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State Policies and Good Intentions Cause an Influx of Stroke Patients

By: | Tags: , , , | January 27th, 2020

States like Colorado, Florida, New York and Massachusetts have changed state policies to instruct EMS to take stroke cases straight to thrombectomy qualified stroke centers. 

The shocking statics: According to the American Stroke Association, stroke is the second leading cause of death worldwide and the leading cause of disability. On average, someone dies of a stroke every 3.7 minutes, which adds up to around 389.4 deaths from stroke each day in the United States alone.

The push for thrombectomy:
Most states still rule that Emergency Medical Services (EMS) should take stroke victims to the nearest stroke certified facility whenever possible. However, this practice may be short-lived. Policies that dictate how EMS handles stroke patient transport change from state-to-state and some of these changes seem to challenge the American Heart Association’s (AHA) recommendation.

Why the sudden change?
According to EMS1.com, the recommendation of transporting stroke patients to the nearest stroke certified facility came before the discovery of thrombectomy, the procedure that can remove blood clots from the brain during a stroke episode. New research on the procedure has provided physicians with more information that patients who suffer a severe stroke have a much better chance of survival without some of the long-term impairments such as loss of visual-perceptual skills, emotional functioning, and personality changes. It is because of this research that many states are working to change EMS policies to ensure that the most critical stroke patients get the thrombectomy surgery they need as quickly as possible.
   

 “Neurological professional groups recommend that if a comprehensive stroke unit is within a two-hour flight or drive, then severe stroke patients should be transported there, even if a lower-level stroke unit is closer.” – EMS1.com

Another initiative that is gaining momentum and has a hand in states passing these new policies is Get Ahead of Stroke. It is relevant to note that this campaign was founded by the Society of NeuroInterventional Surgery and is backed by industry leaders such as the National Alliance of Pediatric Stroke and the National Association of Emergency Medical Technicians. Their aim is to get all 50 US states on board with their message:

 “Since 2016, Get Ahead of Stroke has worked across the country, creating state legislative changes focused on bringing severe stroke patients to a Level 1 stroke center, where they would have access to a specially trained neuroendovascular care team that can help them 24/7/365.” – GetAheadofStroke.com

The push behind the Get Ahead of Stroke campaign is to transport the stroke patient to the right place, in this case, a Comprehensive Stroke Center (CSC), the first time so that time is not wasted. This is the suggestion for all severe stroke victims, whether the patient is a thrombectomy candidate or not. 

Currently in the US, according to the Joint Commission and the DNV, there are approximately 273 accredited Comprehensive Stroke Centers, compared with 1200+ primary and stroke-ready hospitals that are available to treat stroke patients. Although Comprehensive Stroke Centers have the surgical abilities to treat stroke, the latest state and organizational push to have EMS bypass a Primary Stroke Center (PSC) and go straight to a CSC may even test the limits of the most capable facilities. State and Get Ahead of Stroke initiatives promote the importance of EMS education to vet stroke patients properly, however, due to the lack of training materials available, there is some concern among PCS’s that perhaps a “better safe than sorry” approach from EMS may start to develop.

The states who have adopted the legislation: Colorado, Florida, Massachusetts, Ohio, and New York share the statistic that stroke is the fifth leading cause of death in these states. In addition, these states have implemented a state policy that EMS should take stroke patients to the nearest thrombectomy-qualified stroke center. The length of time varies from state to state, but generally, the maximum amount of time in these particular states is within 2 hours of the patient’s location.

The inevitable issue:
The healthcare business is about saving lives. If a Comprehensive Stroke Center is where the patient needs to be, EMS should transfer the patient there. The concern is that most Comprehensive Stroke Centers are already struggling to retain the proper number of neurologists on staff without overworking their physicians. Often, we’ve heard from our partner hospitals, before hiring TeleSpecialists, that they’ve had to call a neighboring CSC to assist their facility because they didn’t have adequate staff. The shortage of physicians and patient transfers only furthers the delay of treatment to the patient, keeping in mind that the initial CSC could be up to two hours from the patient’s location. 

With the thought “time is brain” being top of mind, facilities still face time obstacles. How does the patient get the treatment they need without the risk of long-term damage? 

Worst case scenario:
Consider the tragic story of a young mother in Wisconsin who suffered a stroke. EMS transported her to a Level 1 stroke center. The facility was at capacity and had to turn the patient away. Consequently, the patient died.
Although good intentions drive the Get Ahead of Stroke Campaign, state policies will inevitably, if they haven’t already, cause an influx of stroke patients, and consequently, every CSC will need to have the neurologist capacity to handle the additional volume.

How will your facility keep up with the sudden influx of stroke patients coming through your hospital doors?

The solution:

The neurology and emergency room staff need the most robust, data-driven stroke program in place that is consistent with providing the same quality care at 0200 as it would at 1400 hours. The facility would need to have neurologists ready 24 hours a day, 7 days a week, 365 days a year and be able to accommodate concurrent stroke alerts without delay.

