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New Data on Stroke Center Referrals Prompt A Call for Better Resources to Avoid Treatment Delays

ARTICLE IN BRIEF

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Investigators in Spain reported that patients that were transferred to stroke centers received neurologic attention sooner, were more frequently treated with tPA, and had a better clinical outcome than patients who first went to a community hospital.

When there is a burn victim or a gunshot wound, emergency medical services personnel know where to take the victims, because of the trauma level system. The worse the challenge, the more the medical resources provided and the higher the level of trauma care needed.

But when it comes to stroke patients, care is more disorganized. Not all hospitals have stroke centers and emergency room staff who are comfortable giving tissue plasminogen activator (tPA). Because time is of the essence in stroke care, and because patients often do not recognize they are having a stroke, any delay once that emergency call is made could have long-term effects.

An April 8 study in Neurology by a team of investigators in Barcelona reported on the effects of a “stroke code” system, which allows immediate transfer of patients with acute stroke to a stroke center staffed 24/7 by trained personnel. The multi-level system can be set into action from community hospital to emergency department and to the stroke center.

OUTCOMES AFTER REFERRALS

Investigators, led by Natalia Pe?rez de la Ossa, MD, of the Stroke Unit at the Hospital Universitari Germans Trias and Pujol affiliated with the University Autònoma of Barcelona, studied 261 consecutive patients who arrived through the “stroke code” system, and found that they received neurologic attention sooner, were more frequently treated with tPA, and had a better clinical outcome than patients who first went to a community hospital.

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DR. GRETCHEN BIRBECK: “Theres a tradeoff between rapid care in terms of getting to any hospital quickly and getting to a stroke center. If the center is more than an hour away, go to the nearest hospital and aim for a transfer.”

Forty-five percent of the patients had a good outcome at discharge and 71.5 percent were treated at the stroke center within three hours of symptom-onset.

In an accompanying editorial, Jose I. Suarez, MD, director of vascular neurology and neurocritical care at Baylor College of Medicine in Houston, and Thomas A. Kent, MD, PhD, pointed out limitations of the study — it was not a randomized controlled trial and the authors did not include long-term outcomes or quality of life measures. But, they wrote, the study demonstrates that it is “feasible to improve practice if patients are managed in a specialized stroke center or the initial responders are trained EMS personnel.”

STROKE CENTER EXPERTISE

Several other stroke experts agreed. “There's a tradeoff between rapid care in terms of getting to any hospital quickly and getting to a stroke center,” said Gretchen Birbeck, MD, director of the International Neurologic and Psychiatric Epidemiology Program at Michigan State University. “If the center is more than an hour away, go to the nearest hospital and aim for a transfer.”

“At every level of care, the provider is more accustomed to stroke — from the CT scanner to the nurse in the emergency department who knows to give stroke patients priority, and the stroke care neurologists who are in the ER right away,” Dr. Birbeck said.

“There are three main reasons stroke care is not what it could be,” said James Grotta, MD, chairman of the department of neurology and director of the stroke program at the University of Texas Medical School in Houston.

“Patients don't get to the hospital in time, and when they do, physicians are unprepared to give tPA or the hospital is not prepared,” said Dr. Grotta. “Or they're taken to the wrong hospital.

Dr. Birbeck said there are many explanations behind those obstacles. Delivering stroke care in New York City is different from creating a stroke network in rural Nebraska, for example. There could also be cultural barriers — patients may simply be used to going to their rural hospital and not willing to drive an hour or two to a primary care center.

Then there are political obstacles, because some hospitals might be hesitant to give up a patient.

Editorialist Dr. Suarez noted that a CDC Morbidity and Mortality Weekly Report on prehospital and hospital delays after stroke onset in the U.S. for 2005–2006, found that 48 percent of patients with stroke arrive within two hours of symptom onset, and only half of them come by ambulance.

Often, victims and their families are not aware of stroke symptoms, and do not react in time. But physicians said organizations, such as the Brain Attack Coalition and the American Stroke Association, are making strides in getting the word out, from small communities to metropolitan urban areas.

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DR. JAMES GROTTA: “There are three main reasons stroke care is not what it could be. Patients dont get to the hospital in time, and when they do, physicians are unprepared to give tPA or the hospital is not prepared. Or theyre taken to the wrong hospital.”

HOSPITAL COORDINATION

Another issue is hospital coordination, said Marilyn Rymer, MD, medical director of the St. Luke's Brain and Stroke Institute and professor of medicine at the University of Missouri at Kansas City School of Medicine.

Although it sounds like a good idea to put a stroke center in every hospital, not every center has the equipment or the staff, she said. So Missouri has worked out a straightforward transfer plan of action.

“If someone arrives in a rural hospital with a stroke, they have one phone number to use, and it hooks the ER up with a stroke neurologist and they make the decision about treatment,” said Dr. Rymer.

In Texas, hospitals have stroke levels that parallel trauma levels. “We sent a letter to each hospital, asking them to tell us what level they were” regarding stroke treatment, said Dr. Grotta. “It was basically, ‘Tell us which one you are and we'll believe you and tell the paramedics to divert patients to the highest level of care as long as there isn't more than a 15 minute delay.’”

Those interviewed here said the medical community needs to step up and start creating a community network for stroke care, from EMS education to telemedicine coordination. But patients and their families also need to be their own advocates, starting with knowing the stroke symptoms and learning what hospitals nearby have primary stroke centers, said Dr. Rymer.

“Patients need to speak with their doctor and ask if the hospital treats patients with tPA and, if so, how often does it happen?” she said. They also need to ask what hospital they will be transferred to if they need more intervention, she added.

Dr. Suarez said the next step is to evaluate the current system and study the impact primary stroke centers are having on both long- and short-term outcomes. He encouraged patients and their families to write their politicians to encourage a stroke system of care.

“We know primary stroke centers give better care and implement all the core measures that we think are good,” he said. “But we don't know what the real impact is on patient outcome.”

REFERENCES

• Perez de la Ossa N, Sanchez-Ojanguren J, Davalos A, et al. Influence of the stroke code activation source on the outcome of acute ischemic stroke patients. Neurology 2008;70:1238–1243.
    • Suarez JI, Kent TA. Editorial: The time is right to improve organization of stroke care. Neurology 2008;1232–1233.
      • Centers for Disease Control (CDC). Prehospital and hospital delays after stroke onset-United States, 2005–2006. Morb Mortal Wkly Rep 2007;56:474–478.