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Spotlight on Stroke

From: The Hospitalist, December 2009

Hospitalists can enhance stroke care through collaboration, training, and specialization

by Larry Beresford

Ethan Cumbler, MD, is board-certified in internal medicine and pediatrics, and has practiced hospital medicine for six years, first at a community hospital and now at the University of Colorado Denver (UCD), where he directs the Acute Care for the Elderly service. The prevalence of stroke in his practice and the daily challenges of managing stroke patients led Dr. Cumbler to seek additional training in stroke care. He is the hospitalist representative to the UCD stroke council, a researcher in the arena of acute stroke care, and is helping UCD become a Joint Commission-certified stroke center.

“There are a variety of roles for the hospitalist in stroke care,” Dr. Cumbler says, explaining that HM physicians can be admitting attendings for stroke patients or part of acute stroke teams, and participate in decisions to start such treatments as intravenous recombinant tissue plasminogen activator (t-PA), the Food and Drug Administration-approved clot-busting therapy. “[Hospitalists] can be medical consultants on stroke patients admitted to other hospital services, managing common comorbid conditions such as blood pressure and glucose levels, which have particular character for patients immediately post-stroke.”

Stroke is the third-leading cause of death in the U.S., as well as a leading cause of serious, long-term disability. How many stroke patients are seen by hospitalists is not known, but it is reasonable to assume that a majority of hospitalized stroke patients will encounter a hospitalist, if not for acute treatment, then for ongoing medical management.

Some hospitalists think stroke and transient ischemic attacks (TIAs)—temporary neurological deficits sometimes called “mini-strokes,” and a major risk factor for full-blown strokes—are among the most common diseases seen by hospitalists.1 Acute stroke care is a growing part of HM practice because neurologist availability in emergent situations varies widely between hospitals. The rapid evolution of stroke treatment and the time-sensitive needs of stroke patients represents a huge opportunity for hospitalists to fill that void for their hospitals—whether they want to or not.

“I think hospitalists are fully capable of learning and mastering stroke care, but it requires both interest and training,” Dr. Cumbler says.

Stroke Guidelines, Resources, and Training Options

HM Can Help Fill a Void

According to the American Heart Association (AHA), there are four neurologists per 100,000 Americans, and not all of those neurologists specialize in stroke care.2 The scarcity of neurological specialists means that in many hospitals, a neurologist won’t be available for the critical assessment and treatment decisions required in the first few hours after a stroke is diagnosed. Yet many hospitalists complain that their preparation during internal-medicine residency did not equip them to care for acute stroke patients.3

S. Andrew Josephson, MD, a neurovascular physician and director of the neurohospitalist program at the University of California at San Francisco Medical Center, says the number of hospitalists on the front lines of acute stroke care is growing every day. “A new stroke is a very treatable neurological emergency that requires ultra-fast intervention,”7 Dr. Josephson says, “and hospitalists, increasingly, are the people who matter most in that intervention.” The reason, in most cases, is hospitalists are available at all times, and neurologists aren’t.

Given variable access to neurologists at the time of urgent need in many hospitals, the actions hospitalists can take in acute stroke management include:

  • Become better trained in stroke care. Sessions on stroke management are included in numerous HM educational programs, including SHM conferences and in continuing medical education (CME) offerings from such groups as the American Academy of Neurology (see “Stroke Training, Resources, and Opportunities,” p. 30).
  • Partner with neurologists in your hospital. One trend is to develop a neurohospitalist practice.
  • Push for increased organization and response times for stroke patients. Given HM’s focus on quality and patient safety, hospitalists are natural champions for improving systems of care for stroke. Hospitalists can work with neurologists, radiologists, pharmacists, and other providers to develop stroke treatment protocols and rapid response capabilities.
  • Help develop a stroke team, and seek certification as a primary stroke center. The Joint Commission certifies stroke centers (www.jointcommission.org/CertificationPrograms/PrimaryStroke Centers) based on demonstrated compliance with disease-based standards, effective use of clinical practice guidelines, and performance-improvement activities.
  • Establish a collaborative relationship with a regional stroke center or tertiary hospital. This could manifest as a telemedicine link to aid in stroke assessment and treatment decisions (see “Rural Response: The ‘Drip and Ship’ Method,” p. 28).
  • Refine approaches to more rapidly identify and work up patients who experience a stroke while they are in the hospital.
S. Andrew Josephson, MDHospitalists are going to continue to be out front on stroke management.
—S. Andrew Josephson, MD, director, neurohospitalist program, University of California at San Francisco Medical Center

Streamline In-Hospital Stroke Response

From 6.5% to 15% of stroke patients experience their stroke while they are in the hospital.4 “Hospitals are not always geared up to deal with neurological emergencies, and yet these patients are firmly within our domain,” Dr. Cumbler says. “We found that it took three times longer in our hospital to complete the evaluation when the stroke happened in the hospital than for strokes presenting in the emergency department.”