TeleStroke is recognized by the AHA/ASA as a service that should be supported as a method to ensure adequate 24/7 coverage and care of acute stroke patients. (see excerpt from the 2019 update from the 2018 guidelines for early management of acute ischemic stroke below)

Nattasha Acevedo, MD

Dr. Acevedo received her medical degree from the Ponce School of Medicine in Puerto Rico and did her neurology residency at Montefiore Medical Center in New York. She went on to do a clinical neurophysiology fellowship at Emory School of Medicine in Atla nta, Georgia and then joined private practice in Fort Myers, Florida. She currently resides in San Juan, Puerto Rico. She likes running, paddle boarding and spending time with family.
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Bernadette Borte, MD

Dr. Borte received her medical degree from St. Matthew’s University School of Medicine in Grand Cayman. She completed her neurology residency at the University of Iowa Hospitals and Clinics in Iowa City, Iowa. Her areas of interest include inpatient neurology and acute stroke. When not working, she enjoys spending time outdoors with her family. Dr. Borte joined the TeleSpecialist family in March of 2019.
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Mazen Almidani, MD

Dr. Almidani is board certified in pediatrics by the American Board of Pediatrics and board certified in epilepsy, as well as neurology with special  qualification in child neurology by the American Board of Psychiatry and Neurology.  Dr. Almidani is happily married with 4 children. His oldest son has autism and his daughter has complicated seizures; both were a drive for him to become a neurologist. Dr. Almidani enjoys soccer, running and spending time with his family. He is very involved with his sons’ therapy and helping with daily challenges. He is double board certified in Pediatric and Adult Neurology and Epilepsy. He sees children and adults. He also participates in charities for children in Syria who may be underprivileged and/or affected by the war. Dr. Almidani joined TeleSpecialists in August 2020.
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Amanda Cheshire, MD

Dr. Cheshire received her medical degree from the University of Louisville School of Medicine in Louisville, Kentucky. She completed her neurology residency at the University of Cincinnati Medical Center in Cincinnati, Ohio. She did a fellowship in neurophysiology at the University of Michigan Medical School in Ann Arbor, Michigan. Dr. Cheshire is double board certified in neurology and clinical neurophysiology. She enjoys traveling, reading and music. She currently resides in Viera, Florida.  Dr. Cheshire joined TeleSpecialists in June 2019.
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Jessica Floyd, MD

Dr. Floyd completed her neurology residency at Mayo Clinic in Jacksonville, Florida followed by fellowship training in clinical neurophysiology with focus in EEG and epilepsy at the Medical University of South Carolina in Charleston, South Carolina. She has particular interest in hospital neurology and patient education as well as the blossoming specialty of lifestyle medicine. She strives to take advantage of every encounter with patients and medical staff to empower them to do their own research into how daily thoughts, choices, and habits can add up to create greater and longer-lasting brain and neurologic health for ourselves and our loved ones. She lives in Florence, South Carolina with her awesome husband of 13 plus years and three beautiful children. She is an avid yogi, astrologer, and lover of food and all things neurology! Dr. Floyd joined the TeleSpecialist family in July 2017.
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Nancy Futrell, MD

Dr. Futrell received her medical degree from the University of Utah in Salt Lake City, Utah. She also did her neurology residency at the University of Utah as well as a research fellowship in cerebral vascular disease at Jackson Memorial Hospital in Miami, Florida. She currently resides in Salt Lake City, Utah. She has authored 2 books and 50 peer reviewed papers. 
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Rebecca Jimenez-Sanders, MD

Dr. Jimenez Sanders received her undergraduate degree from Emory University, and her medical degree from the San Juan Bautista School of Medicine in Puerto Rico. She completed her neurology residency at the University of South Florida in Tampa, Florida, where she also did a specialized headache medicine and facial pain fellowship. She currently resides in Tampa, Florida with her husband and her two daughters. She is also fluent in Spanish and Italian languages, and enjoys photography, baking, boating, and biking.
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Cory Lamar, MD

Dr. Lamar received his medical degree from Meharry Medical College in Nashville, Tennessee. He completed his internship and residency at Wake Forest Baptist Health in Winston Salem, North Carolina. Following residency, he completed a clinical fellowship in neurophysiology, with a concentration in epilepsy. He currently resides in Florida and enjoys outdoor activities.
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Clifford Meyers, MD

Dr. Meyers received his medical degree from Brown University in Providence, Rhode Island and his MBA from the Simon School of Business at the University of Rochester in Rochester, New York. He completed his neurology residency at the University of Rochester, where he also did a neurophysiology fellowship. Dr. Meyers resides in Webster, New York with his wife and daughter. When not doing teleneurology, he enjoys playing sports with his wife and daughter.
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Tao Tong, MD

Dr. Tong received her medical degree from the University of Miami School of Medicine in Miami, Florida. She completed her neurology residency at Jackson Memorial Hospital in Miami, Florida, where she also did a neuromuscular/EMG fellowship.  She currently resides in College Station, Texas. Dr. Tong is married with two boys. She enjoys spending time with her family, traveling and reading.
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Shubhangi Chumble, MD

Dr. Chumble attended BJ Medical School. She is a board certified neurologist with a subspeciality interest in sleep medicine. Dr. Chumble did her residency at Howard University in Washington DC and has practiced neurology since 2001 in private and corporate settings. She lives in Melbourne, Florida and loves the sunshine state. Her hobbies include yoga, meditation, cooking , traveling and meeting new people. She also loves to do stained glass, pottery and painting. She joined TeleSpecialists in June 2019.
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