurgery. It is also a great recruiting tool to say residents will get top-notch training in neurologic complaints. The Neuro ED runs 10 to 12 hours a day until we can staff it 24 hours a day, so the main ED sees plenty of neuro cases during our off hours.

EM: The Neuro ED is certainly an advance that seems to be helping patients, faculty, and residents. It's an exciting time for it as we see landmark advances in neurologic imaging and stroke care. Thank you for sharing your experience with us.

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