Nearly 800,000 strokes happen in the United States each year.1 Like heart attacks, strokes are time-sensitive emergencies. Nearly two million neurons are at risk of permanent damage for every minute that elapses until the blocked artery is opened up and circulation is restored, meaning “time is brain” during a stroke.2
At Memorial Healthcare System in South Florida, a team of physicians and EMS professionals have transformed stroke care and more than halved the median door-to-needle time for the administration of IV tPA from 82 to 34 minutes from 2014 to Q1 of 2016.3
The team, led by a neurointerventional surgeon, an EMS medical director and a fire chief, overhauled the stroke care system by implementing the latest findings on effective prehospital stroke triage and in-hospital treatment to achieve better patient outcomes. This collaborative approach to stroke care allows EMS providers to communicate with specialists in real time, making it possible for the EMS team to activate the catheterization lab from the field, and helping create a transparent time-tracking system for all healthcare providers involved in a code stroke, which drives accountability and quality improvement.
Transformation of Stroke Care Motivated by Personal Experiences
For Peter Antevy, MD, a pediatric emergency physician at Memorial Healthcare and EMS medical director for several agencies in Broward and Palm Beach counties, improving stroke care is personal. His grandfather suffered a stroke in 2005, soon after Antevy moved to Florida.
“I was coming back home from Pittsburgh when he was taken to the hospital,” says Antevy. “They didn’t do the right thing; they didn’t take him to the cath lab. We ended up with my grandfather in a vegetative state for seven years.”
After that experience, Antevy carefully evaluated regional stroke treatment patterns and regularly followed up on stroke patients that his EMS team cared for. He began to realize that some hospitals were better equipped to treat stroke patients than others. He started advocating for Broward County’s EMS services to use a pre-hospital stroke assessment tool and to bypass primary stroke centers in favor of comprehensive stroke centers for patients with severe strokes, as they might require treatment in the cath lab.
Mark Ellis, interim fire chief with Hallandale Beach Fire Rescue, also in Broward County, was motivated to advocate for systemic change after his wife had a stroke nearly a decade ago. “She was 36 when it happened and in perfect health,” says Ellis. “She didn’t drink or smoke and was running seven miles every other day. They just assumed she couldn’t be having a stroke.”
Ellis says clinicians did not immediately recognize or treat his wife’s symptoms, even when he expressed concerns that she was having a stroke. While his wife made a near full recovery, the experience showed Ellis that many people with stroke symptoms do not receive appropriate treatment and timely evaluation, possibly costing them a chance at recovering.
Changing Perceptions of Stroke
Antevy and Ellis were not alone in their frustration with the response to strokes. Despite advances in stroke care, including FDA approval of the clot-busting medication IV tPA in 1996,4 treatment of acute stroke has not changed significantly in the past two decades.
One of the biggest challenges to improving stroke response is educating community members, EMS teams and other healthcare professionals to recognize stroke symptoms and take fast action. Very few stroke patients call 9-1-1 within the first hour of acute onset. Only about 8% of patients arrive at the hospital within three hours of symptom onset,5 the window for administering IV tPA. Recent clinical trials suggest this window could be extended up to 4½ hours in a subset of patients that meet specific safety criteria, although the FDA has not yet approved the longer timeframe.6
However, even when patients do arrive at the hospital, overall treatment rates remain abysmally low. Less than one third of patients receive IV tPA within the first 60 minutes of arrival,7 a timeframe referred to as the “golden hour” because of the potential for treatment within the first hour to have a significant, positive impact on the patient’s outcome.
“With a stroke patient, you don’t see the same acuity as with trauma: There’s no blood, there’s no guts,” says Ellis. “What you have is someone who is basically trapped inside their body, wondering why everything they normally do is not working anymore.”
Yet, treating stroke victims quickly is just as important as it is for trauma patients, says Ellis. “Although you can’t see it, their brain is suffering a traumatic injury,” he explains. “It’s just that these people’s trauma is simply from within.”