Through a hospitalwide quality-improvement (QI) project, UCD’s in-hospital stroke response time was reduced to 37 minutes from 70 minutes.

A comprehensive approach to stroke QI should include training first witnesses in the hospital (e.g., nurses, physical therapists, and housekeepers) to recognize potential stroke symptoms; creating a rapid response capability from personnel who understand how to evaluate and treat suspected stroke and are able to respond quickly; and making suspected stroke a top priority in the radiology lab.

Listen to Lee H. Schwann, MD, discuss the benefits of his telestroke center at Massachusetts General Hospital.

Stroke patient management processes need to be improved and provider roles better defined. Hospitalists can help on the frontlines, and should advocate for quality and patient safety measures.

“Stroke has so many facets: the need to reduce risk, to educate the public about the need for prompt response, the appropriate evaluation of risks and benefits of treatment,” Dr. Cumbler says. “How do you achieve a system in the hospital where patients are fully able to realize benefits of all these advances? I think there’s something in stroke treatment for every hospitalist and, for those with a particular interest, opportunities to play leadership roles.”

Rural Response: The “Drip and Ship” Method

For hospitals with limited access to neurologists, one emerging approach is to develop a collaborative relationship with a regional medical center, perhaps via a telemedicine link. With videoconferencing or phone consultations from stroke experts at the regional center, hospitalists at rural hospitals can initiate t-PA treatment within the critical window of opportunity recommended by the guidelines, then arrange for the patient’s transfer to the regional center for ongoing stroke management.

When a patient presents with stroke symptoms in the ED at Riverside Tappahannock Hospital in rural Tappahannock, Va., hospitalists call the stroke team at Medical College of Virginia in Richmond, about a 45-minute drive away. Typically, the stroke attending in Richmond directs hospitalists to either start thrombolytics following an established protocol, then transfer the patient to the Medical College of Virginia, or transport the patient without starting the treatment. If it’s too late for thrombolytics or a palliative approach is indicated, the patient could remain at Riverside.

Riverside hospitalist Laurie Lavery, MD, says the decision to start thrombolytics is one of the biggest challenges rural physicians face. “We actually don’t have a very formal process for stroke management here,” she explains. Initial assessment typically is done in the ED, and the patient might be transferred immediately to the tertiary center. In other cases, hospitalists assess whether t-PA is appropriate. “If we opt for starting t-PA … the patient is then shipped out, because we do not have the capability for managing complications or for close clinical monitoring,” Dr. Lavery says.—LB

New Era in Stroke Care

Many compare the evolution of stroke care to that of more common conditions, and hospitalists have a buffet of new and improved treatments and technologies at their disposal. “This is an interesting time in the treatment of stroke,” Dr. Cumbler says. “We are at the cusp of a new era. Previously, stroke was one of the classic neurologic issues in hospital medicine, but we did not have much to offer. Now, as with heart attack, we have a growing array of urgent and effective treatment options, and new imaging techniques to determine whether to treat and with what type of treatment.”

New and emerging treatment approaches include:

  • Induced hypothermia, to protect the brain;
  • Enhanced thrombolytics by ultrasound;
  • Perfusion-based treatment time windows;
  • Recanalization;
  • Extended cardiac telemetry targeting atrial fibrillation;
  • Neuroprotective agents; and
  • Pressor usage to raise blood pressure in the post-stroke patient.

Interventional strategies seek to combine intravenous t-PA with localized techniques to open occluded vessels. While these are cutting-edge and not yet integrated into medical routine, “they illustrate why stroke management is so exciting right now,” Dr. Cumbler says.

As stroke treatment becomes more standardized, hospitals will expect HM physicians to be thoroughly versed in optimal stroke care, says David Yu, MD, MBA, FACP, medical director of hospitalist services at Decatur Memorial Hospital in Illinois and a member of Team Hospitalist. “There will be a shift in hospital medicine, with the practice of neurology becoming more open to non-neurologists,” he says. “As opportunities for stroke treatment increase, more responsibility will fall on hospitalists. It is part of the evolution of our field.”

