Stroke Centers

[chaz90]

I figured this might be better on its own thread rather than hijacking the other one.

Are there a lot of EMS receiving facilities with 24/7 EDs that are not some kind of stroke center? Admittedly, my experience is limited to Colorado and Delaware, but every ED I have ever utilized is able to take acute strokes, if only for imaging, thrombolytics, and transfer.

I found this diagram on the Joint Commission's website.

I knew about Primary vs. Comprehensive stroke centers, but I had never heard of an "Acute Stroke Ready Hospital" before. Really, if CT imaging and an ED physician is available it doesn't seem like it should be terribly difficult to achieve certification. I've seen some pretty small EDs manage to become stroke certified. With modern access to telemedicine and consults, access to neuro expertise should be growing more widespread.

Does anyone have much experience with a local facility that won't accept CVA patients? How far away is your nearest facility that will?

 

[Jim37F]

In my area, we will, every time, bypass the closer hospital if they are not an Approved Stroke Center.

 

[chaz90]

In my area, we will, every time, bypass the closer hospital if they are not an Approved Stroke Center.

Right, but how many hospitals are not stroke centers?

 

[Jim37F]

Right, but how many hospitals are not stroke centers?

There are 74 911 Receiving Hospitals in LA County, and only 33 of those are Approved Stroke Centers

http://file.lacounty.gov/dhs/cms1_206228.pdf

 

[DesertMedic66]

We have 3 different types of stroke hospitals. We have "Stroke ready hospitals", "Primary stroke center", and "Interventional stroke center".

If the onset of stroke symptoms is 0-3 hours then we can transport to any of our stroke hospitals.

If the onset is 3-8 hours then we transport to our Interventional Stroke Centers.

If the onset is unknown or past 8 hours we transport to any of our stroke hospitals.

8 out of our 17 hospitals are a Stroke Ready Hospital or Primary Stroke Center. Only 2 of our 17 hospitals are Interventional Stroke Centers. So we have 7 hospitals who do not take stroke patients.

 

[Aprz]

Two out of seven hospitals in the county I work in are not stroke centers.

 

[TransportJockey]

I have two stroke centers, out of four local hospitals. All four are chest pain centers, though. I have worked in places thatthere were only drip and ship facilities available, though

 

[EpiEMS]

I figured this might be better on its own thread rather than hijacking the other one.

Are there a lot of EMS receiving facilities with 24/7 EDs that are not some kind of stroke center? Admittedly, my experience is limited to Colorado and Delaware, but every ED I have ever utilized is able to take acute strokes, if only for imaging, thrombolytics, and transfer.

Curious if the "freestanding EDs" that can be transported to in some systems have the appropriate imaging equipment...

In terms of some brief Googling:

- "By 2011, there were over 800 The Joint Commission primary stroke centers in the US out of some 4000-5000 total hospital facilities."
- "Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance"

 

[MonkeyArrow]

We have 3 different types of stroke hospitals. We have "Stroke ready hospitals", "Primary stroke center", and "Interventional stroke center".

If the onset of stroke symptoms is 0-3 hours then we can transport to any of our stroke hospitals.

If the onset is 3-8 hours then we transport to our Interventional Stroke Centers.

If the onset is unknown or past 8 hours we transport to any of our stroke hospitals.

8 out of our 17 hospitals are a Stroke Ready Hospital or Primary Stroke Center. Only 2 of our 17 hospitals are Interventional Stroke Centers. So we have 7 hospitals who do not take stroke patients.

But why are the time cut-offs like that. The interventional stroke centers that can perform endovascular thrombectomies have a smaller time window than 8 hours, I thought, according to the literature I read, not that there is a general consensus on whether interventional neuroradiology is actually beneficial to stroke patients. I guess with the outside of 3, the primaries would no longer be giving tPa but I would guess that the interventional would also not be intervening any more.

 

[TransportJockey]

Curious if the "freestanding EDs" that can be transported to in some systems have the appropriate imaging equipment...