Making Evidence-Based Changes in Prehospital and Hospital Stroke Treatment
Although the majority of ischemic strokes (which make up 87% of all strokes8) are small-vessel blockages,9 as many as 34%–50% are caused by large-vessel occlusions (LVO).10 LVO strokes occur when a large vessel in the brain is blocked, and these types of strokes are considered more severe and more likely to result in death or lasting deficits.11 With these cases, the standard treatment, IV tPA, is far less effective.12
In 2015, results from a large study out of the Netherlands, referred to as the MR CLEAN trial, demonstrated the effectiveness of intra-arterial treatment known as mechanical thrombectomy to open up blocked arteries, in preventing permanent disabilities and saving lives in patients with LVO strokes.13 These findings made it imperative for healthcare professionals to quickly identify and treat patients who might be experiencing a stroke due to a LVO.
In cases of heart attack or trauma, prehospital notification of hospital-based care teams by EMS has been shown to reduce delays in treatment upon arrival to the ER. For stroke patients with an LVO, this is also important because stroke care involves many care teams—neurology, radiology, pharmacy, cath lab and anesthesia—all of which could benefit from early notification of patient arrival.
The ability for prehospital providers to identify LVOs in the field has the potential to transform how quickly stroke patients get the most appropriate treatment. Several studies have indicated that new stroke scales will be able to help triage stroke patients based on severity of symptoms.
“Historically, the old stroke scales just helped you identify a patient who was having a stroke but did nothing to gauge severity beyond that,” says Ellis. “But for a person suffering from a minor stroke versus a major stroke, their treatment options are different.”
For example, a new scale called the Rapid Arterial Occlusion Evaluation (RACE) has been shown to be effective in aiding in prehospital identification of large-vessel occlusion stroke.14 Patients with severe neurological deficits will have an elevated RACE score, which is considered to be predictive of their risk for having experienced LVO and can serve as a reliable trigger for mobilizing the acute stroke team members. Other scales, such as the Cincinnati Prehospital Stroke Severity Scale,15 have also been developed and shown to have potential for helping EMS providers identify LVO. As these scales are further tested, validated and refined, EMS systems and stroke centers can determine which is the best fit for their communities.
Primary vs. Comprehensive Stroke Centers
The designation of hospitals as primary or comprehensive stroke centers by the healthcare accreditation organization The Joint Commission was another big change in stroke care.16 The designations were intended to offer EMS and other healthcare professionals a quick way to direct patients to facilities that are appropriately equipped to treat stroke.
The American Stroke Association recognizes primary stroke centers as hospitals that are able to administer IV tPA in a timely fashion, have a stroke neurologist on-call 24/7, and have round-the-clock rapid imaging capabilities and a designated stroke unit, where stroke patients can be managed and monitored. Comprehensive stroke centers include all the capabilities of a primary stroke center, but also provide a neurosurgical/neurointerventional team on-call 24/7 to treat LVO strokes as well as bleeding in the brain, for example, in cases of a ruptured aneurysm.17,18
Depending on a patient’s location and the distance to the closest stroke center, patients may be taken to either a comprehensive or primary stroke center. However, in cases of suspected LVO strokes, it becomes imperative to get a patient to a hospital with neurointerventional capabilities, typically recognized as a comprehensive stroke center by state mandates or the Joint Commission.
Transforming Stroke Care at Memorial Healthcare
With stroke specialists anticipating the results of the MR CLEAN trial, as well as several additional positive landmark studies that followed, and a national push toward using the primary and comprehensive stroke center designations for appropriately triaging patients, Memorial Healthcare hired Brijesh P Mehta, MD, in 2014 to overhaul its stroke program.
A neurointerventional surgeon by training, Mehta came on as the medical director for stroke and neurocritical care. He had previously worked at the Massachusetts General Hospital (MGH) in Boston, where he led a clinical process improvement program and a successful project to streamline stroke care through workflow analysis and reform.