That evolution is reflected in Medicare’s decision in 2005 to begin paying hospitals a higher diagnostic-related grouping (DRG) rate for administering intravenous t-PA.5 DRG 559 pays a hospital about $6,000 more, regionally adjusted, for stroke treatment that includes intravenous t-PA, compared with stroke care without it. That differential creates incentives for the hospital to invest in infrastructure, staffing, and training.

The Neurohospitalist

Recent journal articles have explored the emergence of neurohospitalists—hybrid physicians who are loosely defined as neurologists whose primary focus is the care of hospitalized patients. The neurohospitalist trend is spurred by the same time and fiscal constraints that drove the HM movement, says William Freeman, MD, neurologist at the Mayo Clinic in Jacksonville, Fla., and coauthor of one of those articles.6

Office-based neurologists increasingly are unavailable to respond to neurological emergencies in the hospital. Depending on the size of the hospital and its need for specialist access, an organized neurohospitalist group covering a schedule in the hospital could make significant contributions to quality of care, length of stay, and other stroke outcomes, Dr. Freeman says. “This field is starting to gel and crystallize, as more neurologists find themselves focusing their practice on site of care,” he notes.

Although not all experts agree, Dr. Freeman says that general hospitalists could become neurohospitalists, and vice versa. Neurologists could learn more internal medicine, and the two groups could work together more closely, he says.

Dr. Josephson of the University of California at San Francisco Medical Center reserves the term “neurohospitalist” for neurologists, but adds that medical hospitalists can manage neurologic disorders. He also sees potential for joint research on the management of hospitalized neurologic patients.

Drs. Freeman and Josephson have led discussions of the neurohospitalist model, both within AAN and in a recent conference call with SHM representatives. Data are limited on the numbers of physicians practicing this specialty, but job postings are growing and a neurohospitalist listserv sponsored by AAN grew to 250 members from 50 within six months. The University of California at San Francisco Medical Center established the first neurohospitalist fellowship in 2008, and a neurohospitalist journal is in development. “Most stroke patients are not seen by neurologists. I keep saying that at stroke conventions,” Dr. Josephson explains. “Hospitalists are going to continue to be out front on stroke management. Some will have a neurologist available. More likely, the hospitalist and neurologist will be participating in acute stroke management as part of some system of care with the emergency department or critical care.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

Stroke Training Resources and Opportunities

American Stroke Association International Stroke Conference
Feb. 24-26, 2010
San Antonio, Texas
http://strokeconference.americanheart.org/portal/strokeconference/sc/

The Stroke Collaborative
Give Me Five For Stroke: Resources for Health Professionals
www.givemefiveforstroke.org/healthcare/professionalResources/

National Stroke Association
Stroke Educational Materials
http://www.stroke.org/site/DocServer/MaterialsOrderFrom.pdf?docID=841

The Neurology Channel: Your Neurology Community
Stroke information at www.neurologychannel.com/stroke/index.shtml

References

  1. Glasheen J, Cumbler E, Tailoring internal medicine training to improve hospitalist outcomes. Arch Intern Med. 2009;169:204-205.
  2. Telemedicine helps experts treat stroke from afar. National Stroke Association Web site. Available at: http://www.stroke.org/site/News2?page=NewsArticle&id=8208&news_iv_ctrl=1221. Accessed Nov. 4, 2009.
  3. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3)247-254.
  4. Blacker DJ. In-hospital stroke. Lancet Neurol. 2003;2(12):741-746.
  5. Demaerschalk BM, Durocher DL. How diagnosis-related group 559 will change the US Medicare cost reimbursement ratio for stroke centers. Stroke. 2007;38:1309-1312.
  6. Freeman WD, Gronseth G, Eidelman BH. Is it time for neurohospitalists? Neurology. 2009;72:476-477.
  7. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
  8. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945-2948.
  9. Lyden P. Thrombolytic therapy for acute stroke—not a moment to lose. N Engl J Med. 2008;359:1393-1397.
  10. Doheny K. Few stroke patients get clot-busting drug. Business Week Web site. Available at: http://www.businessweek.com/lifestyle/content/healthday/624280.html. Accessed Sept. 23, 2009.
  11. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent strokes. N Engl J Med. 2008;359:1238-1251.
  12. Cumbler E, Glasheen J. Risk stratification tools for TIA: Which patients require hospital admission? J Hosp Med. 2009;4:247-251.
  13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369:283-292.
  14. Cumbler E, Glasheen J. Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. J Hosp Med. 2007;2:261-267.

