The regional stroke center, the Mid America Brain and Stroke Institute at Saint Luke's Hospital in Kansas City, Mo., is staffed by a team of six neurologists – who help outlying physicians evaluate patients, decide on treatment and transfer patients to Kansas City when necessary – plus two neurointerventional radiologists. The system includes a central phone number, nicknamed Doc One, that physicians within a 100-mile radius of Saint Luke's can call. A nurse, who gets patient information and relays it to the neurologist on call, staffs Doc One round-the-clock.
Ischemic stroke, the most common type, is caused by a blood clot that blocks blood flow to the brain. Giving intravenous tissue plasminogen activator (IV tPA) dissolves the clot and helps reduce permanent disability. It is the only approved treatment for acute ischemic stroke, but it must be delivered within three hours of symptom onset to be effective.
In this 30-month study, tPA was used in 18.2 percent (142 of 781) of ischemic stroke patients, which is significantly higher than in previous studies, researchers say. Of the patients treated with tPA, 70 percent (99 patients), were transferred from smaller hospitals within a 100-mile radius of the Kansas City regional stroke center.
"When we see that number on our beeper, we guarantee them a call back within five minutes," says Marilyn M. Rymer, M.D., medical director of the Saint Luke's Hospital Stroke Center in Kansas City. The Saint Luke's doctors then decide whether to transport qualifying patients by ground or air ambulance.
"We didn't expect the regional network to look so strong, although we knew we were intervening a lot. The fact that we were able to have such widespread impact over the region was really wonderful," Rymer says.
The American Heart Association recently issued new recommendations for acute stroke care, reaffirming the use of tPA and recommending that regional or local stroke programs be organized nationwide to expedite care and increase the number of stroke patients treated with tPA.
Many patients who would qualify for tPA don't get it, particularly at rural and suburban hospitals, Rymer says. The drug can trigger hemorrhaging (bleeding) in the brain, which might make some physicians hesitant to use it. In other cases, a hospital may lack equipment for brain scans to diagnose an ischemic stroke, or they may have the equipment but lack the staff to use it 24 hours a day, she says.
The Saint Luke's stroke team also used intra-arterial (IA) tPA treatment, which uses a catheter to deliver tPA directly to the spot in the brain where the artery is blocked. The still-experimental procedure extends the treatment window to six hours, but it requires the skills of a highly trained neurointerventional radiologist, Rymer says.
Of the stroke patients in the study treated with tPA, 36 percent arrived within the three-hour window with mild stroke symptoms and were treated with IV tPA; 25 percent arrived within three hours suffering from a severe stroke and received IV tPA followed by IA tPA. Thirty-nine percent who arrived in the three to six hour window with severe strokes received IA tPA alone, she says.
The overall death rate in the three tPA protocols was 12.7 percent (18 of 142 patients), and 9.2 percent of overall patients developed bleeding in the brain (symptomatic hemorrhage).
With the support of the regional center, 37 percent of the cases from the outlying hospitals were able to start IV tPA therapy before being transferred. More than half of the patients transported to Saint Luke's came from hospitals with fewer than 60 beds. Many of these patients would have been unlikely to get tPA without the regional system support, Rymer says.
The average times from onset of symptoms to treatment with the clot-buster was about two hours for the patients who got intravenous therapy and three and a half hours for those who had IA tPA.
"The two-hour time-to-treatment times in both IV tPA groups in this series could not have been accomplished without the initiation of therapy in the regional hospitals," the researchers write. "Many of these cases would have fallen outside the three-hour window if they had been transferred without initiation of treatment."
"A stroke center and central number that supports a regional response can have a significant impact on intervention and, more important, on outcomes – which translates to less disability and a better quality of life for patients no matter where they live within the region," Rymer says.
Co-authors are Duane Thurtchley, R.N., and Deborah Summers, R.N., M.S.N.
The study was supported with a grant from Genentech, Inc.
Editor's note: For more information on stroke, visit the American Stroke Association Web site: http://www.strokeassociation.org.
NR03-1062 (Stroke/Rymer)
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