Soon after joining Memorial Healthcare, Mehta met with Antevy and Ellis, who were eager for someone to take the helm of the regional stroke systems of care and implement broad-scale changes. Mehta recognized many of the same challenges at Memorial Healthcare that he and his colleagues had faced at MGH. As a first step, he spent weeks investigating the reasons for delays in the stroke system.
“Our times to treatment for IV tPA and treatment in the cath lab were very long, and I found it personally unacceptable,” says Mehta. “If we call ourselves a comprehensive stroke center that means we expect patients to come here, but then we were not providing them the best care possible.”
Mehta brought the results of his analysis of the Memorial Healthcare stroke program and plans for reform to hospital executives, including the CEO, ER director, neurologists, radiology group and stroke coordinator, as well as prehospital response teams. His plan drew heavily from the American Stroke Association “Target: Stroke” initiative, which outlines proven steps to improve pre-hospital and in-hospital stroke care with the goal of delivering IV tPA within 60 minutes of hospital arrival.19
Mehta says building rapport within the hospital, as well as with EMS, was essential to achieving meaningful change in the system. Mehta held regular meetings with other teams involved in the stroke response and ran mock stroke scenarios to practice new protocols.
“It takes a lot of support from the [hospital] administration,” says Mehta. “You absolutely have to have a stroke champion in the ER and someone who is going to support you from the prehospital setting.”
As a part of the system overhaul, Mehta also led a concerted data collection effort, modeled on work he had done at MGH, with the goal of using data to drive continual system analysis and improvement.
“We started collecting times and metrics and reviewing those numbers at stroke committee meetings,” says Mehta. “We went case by case, figuring out where the delays were and how we could resolve these issues prior to the next stroke patient.”
A Mobile App Connecting Teams for Better Care
The next step in transforming the stroke care system at Memorial Healthcare was the introduction of a mobile platform, Pulsara, which enables better coordination of acute care teams via its apps for iPhone and Android.
Initially envisioned simply as a logistics tool, the new technology can help care teams understand critical delays and other recurring problems in the stroke process, says Mehta. First, it offers EMS teams the ability to quickly and easily trigger stroke alerts and activate the stroke team from the field. This key change allows stroke response to start among multiple teams simultaneously —EMS, the ER, radiology, neurology and the neurointerventionalist—rather than the traditional response where the patient is transitioned from one team to the next in a series of steps that take up valuable time.
The second key change is enabling a system for real-time feedback and conferencing by tracking the care process between and among each link in the stroke care chain. “We want accountability at each hospital that performs stroke treatment and the best way to do that is data transparency,” says Mehta.
However, Pulsara is not the panacea for better stroke care, cautions Antevy. Rather, the mobile app is one tool that helps hospitals detect, understand and work to correct delays in their stroke response systems.
“If you think one piece of technology is going to change everything, it won’t,” says Antevy. “What it does is basically expose all your weaknesses and then allows your team go back and uncover the deficiencies. But for hospitals that want to make a significant improvement, Pulsara is definitely a game changer.”
Tools like this can help put “much needed pressure” on hospitals, says Mehta, because they can really bring to light the inefficiencies in a complex system. “But the point is, we don’t just want a fancy app on our smartphones, the intended goal is to show EMS and our surrounding community that we are really committed to providing the best stroke care. In the treatment of acute stroke, patients only get one chance and thus being mediocre is not an option.”
Collaboration Is Key
Through the collaborative efforts of many teams and using new technology to help coordinate care, Memorial Healthcare was able to revamp and drastically improve its stroke response system in just two years. For example, the team was able to bring its door-to-cath-lab times down from an average of 184 minutes in 2013–2014 to 51 minutes in 2014–2015.3
These efforts have earned Memorial Heathcare the highest level of recognition from the American Stroke Association, the Target: Stroke “Elite Plus” designation at both of the system’s comprehensive stroke centers. The designation signifies that the hospitals each deliver door-to-needle (i.e., IV tPA) in less than 60 minutes for more than 75% of patients and in less than 45 minutes more than 50% of stroke patients.
