Minutes count in treating stroke. In recent years a number of hospitals and clinics have made important progress in reducing the time it takes emergency rooms to diagnose and treat apparent stroke victims.
Locally, an impressive advance was reported late last year, when Kaiser Permanente announced that it has cut its response time in half for dealing with stroke victims at all 21 of its Northern California hospitals.
Average treatment time for a patient arriving at these hospitals is now 34 minutes, Kaiser reported.
This easily meets the national standard of treatment within 60 minutes, as recommended by the American Heart Association and American Stroke Association. (The two associations are typically listed separately although the latter is a division of the former.)
In a study published in the journal Stroke, Kaiser reported that 87% of its stroke patients were treated in 60 minutes or less, 73% in 45 minutes or less and 41% in under 30 minutes.
Last week, the American Heart Association and American Stroke Association recognized Kaiser’s Northern California rapid-response stroke program by giving achievement awards to each of its hospitals.
Stroke occurs when there is inadequate blood flow in the brain, and cells begin to die. The longer treatment is delayed, the more cells will be lost.
According to the American Heart Association and American Stroke Association, 10% of brain function may be lost every 30 minutes without treatment.
Some 130,000 Americans die of stroke each year, with nearly half a million experiencing non-fatal strokes.
Most strokes – nearly 90% – are caused by blood clots. These are called ischemic strokes. The only medication approved by the federal Food and Drug Administration to treat them is intravenous r-tPA, also known as alteplase, which is administered to dissolve the clots.
It is vital for emergency teams to distinguish ischemic strokes from the less common hemorrhagic strokes, which can be made worse if treated with clot-dissolving drugs.
Kaiser calls its program EXPRESS, for EXpediting the PRocess of Evaluating and Stopping Stroke.
The program is now two years old. It relies on both modern technology and carefully orchestrated teamwork to achieve consistent results with large numbers of patients over a wide geographic area, according to Mai Nguyen-Huynh, the program's director.
Nguyen-Huynh is a vascular neurologist and lead author on the Stroke paper. In an interview, she said that Kaiser has stroke neurologists on duty from seven in the morning until midnight, able to examine a local patient in person or a distant one remotely using robotic high-resolution telemedicine systems.
The EXPRESS program will move to 24 hours per day once Kaiser is able to hire additional required medical personnel, she said.
Members of Kaiser’s stroke response teams – doctors, nurses, IT specialists -- literally have role cards with individual instructions and responsibilities, Nguyen-Huynh said. The result is a consistent, standardized level of care that can be repeated whenever stroke is suspected.
The Stroke article’s co-author, Jeffrey Klingman, who is chair of the chiefs of neurology for Kaiser in Northern California, said that one key to speeding up stroke response was learning to carry out activities in parallel rather than sequentially.
The idea is not original with Kaiser – it is sometimes called the Helsinki model for a much imitated fast-response program pioneered in Finland – but applying it successfully to 21 hospitals across northern California is a substantial organizational feat, as indicated by the awards from the American Heart Association and American Stroke Association.
One surprising finding from the Kaiser stroke program is that non-Kaiser patients are being treated as rapidly as patients who are Kaiser members, Nguyen-Huynh said.
“We really thought that might be a hangup. If a non-Kaiser member comes in and we don’t know their past history and couldn’t access their medical charts, did that slow things down?
“It was a legitimate question, but it turns out, there was no difference. Everyone was just so focused on the goal: has this patient had a stroke, does this patient qualify for a treatment? Then get going! Everything else just falls in place.”
Another surprise, she said, is that during 2016, Kaiser’s stroke response program was as successful for stroke victims in their 90s as for those who are younger.
The program treated 62 patients that year, and Nguyen-Huynh is quick to acknowledge that larger numbers will need to be studied before reaching firm conclusions.
In addition, as she reported a medical conference in Southern California earlier this month, patients in their 90s often have other conditions (called co-morbidities) that make hospital stays longer or riskier – atrial fibrillation, for example, or high blood pressure.
Once those added conditions were accounted for under the 2016 program, however, treatment returned 90-year-old patients to their pre-stroke lives as successfully as it did patients in their 80s, 70s and younger, she said.