In terms of some brief Googling:

- "By 2011, there were over 800 The Joint Commission primary stroke centers in the US out of some 4000-5000 total hospital facilities."
- "Of the 309 million people in the United States, 65.8% had ≤60 minute PSC access by ground ambulance"

Our four freestanding ERs (I forgot about them when I did my other post here) all have CT capabilities. But all services who can transport locally to them have written guidelines to prevent any ACS/CVA patients from being transported to one.

 

[Tigger]

Our local hospital is a "stroke center" in that they can write it in brochures, have a CT scanner, and tPA. That said, they will not accept potential CVA patients from EMS. At one point we were supposed to transport there if transport time exceeds an hour. That seems to have disappeared for CVAs, with the local facility no longer being in the destination guidelines for strokes. Incidentally we are still supposed to go there with MIs in the event transport time a PCI center will exceed an hour.

 

[DesertMedic66]

But why are the time cut-offs like that. The interventional stroke centers that can perform endovascular thrombectomies have a smaller time window than 8 hours, I thought, according to the literature I read, not that there is a general consensus on whether interventional neuroradiology is actually beneficial to stroke patients. I guess with the outside of 3, the primaries would no longer be giving tPa but I would guess that the interventional would also not be intervening any more.

Honestly not sure why the time frames are set up that way. I haven't been able to make it to any of the hospitals stroke CEs due to schedule conflicts.

 

[LACoGurneyjockey]

All 10 ER's in county have CT and tPA, but there's a long list of contraindications to transport there, in which case we'd have to go to our nearest stroke center 90 miles away. Patients who are eligible can get CT and tPA if appropriate at the nearest ER.
For a while, there were 2-3 ER's that had CT, but would not give tPA and instead just fly patients to the stroke center, but that got fixed eventually.

 

[EBMEMT]

For thrombolytics, the odds ratio plot for favorable outcome at 3months declines roughly linearly and intersects 1.0 at about 6 hours duration of ischemia give or take an hour beforedipping below i.e mire harm than good.

For interventional neuroradiology, I think it was 12-36 hours with current tech.

If it has been less than 36 hours patient may still have time sensitive treatment options.

 

[LACoGurneyjockey]

For thrombolytics, the odds ratio plot for favorable outcome at 3months declines roughly linearly and intersects 1.0 at about 6 hours duration of ischemia give or take an hour beforedipping below i.e mire harm than good.

For interventional neuroradiology, I think it was 12-36 hours with current tech.

If it has been less than 36 hours patient may still have time sensitive treatment options.

Not doubting you but just curious, can you post a link to those studies regarding the 36 hour mark.

 

[Akulahawk]

Where I work, we do take stroke patients, but our job is basically to receive, quick exam by MD, move straight to CT, get a neuro consult ASAP while working on an emergent transfer, all the while getting TPA underway, if the patient meets the proper time criteria (<3-4.5 hours). The patient doesn't get off the EMS gurney until they're at the CT scanner.

 

[chaz90]

Where I work, we do take stroke patients, but our job is basically to receive, quick exam by MD, move straight to CT, get a neuro consult ASAP while working on an emergent transfer, all the while getting TPA underway, if the patient meets the proper time criteria (<3-4.5 hours). The patient doesn't get off the EMS gurney until they're at the CT scanner.

This is pretty much exactly what our Primary Stroke Centers do. Most CVA patients that end up receiving TPA are transferred out to a comprehensive stroke center by ground ambulance shortly after treatment if no other needs immediately arise.

 

[EBMEMT]

Not doubting you but just curious, can you post a link to those studies regarding the 36 hour mark.

I was overly brief as I was posting from a cell phone. I didn't see the studies, just a presentation by those who perform the procedures, and I am not sure about the 36 hour number being specifically associated with the mechanical interventions. I came out of the presentation with the idea that there were various types of treatment with windows up to 36 hours duration of ischemia. And that some of this was pretty new.

I did find a couple studies using google:
Here is one saying there can be benefit at 18-24 hours for endovascular treatment.
http://circ.ahajournals.org/content/123/22/2591.full.pdf
And this one shows some benefit to drug therapy within a 36 hour window.
http://www.ncbi.nlm.nih.gov/pubmed/19849660

 

[evantheEMT]

I'm lucky I work in and around Boston,MA so pretty much all the hospitals can do everything which makes it easy.