The improvements made to the entire stroke system of care were possible because changes were grounded in evidence-based medicine, took advantage of technology and data transparency, and stemmed from a collaborative effort involving scores of dedicated healthcare professionals. Their passion for helping patients and willingness to look critically at their own performance means the next time someone’s grandfather or wife has a stroke, they are assured the most optimal care and the greatest chance at recovery.
Strategies for Improving Stroke Care
For more information and resources on strategies and tools for improving your system’s stroke response, see the American Heart Association/American Stroke Association’s Target: Stroke quality initiative at EMSWorld.com/12230032. The initiative offers EMS and hospital-based teams 11 best-practice strategies, as well as five time-interval goals aimed at helping teams lower door-to-needle time to within 60 minutes in 75% or more of acute ischemic stroke patients treated with IV tPA and eventually reach 45 minutes or less with 50% of patients.
EMS World Expo 2016
Peter Antevy, MD, Brijesh Mehta, MD, and Mark Ellis will present a four-hour workshop on Oct. 4 at EMS World Expo. “Building an Effective System of Care in Your Community” provides an overview of their experiences and strategies for effective integration of EMS in stroke care, with a demonstration of clinical assessment tools and technology. Breakfast and lunch will be provided. Attendance is limited to managers, directors, physicians, nurses, officers and above. Registration fee is $99 by 9/2; $125 after 9/2. Brijesh Mehta is also a presenter at EMS World Expo’s Opening Keynote on Oct. 5. Both the workshop and Opening Ceremonies/Keynote are sponsored by Medtronic.
1. Centers for Disease Control and Prevention. Stroke Facts. 2. Saver JL. Time is brain—Quantified. Stroke, 2006 37(1):263–266. 3. Mehta BP. Memorial Stroke Program presentation [Powerpoint slides]. Shared via e-mail June 16, 2016. 4. The Stroke Collaborative. Tissue Plasminogen Activator, What You Should Know. 5. Bambauer KZ, Johnston SC, Bambauer DE, Zivin JA. Reasons why few patients with acute stroke receive tissue plasminogen activator. Arch Neurol, 2006 63(5):661–4. 6. Cheng NT, Kim AS. Intravenous thrombolysis for acute ischemic stroke within 3 hours versus between 3 and 4.5 hours of symptom onset. Neurohospitalist, 2015 5(3):101–109. 7. Saver JL, Smith EE, Fonarow GC, et al. The "golden hour" and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset. Stroke, 2010 41(7):1431–9. 8. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation, 2016133:000-000. 9. Centers for Disease Control and Prevention. Types of Stroke. 10. English JD. Endovascular Treatment of Acute Ischemic Stroke. 11. A certain type of stroke increases risk of death and poor outcome. Research Activities, June 2010, No. 358. June 2010. Agency for Healthcare Research and Quality, Rockville, MD. 12. Skagen K, Skjelland M, Russell D, Jacobsen EA. Large-vessel occlusion stroke: Effect of recanalization on outcome depends on the National Institutes of Health stroke scale score. J Stroke Cerebrovasc Dis, 2015 24(7):1532–9. 13. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med, 2015 1;372(1):11–20. 14. Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke, 2014 45(1):87–91 15. Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke, 2015 46(6):1508–12. 16. The Joint Commission. Facts about Joint Commission stroke certification. 17. American Heart Association/American Stroke Association. Comprehensive Stroke Center Certification. 18. American Heart Association/ American Stroke Association. Primary Stroke Center Certification. 19. American Stroke Association. Stroke Phase II.: http://www.strokeassociation.org/STROKEORG/Professionals/Target-Stroke_UCM_314495_SubHomePage.jsp. 20. Mehta BP. Memorial Stroke Program presentation [Powerpoint slides]. Shared via e-mail June 16, 2016.
Susanna J. Smith is a journalist and content strategist, who focuses on the future of healthcare and new technologies, platforms, and care models that are reshaping the healthcare industry. She holds a master’s in public health from Columbia University. Follow her work at @SusannaJSmith and susannajoysmith.com.