Not all hospitals created equal in stroke care

Dr. José Otero, a former CSU professor, benefited from specialized stroke care at UCHealth
December 16th, 2015
Dr. José Otero, a former Colorado State University Spanish professor and longtime Fort Collins resident, pictured in his home on Oct. 12, suffered two mild strokes within the past year. Photo by Joel Blocker, for UCHealth.

In two separate episodes, Dr. José Otero noticed that his speech began to slur. The first time was a year ago, when the now 83-year-old was visiting family in his hometown of Archidona, Ecuador.

“My brother-in-law took me to the local hospital,” said Dr. Otero, Ph.D., a former Colorado State University Spanish professor and longtime Fort Collins resident.

“Since the hospital there didn’t have the required equipment, I was then sent by ambulance to the regional hospital in Tena, 10 miles away. They thought I had had a mild stroke, but an MRI showed inconclusive results. They kept me several days for observation, but as my speech had returned to normal, I asked to be discharged so I could continue on with my vacation. I thanked the nurses and doctors there, who were wonderful.”
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The second onset of garbled speech was in July 2015. Dr. Otero was at home, just a few doors down from UCHealth Northern Colorado’s Poudre Valley Hospital (PVH) in Fort Collins. “This time I knew what was happening because the symptoms were the same,” he said. Wisely, he again headed straight to the hospital.

At PVH, Dr. Otero benefited from specialized stroke care. The emergency room physician immediately noted that he had several concerning symptoms. In addition to the slurred speech, the right side of his face drooped a bit, and he was having trouble coming up with words — all signs of a stroke.

So the doctor called a Stroke Alert, triggering the arrival of a stroke neurologist, a stroke nurse, and a rapid diagnostic and treatment protocol.

“Both PVH and Medical Center of the Rockies [MCR] are certified by the Joint Commission as Primary Stroke Centers,” said Leigh Ann Creighton, a UCHealth nurse and the PVH/ MCR stroke program coordinator. “That means they have the staff, resources, and processes in place to deliver fast, optimal care to stroke patients. And when it comes to stroke, every minute counts. Time is brain.”

To measure a stroke’s severity, the National Institutes of Health developed an 11-item neurologic exam that a physician can conduct in just 10 minutes. Patients receive a score ranging from zero to four for each item on the checklist. Zero means the patient is not displaying that symptom; four means the symptom is severe. The maximum possible total score is 42, with anything higher than 21 considered a severe stroke.

The Stroke Alert team examined Dr. Otero and gave him a stroke score of three. He was having symptoms of a mild stroke.

About 87 percent of all strokes are ischemic, according to the American Heart Association. They’re caused by blood clots blocking the flow of blood to the brain. (The other 13 percent are hemorrhagic strokes, which means they’re caused by bleeding in the brain.) Doctors treat severe ischemic strokes with a drug called alteplase, or tPA (tissue plasminogen activator). The synthesized enzyme dissolves blood clots, but it can only be used within four-and-a-half hours of the onset of the patient’s symptoms. That’s why time is critical — and why Primary Stroke Centers’ protocols can save lives.

“As stroke centers of excellence, PVH and MCR have teams of experts who are committed to providing the best care to each individual patient every time,” Creighton said. “When a stroke patient is admitted to one of our designated stroke units, the multidisciplinary team gets stroke patients immediately engaged in whatever therapies might help them gain independence and recovery, such as physical, occupational and/or speech. The team includes doctors, nurses, therapists and case managers all trained to deliver excellent stroke care. The team tracks patient outcomes and continuously looks to improve their effectiveness. Compared to other stroke centers in the nation, PVH and MCR stand out with performance that exceeds national goals.”

As a Stroke Alert patient, Dr. Otero received this focused care at PVH throughout his two-day stay. He also chose to enroll in a mini-stroke research study. According to the American Heart Association (AHA), research shows that stroke patients like Dr. Otero have better outcomes when they are treated at Primary Stroke Centers, even when tPA is not an option.

“All hospitals are not created equal when it comes to stroke care,” said Dr. Gerald McIntosh, UCHealth’s stroke program medical director. “Primary Stroke Center certification indicates that a hospital is dedicated to delivering the best possible care to stroke patients.”

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Study looks at treatment for mini-strokes

Patients like José Otero with mild stroke symptoms do not routinely receive the drug that so often saves the lives of people who’ve suffered a severe stroke. That’s because tPA thins the blood, raising the risk of hemorrhage, and for mini-strokes this risk is thought to outweigh the possible benefits.

It’s a catch-22, though, because many mild stroke patients continue to suffer debilitating symptoms months later. “Thirty to 40 percent of mild stroke patients end up with substantial disabilities,” said Leigh Anne Creighton, the stroke program coordinator at PVH and MCR.

What’s more, mild strokes are known to be precursors to major strokes. According to the AHA, about a third of people who experience a mild stroke, or TIA, go on to have a severe stroke within a year. “That’s why we also call mini-strokes ‘warning strokes,’ ” Creighton said.

Since April 2014, PVH has been participating in a research study called PRISMS, which analyzes whether or not tPA should be used for mild strokes. The Stroke Alert team identified Dr. Otero as a possible candidate for the trial. After learning about the benefits and drawbacks of participating in PRISMS, Dr. Otero agreed. “If I can be instrumental for people in the future, I’m happy to do it,” he said.

As required in a double-blind study, neither Dr. Otero nor the stroke team knows if he received tPA or aspirin, which is the current standard of care. All he can say is that when he left PVH, he was feeling better, and his NIH stroke score had dropped from a three to a one.

PRISMS will wrap up in 2018. “It’s a very important study because so many mild stroke patients are debilitated,” said Kathy McIntosh, a clinical research coordinator at PVH and MCR. “We hope this study will expand our treatment options for patients like José, and more people will be able to get back to their lives sooner.”