High-level stroke care lim­ited in Connecticu­t

The News-Times - - FRONT PAGE - By Lisa Backus

Get­ting to the hospi­tal quickly af­ter suf­fer­ing a stroke im­proves your chances of sur­vival, but in Connecticu­t there are ar­eas where ac­cess to the top level of stroke care is lim­ited, health ex­perts say.

Two hos­pi­tals, Yale New Haven Hospi­tal’s main cam­pus and Hart­ford Hospi­tal, are na­tion­ally cer­ti­fied as Com­pre­hen­sive Stroke Care Cen­ters, pro­vid­ing the high­est level of stroke care avail­able, which in­cludes 24-hour ac­cess to neu­ro­log­i­cal prac­ti­tion­ers and the abil­ity to per­form com­plex en­dovas­cu­lar ther­a­pies, in­clud­ing thrombec­tomies and en­dovas­cu­lar coil­ing of an aneurysm, among other surg­eries.

Yale and Hart­ford hos­pi­tals are two of only 178 cer­ti­fied na­tion­ally as com­pre­hen­sive stroke cen­ters, ac­cord­ing to The Joint Com­mis­sion, which cer­ti­fies hos­pi­tals.

But when time is crit­i­cal, trav­el­ing to New Haven or Hart­ford can be a risky com­mute from the north­west­ern and north­east­ern parts and other parts of the state, where hos­pi­tals cer­ti­fied in stroke care are sparse.

In all, the state has 23 hos­pi­tals that are cer­ti­fied in some level of stroke care, up from 16 in 2013.

Nine­teen hos­pi­tals — in­clud­ing Norwalk Hospi­tal, Stam­ford Hospi­tal, St. Vin­cent’s Med­i­cal Cen­ter in Bridge­port, Bridge­port Hospi­tal, Dan­bury Hospi­tal, Green­wich Hospi­tal, Mid­dle­sex Hospi­tal in Mid­dle­town — are cer­ti­fied as pri­mary stroke cen­ters, and are equipped to do brain scans, ad­min­is­ter clot­bust­ing drugs (IV-tPA) and pro­vide neu­ro­sur­gi­cal ser­vices.

In ad­di­tion to Yale and Hart­ford Hospi­tal, UConn Health John Dempsey Hospi­tal in Farm­ing­ton, St. Fran­cis Hospi­tal & Med­i­cal Cen­ter in Hart­ford, Stam­ford Hospi­tal, Dan­bury Hospi­tal are among the fa­cil­i­ties that per­form thrombec­tomies, ac­cord­ing to a mem­ber of the state’s Stroke Ad­vi­sory Com­mit­tee . A com­plete list was not avail­able. The Joint Com­mis­sion does not re­quire pri­mary stroke cen­ters to per­form thrombec­tomies.

Grif­fin Hospi­tal in Derby and John­son Memo­rial Hospi­tal in Stafford Springs are cer­ti­fied as acute stroke-ready hos­pi­tals, pro­vid­ing ba­sic care, in­clud­ing ad­min­is­ter­ing drugs to break up a clot and eval­u­at­ing whether a patient needs to be trans­ferred to a pri­mary or com­pre­hen­sive stroke cen­ter.

Seven fa­cil­i­ties, Char­lotte Hunger­ford Hospi­tal in Tor­ring­ton, Bris­tol Hospi­tal, Water­bury Hospi­tal, Mil­ford Hospi­tal, New Mil­ford Hospi­tal, Wind­ham Hospi­tal in Wil­li­man­tic, and the West Haven VA, have no stroke cer­ti­fi­ca­tion.

Even with more hos­pi­tals na­tion­ally cer­ti­fied, Connecticu­t is lag­ging in some ar­eas of care, said Dr. Joseph Schindler, an as­so­ciate pro­fes­sor neu­rol­ogy and neu­ro­surgery, di­rec­tor of Acute Stroke and TeleStroke Ser­vices and di­rec­tor of the Vas­cu­lar Neu­rol­ogy Fel­low­ship Pro­gram at Yale New Haven.

