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Hospitals putting a focus on stroke; N.J. designating treatment centers

NEWARK, N.J. At home in Pompton Lakes one cold day last January, Louis Milone suddenly realized he couldn’t move his left side. Soon his words began to slur. His wife immediately called 911.

When the ambulance arrived, crew members asked Christine Milone where she wanted her husband to be taken.

“I told them Chilton, mostly because it was the closest hospital and we were scared, not knowing what was wrong with him,” she recalled, referring to Chilton Memorial Hospital in Pompton Plains.

It was a lucky call. The hospital is ranked among the top 5 percent of hospitals in the nation for stroke care by HealthGrades, a leading national independent hospital ratings firm.

At Chilton, Milone was quickly assessed by personnel trained in stroke care in the hospital’s emergency department and given a clot-busting drug, commonly referred to as tPA, to help reverse the symptoms. Within three hours, he was able to lift his left arm and leg. Twenty-four hours later, he could get out of bed and even stand with assistance.

“I think the hospital we chose made the difference,” said Milone, 48, who is today about 90 percent recovered from his massive brain attack.

Not every hospital emergency room, however, is equipped to effectively treat strokes, the nation’s No. 3 killer and a leading cause of long-term disabilities. Many lack the personnel, expertise and even confidence to make the kind of split-second decisions that could save a life or greatly reduce a stroke’s debilitating consequences.

New guidelines issued last month by the American Heart Association/American Stroke Association now recommend that EMS crews “bypass hospitals that do not have resources to treat stroke and go to the closest facility” capable of treating these patients.

“I think hospitals should get out of the stroke business if they aren’t committed,” said Richard Hodosh, chairman of the association’s stroke advisory board and director of the Brain and Spine Institute for Atlantic Health, which includes Morristown and Overlook hospitals.

New Jersey EMS officials concede stroke is still a “gray” area, hardly as clear-cut as dealing with a burn or trauma patient, for whom there are already designated treatment centers.

“There are time constraints to treating these people and the goal should be to achieve the best outcome for the patient,” said Steven Cicala, the New Jersey representative to the National Association of Emergency Medical Technicians and director of EMS at Holy Name Hospital in Teaneck.

State health officials – aware of the current system’s shortcomings – are in the process of designating hospitals around the state as either primary or comprehensive stroke centers, depending on the level of care they provide.

In order to qualify as a primary stroke center, a hospital – at a minimum – must have a stroke team available within 15 minutes of a patient’s arrival any time of the day or night. The hospital also must have neurosurgical and emergency department personnel trained in the diagnosis and treatment of stroke available around the clock.

Dedicated beds staffed by doctors and nurses experienced in caring for acute stroke patients also are a requirement, as is the ability to provide rehabilitation services.

“We need to do better than what we’re doing now for patients,” said State Health Commissioner Fred Jacobs. “There are variations in how well hospitals can manage stroke, and the intent is to have places that are accessible that can provide the highest level of care.”

Although applying for the new designation is voluntary, Jacobs said he believes it will result in more hospitals statewide able to offer patients a better chance for survival and recovery.

“The better you recover initially, the more likely you are able to participate in an aggressive rehabilitation program that might get you to a higher level of function,” said Uri Adler, who directs the stroke program at Kessler Institute in West Orange.

To qualify as a comprehensive stroke center – the highest level of care available – a hospital must meet all the requirements of a primary center, plus have a neurosurgical team in place capable of handling complex cases, a neuro-radiologist on staff, as well as the most sophisticated imaging equipment.

Five hospitals have so far applied to become comprehensive stroke centers, though only one – Overlook in Summit – has been granted that designation, said health department spokeswoman Marilyn Riley. In addition to having an acute stroke team available 24/7 with the ability to perform procedures like retrieving blood clots directly from the brain, Overlook also has its own helicopter landing pad dedicated to stroke patients.

“Response can mean the difference between life and death and between severe disability and minor disability,” said Shalini Bansil, medical director of Overlook’s stroke center.

The other hospitals that have applied for comprehensive designation are Robert Wood Johnson University Hospital in New Brunswick, Morristown Memorial Hospital, JFK Medical Center in Edison and St. Joseph’s Regional Medical Center in Paterson, according to Riley.

Chilton officials, meanwhile, said they plan to apply to become a state-designated primary stroke center. The hospital has signed an agreement with Atlantic Health (Morristown and Overlook) to have stroke patients who require additional care transferred to those facilities.

Other hospitals that have already applied for primary designation are Robert Wood Johnson-Hamilton, University Medical Center in Princeton and Kennedy Health Systems-Voorhees, Riley said.

“We have created a two-tiered system for stroke care so that no patient would ever be more than a 20-minute ambulance ride away from a hospital able to provide the best care,” said Sen. Barbara Buono (D-Middlesex), who wrote the bill creating the designations after she saw her mother left severely disabled by a stroke seven years ago.

Now 14 months into his recovery, Milone credits treatment with the drug tPA for his rapid improvement. While he still tires easily and has occasional problems finding the right word, he knows he would have been far worse off without it.

The drug is only effective on the type of stroke Milone suffered – known as ischemic stroke – and cannot be given in cases where attacks are caused by bleeding in the brain. It must be administered within three hours after symptoms begin, with the best results coming the sooner it is given.

While tPA can break up the blood clots that cause about 80 percent of all strokes, it is given to only about one in 10 eligible patients, studies have shown.

Some emergency room doctors are still hesitant to use the FDA-approved drug – especially if they don’t have neurology backup – because it does carry about a 6 percent risk of cerebral bleeding. But the neurologist who treated Milone at Chilton said the benefits far outweigh the risks.

“It should be a standard of care, not optional,” said Eyad Nayal. “When it works, it works a miracle.”