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REACH brings Level 1 stroke care to KershawHealth

Posted: February 3, 2014 9:13 a.m.
Updated: February 3, 2014 9:11 a.m.

Every 40 seconds, someone in the U.S. has a stroke, and in 2010 South Carolina had the sixth largest number of strokes in the country, in part because of its particularly high incidence of cardiovascular disease, diabetes, and smoking. In addition, African Americans tend to have more debilitating strokes, and have them earlier in life, than other groups -- likely because one in three African Americans suffers from high blood pressure, the number one risk factor for stroke. Given statistics like that, treating stroke in South Carolina is essential.

Time is a critical aspect in treating stroke; time lost is brain lost. The brain needs a constant supply of blood, which carries the oxygen and nutrients it needs to function. The most common type of stroke occurs when one of the arteries carrying blood to the brain is blocked by a blood clot. As a result, part of the brain does not get the blood it needs, so it starts to die. That damage to the brain can cause death or debilitating problems with movement, speech, or memory. Fortunately, strokes can be treated, but time is of the essence.

Enter Medical University of South Carolina’s (MUSC) Reach Stroke Network -- a strategic collaboration between the Medical University of South Carolina in Charleston and community hospitals throughout South Carolina, including KershawHealth. As Dr. Robert Adams, director of the MUSC Stroke Center notes, community hospitals need urgent stroke expertise to provide the best care for their patients, and REACH brings the resources of a comprehensive primary stroke center right to their door. It connects partnering hospitals with immediate, round-the-clock access to stroke care experts, who can remotely provide urgent consultations after virtually examining patients and brain imaging studies. The local ER physician remains the primary physician, overseeing patient care and providing the patient and family members with the information and support they need. Dr. Adams’ ultimate goal is to have every hospital in South Carolina connected to either a primary stroke center or to one of these acute stroke-ready telemedicine hospitals.

“REACH was one of the best things KershawHealth ever did,” says Dr. Ron Washington, medical director of the KershawHealth ER. “In just minutes, we can have a consult with a neurologist, and that’s critical for stroke patients and important for our physicians. It’s all about the quality and scope of care we’re able to provide.”

Telemedicine consultations enable ER physicians at the partner hospital to begin administering the “clot-busting” drug tPA as quickly as possible, opening the blocked artery and reestablishing blood flow to the brain. The earlier tPA is administered, the better the patient’s outcome is likely to be.

That so-called “door-to-needle” time (from the moment when the patient arrives at the emergency room until tPA is administered) is where KershawHealth has made significant strides, and it now has one of the best rates -- about 63 minutes -- in South Carolina. According to registered nurse Ellen Debenham, MUSC Stroke Center Clinical & Research Project Manager, KershawHealth is leading the way in reduced door-to-needle times among hospitals in the network, and they plan to share the changes made here with other hospitals.

“It was a collaborative effort,” says Emergency Services Director Danny Wharton. “Wayne Priester (EMS assistant director), April Wach (ER nurse manager), and I took a look at the whole process -- from when EMS arrives until a stroke patient leaves the ED – and said ‘Where can we do better?’ It didn’t take long to figure things out. Once we did, everybody got on board quickly.”

Where they saw room for improvement was in the time it took to get a CT scan upon arrival. Without that critical diagnostic test, tPA cannot be administered. The minute EMS arrives at a patient’s side they begin to determine the possibility of a stroke using a standardized stroke alert checklist and then they alert the ER that a stroke patient is in transit. In the past, once a patient arrived at KershawHealth, they would be assessed by the ER physician, be registered, and finally a CT scan could be ordered. Valuable minutes were being lost in the process.

Today, as soon as EMS notifies the KershawHealth emergency room that a stroke patient is on the way, a new protocol takes effect. Radiology is immediately notified that a CT scan will be needed, basic registration information is collected over the phone, a CT scan is ordered, and the ER physician remains on standby.  Upon arrival, the ER physician conducts their assessment as the patient is moving to radiology, in effect eliminating a stop in the ER. Once the CT scan is complete MUSC physicians have immediate access to the images, and through telemedicine can do a remote interview with the patient and consult with the KershawHealth ED physician, who initiates treatment.

This relatively simple process change, Wharton notes, has cut critical minutes from “door-to-needle” times. Typically, patients will begin their CT scan in 16-18 minutes, and tPA will be administered in less than 63 minutes -- times better than the vast majority of hospitals, and equaling those of many primary stroke centers.

Commenting in Medscape Medical News, Dr. Adams of MUSC noted that difficulty of reducing door-to-needle times. “There can be lots of time losers in the process, and we have to start looking at these in a systematic way.” That is exactly what the team at KershawHealth did.

There’s often the assumption that “bigger is better”, but in this case, small and nimble is a big advantage. Process change can often be identified and enacted more quickly in a small organization, especially when change is driven by a staff dedicated to continuous process improvement. The REACH telestroke program, on the other hand, gives the hospital access to specialists only available at larger medical centers, and that can make all the difference in patient care.

Today, there’s just one final hurdle in stroke care -- awareness. As Dr. Washington notes, “If we could just get people to recognize the signs of a stroke and get to the hospital that would make all the difference. We need to get folks aware of this.”

According to the National Stroke Association, fewer than one in five people in the US can recognize even one symptom of a stroke. And that means all too often, the critical first call to EMS doesn’t get made in time. There is, however, a simple method for recognizing the signs of stroke. F.A.S.T. Does the face droop on one side? Do the arms drift downward when raised? Is speech slurred? If so, it’s time to call 911 immediately. Paired with access to stroke experts across South Carolina, that can make a significant difference in the lives of thousands of South Carolina citizens.

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