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November 15, 2010
Calif. county network to speed stroke victim care
By Jim Steinberg
SAN BERNADINO, Calif. — A decade ago, medical science had little to offer a stroke victim.
But new techniques and a greater realization of how delays in treatment can further brain damage have led to the creation of networks linking hospitals that have stroke treatment expertise with emergency service providers.
Under this system, emergency system operators would take persons with stroke-like symptoms to the nearest stroke specialty center, at times bypassing a closer hospital that lacks this knowledge and experience.
Tick tock: Every minute can mean the death of 2 million brain cells.
In April 2009, Orange County began operating such a network.
A year ago, Los Angeles County activated its network — with nine hospitals initially. Since then, that number has increased to 20, and there are plans to add more.
Strokes kill nearly 4,000 L.A. County residents a year.
Nationally, strokes are the leading cause of long-term disability.
Now emergency medical service administrators for San Bernardino County say they hope to have a network of stroke specialty care centers operational on July 1.
The system will start with four hospitals spanning a wide segment of the county, said Dr. Reza Vaezazizi, medical director for the Inland Counties Emergency Medical Agency, which operates and manages an emergency medical services system in San Bernardino, Inyo and Mono counties.
The initial four will likely be Arrowhead Regional Medical Center in Colton, San Antonio Community Hospital in Upland, Loma Linda University Medical Center and St. Mary Medical Center in Apple Valley, Vaezazizi said.
Among those also interested in being part of the network are Redlands Community Hospital and Pomona Valley Hospital Medical Center in Pomona, which plans to participate in stroke networks for both Los Angeles and San Bernardino counties.
Vaezazizi said that San Bernardino County's stroke system may not roll out with all four hospitals on July 1.
"It may start with just two. But the other two will be rolled in over a period of several months," he said.
Two hospitals in San Bernardino County have already been designated as stroke centers by different medical accreditation agencies. Others are pursuing that certification.
In May, Arrowhead Regional was the first San Bernardino County hospital to become certified.
Earlier this month, Loma Linda University Medical Center announced that it had won certification from the Joint Commission. Arrowhead Regional was certified by the Health Care Facilities Accreditation Program. Stroke center experts say the criteria for both organizations is virtually identical.
Vaezazizi said all hospitals in the network would need to be certified as stroke centers by one of the several accrediting agencies.
For the San Bernardino County system to grow beyond the original four hospitals, Vaezazizi said demand would need to be large enough so that medical practitioners "can retain their competency."
Since the stroke center at Arrowhead Regional has been accredited, it has averaged about 30 cases per month, officials say.
Looking ahead, Vaezazizi said, "We have a lot of work left to do."
Not only must the other hospital participants get their certifications, but ambulance personnel and other emergency service providers must get training to learn how to identify stroke victims, he said.
A subcommittee is developing this educational component, he said.
One aspect of the certification process requires hospitals to do public education about the signs and symptoms of strokes.
Pomona Valley Hospital Medical Center did public education at its booth at the L.A. County Fair, said Deborah Keasler, director of the hospital's heart and vascular center.
Studies have found most Americans cannot identify even one stroke symptom.
Often when symptoms occur, such as loss of vision in one eye, people will rest, hoping the condition will clear up. But such delays can substantially worsen the outcome, experts say.
"They should call 9-1-1," Keasler said.
Vaezazizi said the emergency medical agency needs to decide on many guidelines, including how long after a stroke it would be appropriate for patients to be brought to a stroke center.
There are two kinds of strokes. By far the more common one involves a clot that blocks vessels in the brain, cutting off the supply of oxygen and brain cell nutrients.
The other is caused by the bursting of a blood vessel in the brain. The leakage of blood can cause a dangerous buildup of pressure.
For the more frequent stroke type, scientists have perfected a "clot buster" medicine, known as tPA, which dissolves brain clots.
Ideally, this medicine should be administered within the first three hours of a stroke, said Dr. Sarah Uffindell, a neurologist and stroke director at Loma Linda University Medical Center.
There are times when it has been pushed to four hours or a little more, "but if you go too far out, the risk outweighs the benefit," she said.
That's why when a person wakes up with a stroke, the clot buster is not used. There's no way to determine when in the sleep cycle the stroke began, Uffindell said.
Using the "clot buster" on the wrong kind of stroke — the brain hemorrhage — will most likely be fatal, doctors say.
Part of the challenge of a stroke center is to quickly determine if the patient's stroke is the type the "clot buster" can help.