“It’s left up to the hos­pi­tals to make in­vest­ment in pro­vid­ing stroke care,” Schindler said. “Connecticu­t is a cou­ple of states be­hind more pro­gres­sive states like Rhode Is­land or Mas­sachusetts when it comes to stroke care.”

Connecticu­t’s EMS pro­to­cols, up­dated in 2017, de­lin­eate the steps emer­gency re­spon­ders should take to trans­port a stroke patient to a hospi­tal quickly. The steps in­clude no­ti­fy­ing a hospi­tal im­me­di­ately that a stroke patient is on the way and get­ting wit­ness in­for­ma­tion on when symp­toms started. But the pro­to­cols don’t spec­ify where EMTs should trans­port a stroke patient.

Rhode Is­land, Vir­ginia and Colorado are among a hand­ful of states that re­quire EMTs to trans­port a per­son suf­fer­ing from a stroke to a hospi­tal des­ig­nated as a com­pre­hen­sive stroke cen­ter. Mas­sachusetts leg­is­la­tors are con­sid­er­ing im­ple­ment­ing sim­i­lar pro­to­cols. Cur­rent Mas­sachusetts law re­quires EMTs to take pa­tients directly to a pri­mary stroke cen­ter.

Na­tion­ally, about 140,000 peo­ple die of a stroke an­nu­ally, and more than 795,000 peo­ple will have a stroke, the Cen­ters for Dis­ease Con­trol and Pre­ven­tion (CDC) re­ports.

In 2017, 1,403 peo­ple died in Connecticu­t from strokes, a death rate of 27.8 per 100,000 res­i­dents — the third low­est rate in the coun­try, the CDC re­ports. Connecticu­t’s stroke death rate has re­mained be­low the na­tional av­er­age of 37.3 per 100,000 peo­ple since 2015, the CDC said.

By com­par­i­son, states in the “stroke belt” — such as Ken­tucky, Mis­sis­sippi and Ten­nessee — have a death rate 10 per­cent higher than the na­tional av­er­age, ac­cord­ing to the Na­tional Heart, Lung and Blood In­sti­tute.

Stroke care

In ad­di­tion to pro­vid­ing top-level stroke care, Yale and Hart­ford of­fer telestroke ser­vices to some hos­pi­tals, which pro­vides quick ac­cess to neu­ro­log­i­cal ex­perts by video screen.

Yale’s telestroke ser­vices are pro­vided to nearly a dozen hos­pi­tals in­clud­ing Sharon Hospi­tal, St. Fran­cis Hospi­tal & Med­i­cal Cen­ter, Grif­fin Hospi­tal, and Yale’s St. Raphael’s cam­pus, Schindler said. Green­wich Hospi­tal is ex­pected to join the telestroke pro­gram with Yale in the com­ing months.

Hart­ford Hospi­tal’s Tele­health Net­work in­cludes Wind­ham Hospi­tal, Char­lotte Hunger­ford Hospi­tal, MidS­tate Med­i­cal Cen­ter in Meri­den and Backus Hospi­tal in Nor­wich, all of which are un­der the um­brella of Hart­ford Health­care.

The im­me­di­ate video con­fer­ences al­low physi­cians to re­ceive ex­pert con­sul­ta­tions on the ap­pro­pri­ate use of an in­tra­venous drug to break up clots. The drug must be ad­min­is­tered within 4½ hours of the on­set of stroke symp­toms. The video con­fer­enc­ing as­sists in patient eval­u­a­tion to de­ter­mine if a trans­fer to a higher level of stroke care fa­cil­ity is needed.

“An acute stroke-ready hospi­tal is prob­a­bly not go­ing to have all the fancy tools, but they do have a team trained to im­me­di­ately deal with stroke pa­tients and get them where they need to go,” said Rom­mie Duck­worth, an emer­gency re­spon­der in Ridgefield and the founder of the New Eng­land Cen­ter for Res­cue and Emer­gency Medicine.

Stroke pol­icy changes un­der re­view

Connecticu­t of­fi­cials are con­tin­u­ally re­view­ing stroke care through the state Stroke Ad­vi­sory Com­mit­tee, which is work­ing with EMS of­fi­cials to ex­am­ine pro­to­cols for emer­gency re­spon­ders.