Image Source: FORESTPATH/ISTOCKPHOTO.COM

Stroke Management Issues for Hospitalists

The management of stroke is an emergency. That theory is best reflected in the maxim “time is brain,” says Jose Biller, MD, a neurologist at Loyola University Health System in Chicago. “Appropriate treatment begins with correct diagnosis,” he says. “Misdiagnoses of strokes are not uncommon but may have serious consequences.”

Eighty-seven percent of strokes are ischemic (a blood clot blocking a vessel in the brain). The other 13% are hemorrhagic strokes or subarachnoid hemorrhages. The distinction is critical, because IV t-PA is contraindicated when there is evidence of bleeding in the brain. For the most part, it’s tough to tell at first glance if a patient has suffered an ischemic or hemorrhagic stroke. A brain scan, typically a noncontrast computed tomography (CT) scan, is needed to rule out intracerebral hemorrhage.

IV t-PA can reverse the disabling effects of stroke if administered within a narrow therapeutic window of opportunity. National stroke treatment guidelines call for IV t-PA to be administered within three hours of the known onset of symptoms. The clock starts at the time the patient was last seen normal. Intravenous t-PA is not recommended outside the time window or for such contraindications as recent major surgery, stroke, or serious head trauma within the past 30 months, history of intracranial hemorrhage, seizures at onset of symptoms, or arterial puncture at a noncompressible site within seven days.

IV t-PA can have serious side effects, but it remains the gold standard of stroke treatment within the suggested time allotment. Recent research points toward widening the time window for IV t-PA from three hours to 4.5 hours. The multinational, double-blind European Cooperative Acute Stroke Study (ECASS III), published in the Sept. 25, 2008, issue of the New England Journal of Medicine, concluded that t-PA is still beneficial up to 4.5 hours after onset of symptoms, although “sooner is better and every minute counts.”7

This finding eventually will make its way into formal guidelines, Dr. Josephson says, and some hospitals already have adopted the 4.5-hour window for IV t-PA treatment.

In May 2008, an AHA/ASA advisory recommended that IV t-PA be provided up to 4.5 hours after known onset of a stroke, unless the patient is older than 80, takes oral anticoagulants, has an assessed National Stroke Scale score greater than 25, or presents a history of both stroke and diabetes.8 In those cases, AHA/ASA recommends sticking to the three-hour ceiling.

Patrick Lyden, MD, a neurologist at the University of California at San Diego School of Medicine, noted in a September 2008 New England Journal of Medicine editorial that thrombolytic therapy can restore neurological functions if given early enough, and “has stood the test of time, shown benefit in serial community registries on multiple continents, and received approval by every major regulatory authority in the world.”9

In fact, IV t-PA is such a powerful tool for reversing stroke’s effects that the bigger question is, why is it used only for an estimated 2% to 10% of stroke patients? According to data presented at an international stroke conference in February, 64% of U.S. hospitals had not provided any IV t-PA treatments within the prior two years.10 Researchers concluded that some patients get medical help too late, but some hospitals and physicians are uncomfortable administering t-PA, and others lack sufficient protocols for responding quickly with assessment and treatment.

Hospitalists need to understand the medical management of patients who do not qualify for t-PA, approaches which have their own time windows, Dr. Josephson says. Intra-arterial administration of the therapy is supported up to six hours after the onset of stroke, while mechanical embolectomy—physically removing the clot—is recommended for as many as eight hours after onset. Newer systems for performing mechanical embolectomies include the Merci Retrieval System and the Penumbra System.

Past eight hours, stroke treatment involves appropriate choice and intensity of anti-coagulant (heparin, warfarin) and antiplatelet treatments. According to the recent PRoFESS trial, the most common antiplatelet treatment choices, clopidogrel and dipyridamole with aspirin, were found to be equal in efficacy.11

Recognizing the patients who present in the ED with evidence of TIA is critical to treatment options; many are at high risk for a full-blown stroke within the next 48 hours and should be admitted for aggressive management.12 The ABCD Score has been shown to predict which recent TIA patients are at higher risk of stroke, and thus are in need of immediate evaluation to optimize stroke prevention.1,13 “The idea that TIA and stroke are different diseases is giving way,” Dr. Josephson says. “Conceptually, they are the same disorder.”

Other treatment issues include DVT prophylaxis, identifying potential sources of embolisms, and choice of echo exam. Managing blood pressure could include permissive hypertension as high as 220/120 immediately post-stroke in patients who did not receive t-PA, or 180/105 following t-PA, then returning the blood pressure back to normal in a slow and safe manner.14—LB


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