Stroke Recovery May Rely on Ambulance's Destination

Illinois legislation would establish network of specialist stroke centers


 
 

Judith Graham | | Wednesday, May 20, 2009


Phyllis Weiss awoke in the middle of the night, her arms flailing wildly. She tried to speak but couldn't. Her right side was paralyzed. Her husband called 911 and said she was having a stroke.

Hoping to stabilize her quickly, the paramedics took her to the hospital nearest her home in Winthrop Harbor. Now, Weiss said, she believes that was a mistake -- a neurologist didn't evaluate her -- and that she should have gone to a specialist stroke center, such as one at a hospital just across the border in Wisconsin.

On Tuesday, the Illinois Senate voted 58-0 to establish a network of specialist stroke centers in Illinois and allow ambulances to take patients to those facilities, bypassing nearby hospitals. The Illinois House previously passed the bill unanimously, and the legislation now goes to Gov. Pat Quinn.

The new system for stroke patients would mimic how emergency care is organized for people with other substantial trauma -- for instance, gunshot wounds. Generally, ambulances take these patients to hospitals with specialized trauma units instead of the nearest emergency room. Under the proposed legislation, similar arrangements would be made for stroke patients.

The goal is to minimize damage associated with this condition, the third-leading cause of death and primary source of disability in the U.S.

"We have abundant evidence that if patients are taken to a designated stroke center, they receive better care and have better outcomes," said Dr. Mark Alberts, a professor of neurology at Northwestern University's Feinberg School of Medicine.

That was the case for state Rep. Bob Biggins (R-Elmhurst), who collapsed at Chicago's City and County Building almost six years ago on his way to a meeting. After being rushed to Northwestern Memorial Hospital and given immediate treatment, he has recovered almost completely. Biggins is a sponsor of the proposed legislation.

Hospitals designated as stroke centers specialize in rapidly assessing patients and promptly offering recommended treatments. Early intervention prevents millions of oxygen-deprived brain cells from dying by breaking up clots or hemorrhages that impair blood flow.

"Every minute of a stroke, you lose about 2 million brain cells, and that's why speed is of the essence," said Dr. Ali Shaibani, a stroke expert at Northwest Community Hospital in Arlington Heights. Similarly, in trauma care there is a "golden hour" when interventions are most likely to have an impact.

Currently, when people have symptoms that suggest a stroke, they are taken by emergency medical services to the nearest hospital. Under the proposed legislation, each of the 11 EMS regions in Illinois would develop protocols for handling stroke patients.

In Chicago and several suburbs, it's likely that ambulances would be steered to "primary stroke centers" -- hospitals certified as having substantial expertise in treating stroke.

"This will profoundly change the way emergency care is delivered to potential stroke patients," said Mark Peysakhovich, senior director of advocacy for the American Stroke Association's Midwest operations.

Currently, there are 26 primary stroke centers in Illinois, mostly in the Chicago area. As many as eight hospitals expect to receive certification from the Joint Commission, a group that accredits health-care facilities, in the next few months. Another dozen are preparing to apply, said Kathleen O'Neill, director of quality initiatives at the stroke association's Midwest chapter.

In rural parts of the state, smaller hospitals may join networks of medical institutions that coordinate care of stroke patients. Also, someone having a stroke could be taken to an "emergent stroke center" offering basic treatments, stabilized there and then taken elsewhere for more advanced care.

Similar efforts to improve stroke care already have been launched in New York, Florida, Massachusetts, the Bay Area in California and cities such as Houston and Phoenix.

In a 2006 article in the journal Neurology, researchers in New York documented a doubling in the use of a crucial clot-busting drug, tissue plasminogen activator (TPA), after a stroke network was created. In Houston, TPA use for stroke patients more than tripled to 15 percent.

"Unfortunately, TPA remains widely underutilized," said Dr. Shyam Prabhakaran, director of the stroke program at Rush University Medical Center.

Illinois' plan is less prescriptive than many, allowing for regional flexibility, and that proved critical to the Illinois Hospital Association's support, said Howard Peters, the group's senior vice president. Initially, some hospitals were worried about being bypassed and losing patients.

For her part, Weiss, 59, is convinced that the change is needed.

She vividly remembers that night almost two years ago when, mentally alert but unable to control her body, she woke her husband and saw him recognize the terror in her eyes.

Weiss remembers hearing her husband ask the paramedics to take her to Lake Forest Hospital, about 40 minutes away. "That can't be done, she needs to go to the closest hospital to be stabilized," she recalls them responding.

She said that local hospital didn't call in a neurologist or administer TPA.

There's no way to tell if Weiss, who spent more than a year after her stroke learning how to talk again and use her right arm, was compromised by the hospital's care. But a month ago, she stopped by her local fire department with a request.

"I said if I have another stroke, I want them to transport me to a stroke center [hospital] 11 miles away in Wisconsin," said Weiss, who learned about the hospital after her stroke. "At least that way, I'll be taken care of by experts."

jegraham@tribune.com

26 primary stroke centers accredited in Illinois

Seventeen of the primary stroke centers are located in the Chicago region.

Chicago-area hospitals

  1. Evanston Hospital, Evanston
  2. Advocate Lutheran General, Park Ridge
  3. Northwest Community, Arlington Heights
  4. Alexian Brothers Medical Center, Elk Grove
  5. St. Alexius Medical Center, Hoffman Estates
  6. Central DuPage Hospital, Winfield
  7. Rush-Copley Medical Center, Aurora
  8. Edward Hospital, Naperville
  9. Advocate Good Samaritan Hospital, Downers Grove
  10. Loyola University Medical Center, Maywood
  11. MacNeal Hospital, Berwyn
  12. Advocate Christ Medical Center, Oak Lawn
  13. Ingalls Memorial Hospital, Harvey
  14. University of Chicago Medical Center
  15. University of Illinois at Chicago Medical Center
  16. Rush University Medical Center
  17. Northwestern Memorial Hospital

Rockford-area hospitals

Rockford Memorial Hospital

OSF St. Anthony Medical Center

SwedishAmerican Hospital

Central Illinois hospitals

BroMenn Regional Medical Center, Normal

Decatur Memorial Hospital, Decatur

St. John's Hospital, Springfield

OSF St. Joseph Medical Center, Bloomington

St. Francis Medical Center, Peoria

Methodist Medical Center of Illinois, Peoria

Becoming a certified stroke center

The American Stroke Association requires the following major elements for primary stroke center certification.

PRIMARY STROKE CENTER CHECKLIST

(Some checkpoints listed below)

- Does the hospital have acute stroke teams available 24/7?

- Does the hospital have written care protocols for emergency care of stroke patient?

- Are the emergency dept. personnel trained in diagnosing and treating acute stroke?

- Does the hospital provide laboratory services 24/7 with lab results to be completed within 45 minutes of being ordered?

- Does the hospital have outcome and quality improvement activities such as a database or stroke registry to track outcomes?

- Does the hospital conduct at least two annual programs for the general public on prevention, recognition and acute therapies?

SOURCES: American Stroke Association, Joint Commission

ALEX BORDENS AND KEITH CLAXTON / TRIBUNE




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