One con­cept be­ing dis­cussed is whether it’s quicker and more ef­fec­tive to bring pa­tients to the clos­est hospi­tal, no mat­ter what the cer­ti­fi­ca­tion level, to have the patient eval­u­ated to see if they are a can­di­date for a thrombec­tomy, said Raf­faella Coler, the di­rec­tor of the Of­fice of Emer­gency Med­i­cal Ser­vices at the state De­part­ment of Pub­lic Health (DPH).

“The need for in­ter­ven­tional treat­ment (thrombec­tomy) is what would prompt trans­fer to a higher level of care,” Coler said. “This way the patient would get the treat­ment needed if ap­pro­pri­ate in the short­est amount of time but still have the needed eval­u­a­tion to see if they would ben­e­fit from trans­fer.”

About 80 per­cent of stroke vic­tims have is­chemic strokes, which are caused by block­ages in the ar­ter­ies lead­ing to the brain, ac­cord­ing to Dr. Richard Kamin, the EMS di­rec­tor and an as­so­ciate pro­fes­sor at UConn Health, who is also an ad­vi­sory com­mit­tee mem­ber.

An­other 10-15 per­cent have hem­or­rhagic strokes, which are caused by aneurisms or bleeding on the brain. Both types of strokes can cause death or se­vere dis­abil­ity if not treated quickly and prop­erly. About 10 per­cent of is­chemic stroke vic­tims are ap­pro­pri­ate for eval­u­a­tion for a thrombec­tomy, with about 5 per­cent of those re­ceiv­ing the pro­ce­dure, Kamin said.

Kamin said that by­pass­ing a hospi­tal that is close in or­der to trans­port a patient directly to a com­pre­hen­sive stroke cen­ter could also have neg­a­tive im­pact. “There is a sac­ri­fice you make when you go past one hospi­tal to an­other,” he said. “We know that if you have cer­tain types of in­juries you are taken to trauma cen­ter. Pa­tients who are taken there have a bet­ter sur­vival rate with less com­pli­ca­tions. It’s also true with cer­tain types of heart at­tacks. We’re in the process of try­ing to fig­ure that out for stroke.”

Of­fi­cials have been work­ing since 2014 to make leg­is­la­tors aware that the state needs up­dated stroke poli­cies af­ter fund­ing for a DPH state stroke care hospi­tal des­ig­na­tion pro­gram ran out.

In a med­i­cal cri­sis where “time is brain,” ev­ery minute counts, which is why the state needed a sys­tem of care af­ter the state’s des­ig­na­tion pro­gram ex­pired, said Dawn Be­land, a reg­is­tered nurse and co­or­di­na­tor of Hart­ford Hospi­tal’s stroke cen­ter, who sits on the ad­vi­sory com­mit­tee.

“It helps us make sure that that we are be­ing the most efficient in pass­ing that patient from EMS to the emer­gency de­part­ment to the next level of care,” Be­land said.

As part of the ad­vi­sory com­mit­tee’s con­tin­ued work, ev­ery hospi­tal in the state is now be­ing as­sessed for its stroke care ca­pa­bil­i­ties, Kamin and Coler said. Hos­pi­tals that don’t have the ca­pa­bil­ity for stroke treat­ment should be trans­par­ent about what they can and can’t do, Kamin said.

“I think we owe the peo­ple of Connecticu­t, re­gard­less of where they live, an un­der­stand­ing of what’s avail­able to them in their lo­cal com­mu­nity,” Kamin said.

At the same time, the com­mit­tee is try­ing to de­ter­mine how to make sure ev­ery­one in the state has ac­cess to timely and ef­fec­tive stroke care, Kamin said.

“We have gaps,” Kamin said. “Those gaps are be­ing looked at and hope­fully we’re com­ing up with ways to ad­dress them.”

Me­lanie Sten­gel / C-Hit.org

Dr. Joseph Schindler, an as­so­ciate pro­fes­sor of neu­rol­ogy and neu­ro­surgery, di­rec­tor of Acute Stroke and TeleStroke Ser­vices and di­rec­tor of the Vas­cu­lar Neu­rol­ogy Fel­low­ship Pro­gram at Yale New Haven Hospi­tal.

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