Utah working to improve identification, treatment of strokes
When suspected stroke patients arrive at St. Mark's Hospital, they are rushed to a room -- followed by a purple suitcase.
Inside is the hospital's stroke kit, which includes everything doctors and nurses need -- from vials for blood draws to orders for brain scans -- to assess and start treating patients who are having a "brain attack."
Treating strokes is all about time: Oxygen has been cut off to the brain and blood flow needs to be restored. Every minute lost brings a patient closer to disability or death.
In the race against the clock, the Utah Department of Health is helping hospitals who want to boost their care by following national protocols and streamlining assessment and treatment.
St. Mark's is the first to sign up for the state's new stroke network, followed by Park City Medical Center.
Now, instead of relying on memory for what to do and hunting down supplies, St. Mark's staff unzip the suitcase and start asking questions.
"Any time we can standardize care, it is better for us and it's better for patients," says Julie Fox, medical director of St. Mark's emergency department, the first stop for a stroke patient.
She compares the protocols to preflight checklists used by pilots. "It helps us ... make sure everything gets done properly and in the right order," she said. "Absolutely, it's improved care."
Stroke is the third leading cause of death in Utah, behind heart disease and cancer, and it hospitalizes about 3,000 people a year. Nationally, it is the leading cause of long-term disability.
Utah has five hospitals accredited by The Joint Commission as primary stroke centers: University of Utah Hospital in Salt Lake City, Intermountain Medical Center in Murray, Utah Valley Regional Medical Center in Provo, McKay-Dee Hospital in Ogden, and Ogden Regional Medical Center.
But they are major centers, leaving residents in other areas without the same level of care.
The new stroke network builds on that system, urging hospitals throughout the state to sign on as a "stroke receiving facility."
Paramedics with potential stroke patients will bypass nonparticipating hospitals to get them to the closest, best-equipped centers, whether they are one of the new receiving facilities or the Joint Commission hospitals.
"There's no reason why a small community hospital with some protocols and dedication to the process can't deliver the same degree of stroke care that you would get at a major center," said Peter Taillac, who oversees the network as medical director of the state's Bureau of Emergency Medical Services.
Participating hospitals agree to training and to follow national guidelines. They must also designate a stroke coordinator; have an all-hours emergency room and lab; access to a CT scan 24 hours a day with specialists available to read them; and access to a neurologist.
They must also track how they've cared for patients, including the time it takes to see a doctor and get a scan.
Taillac said "many" Utah hospitals don't follow a protocol that treats the attack as an emergency. Instead, they might treat stroke patients like any other ER patient who doesn't appear to have life-threatening problems. "Patients might sit in the waiting room," he said.
That isn't the case in stroke centers.
From the time a potential stroke patient enters St. Mark's, where triage nurses were also trained, ER doctors have 10 minutes to determine whether the confused and possibly clumsy patient truly had a stroke or is suffering from something else, such as diabetic shock.
Doctors ask their age, what month it is, assess if they have any facial paralysis, listen to hear if their speech is slurred and if they can read. They also show them a picture of a woman washing dishes as the sink overflows and a boy who is about to fall while reaching for cookies.
"Somebody who's having a stroke may look at that and they may not be able to recognize the subtleties of what's going on," said Fox, the ER director. "They may say, 'There's a lady and kids.'"
All the questions are in a sealed purple folder in the purple suitcase (the hospital randomly chose purple as its stroke code). If doctors diagnose a stroke, the patients are immediately sent for a CT scan, which must be read in 20 minutes, Fox said.
The rush is to find as many patients as possible who would qualify for the clot-busting drug tissue plasminogen activator (TPA), which can reduce the effects of stroke and reduce permanent disability, according to the American Heart Association.
But it can only be given to patients having a ischemic stroke, which are the most common kind, occurring when a blood vessel in the brain is blocked. Injected into the blood stream, TPA must be given within four and a half hours of when stroke symptoms began.
In 2005, just 1.5 percent of ischemic stroke patients in Utah received TPA, according to the state health department. The drug is not without risks: it will cause a brain hemorrhage in 6 percent of patients, Taillac said.
Some estimates show just 5 percent of stroke patients would qualify for TPA. Those who don't are beyond the four-hour window, are bleeding in the brain, have other health conditions or their stroke symptoms are improving.
Still, all patients benefit from speedy diagnosis, proponents say. Patients whose stroke is caused by a hemorrhage will get quicker treatment to reduce brain swelling or control blood pressure, for example.
St. Mark's estimates it cost $125,000 to boost its stroke capabilities. Hospital CEO Steve Bateman said cost wasn't a factor: "We knew patients' lives would be saved."
Strokes happen to children, too
Primary Children's Medical Center, which treats 15 to 20 children a year for strokes, is exploring whether it will become a "stroke receiving facility" in the state's new network.
Children generally do not have strokes because they are overweight and have high cholesterol, which lead to adult strokes, says pediatric neurologist Susan Benedict. Instead, pediatric strokes are usually caused by birth defects, such as congenital heart disease, blood disorders such as sickle cell anemia, trauma and infections.
She said a tear in an artery can happen after a relatively minor accident, like falling off a bike, causing the child to have a stroke days later. Or a previous infection, including chicken pox, might cause a weakness that leads to a stroke, Benedict said.
One challenge in treating children is that parents don't recognize stroke as a possibility; also, the clot-busting drug used on adults hasn't been approved for children, she said.
But even if children aren't eligible for the drug, "there are things we can do in their stroke management to provide them with a better outcome," Benedict said.
Children are more likely than adults to have a seizure during a stroke, but other symptoms are the same, such as slurred words and facial paralysis.
Since a child's brain is still developing, it has a greater chance of healing, according to the National Stroke Association.
Still, Benedict said many children will struggle to communicate and move one side of their body. Some will have behavior problems, such as impulsivity.
» Being older than 55.
» Being African-American or Hispanic.
» Having family history of stroke.
» Having a previous stroke, heart disease or abnormal heart rate.
» Having high cholesterol, high blood pressure or diabetes.
» Being physically inactive or overweight.
Source: Utah Department of Health
» Sudden numbness or weakness of the face, arm or leg, especially on one side.
» Sudden trouble seeing in one or both eyes.
» Sudden trouble walking, dizziness, loss of balance, or coordination.
» Sudden severe headache with no known cause.
» Sudden confusion or trouble speaking.
Source: Utah Department of Health
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