New Rules on Stroke
Care Center Networks May Save Lives

By Alicia Ault
Special to The Washington Post
Tuesday, April 1, 2008

In the event of a stroke, time is brain -- meaning the more quickly you recognize the problem and get proper medical treatment, the more likely you are to survive and minimize neurological damage. Increasingly, experts are concluding that means getting to the right hospital, and fast.

According to the American Stroke Association and many neurologists, the right facility is one that has been designated by a state agency or the Joint Commission (which accredits hospitals for quality and safety) as having the appropriate medical staff, the ability to quickly administer such diagnostic tests as computed tomography, and a potentially lifesaving drug, tissue plasminogen activator (TPA), which dissolves clots.

In some states, including Maryland, you don't have to worry about which hospital might be best. Ambulance crews who suspect a stroke are required to seek out a designated stroke center, unless the nearest one is an unreasonable distance away.

Now health officials in Virginia and the District say they are considering similar plans.

In March, Virginia Gov. Timothy M. Kaine signed a bill requiring local health officials to rush stroke patients to Joint Commission-certified primary stroke centers. Even though that law has not yet taken effect, emergency medical technicians typically route patients to stroke centers, said Paul Sharpe, trauma and critical care coordinator for Virginia's Office of Emergency Medical Services.

In Washington, Michael Williams, medical director of Fire and Emergency Medical Services, said he soon will issue a protocol requiring transport of suspected stroke patients to Joint Commission-certified stroke centers. That rule should take effect within a month or so.

Until those changes take place, Virginia and District residents might be wise to know the signs of stroke. If they suspect they're having a stroke, they then, directly or through a family member acting on their behalf, might ask to be taken to a specialized stroke center.

About 780,000 Americans have a stroke each year. The vast majority of strokes, 87 percent, are ischemic, caused by a clot that cuts off blood supply to the brain, according to the American Heart Association.

TPA, when given within three hours of the onset of a stroke, can increase the chances of a full neurologic recovery by at least 25 percent, said Robert Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, or MIEMSS. But the drug's associated risks, which include major bleeding in the brain, make it even more crucial to get care at the right facility, Bass said.

Finding a hospital that specializes in stroke care is even more important at a time when most are having trouble finding specialists to "take call" -- that is, to see patients at the hospital.

There are no hard numbers on the shortage, but the American College of Emergency Physicians reported in 2006 that three-quarters of emergency departments nationwide had problems finding specialists such as neurosurgeons to take call. The shortage was especially acute in orthopedics, plastic surgery and neurosurgery.

Being seen by a neurology specialist doesn't guarantee a good stroke outcome. But it is crucial to have a physician trained in stroke care, said Lee Schwamm, vice chairman of the neurology department and director of acute stroke services at Massachusetts General Hospital in Boston.

"Many people assume that stroke can be and is treated by anyone," he said, which simply isn't true.

Massachusetts was the first state to create a stroke care system, in 2004, partly because of the problem of getting on-call specialists. Under the plan, designated hospitals agree to have the appropriate diagnostics and staff (including neurologists on duty or available through telemedicine) and the ability to give TPA within three hours. They also agree to report on the quality of care.

In mid-2005, the state began requiring ambulances to take patients to stroke centers. Within a year, the number of stroke patients receiving TPA increased by 20 percent, Schwamm said. Now the goal is to increase the number of patients who get to the hospital in time, he added. Sixty-eight of the state's 72 hospitals have been designated as stroke centers by the Massachusetts health department.

Several states have followed Massachusetts's lead, including Maryland (in 2007), New York, New Jersey and Florida.

Maryland hospitals that apply for the stroke center designation are evaluated by a state inspection team. Hospitals can also be certified by the Joint Commission.

The nonprofit commission began certifying stroke centers in 2003. So far, 455 hospitals nationwide have received that designation.

Twenty-eight hospitals have received Maryland's five-year stroke center certification. These hospitals can evaluate stroke patients, give the initial treatment and, in most cases, admit patients directly to a special stroke unit in the hospital, Bass said. Since the program's establishment, the number of patients receiving clot-busting therapy has increased 20-fold, said John Young, stroke system coordinator for MIEMSS.

Like the District, Virginia does not have its own stroke center certification process.

Certification isn't a guarantee of superior care, said Ralph Sacco, chairman of the American Stroke Association's Stroke Advisory Committee and chairman of neurology at the Miller School of Medicine at the University of Miami. But it's an indicator that the hospital has the infrastructure in place -- and the commitment -- to deliver high-quality treatment, he and Schwamm agreed.

What should you do if you think you or a loved one are having a stroke?

The keys to a good outcome, Schwamm said, are knowing the warning signs, calling 911 immediately and getting to a primary stroke center.

He and others say they hope that every state adopts a system to require transport to those centers. It could be a lifesaving trip. ¿

Alicia Ault writes frequently for the Health section. Comments:health@washpost.com.