Everywhere in the world, time is critical for stroke care

It's not just in the United States where stroke patients aren't getting to the emergency department in time. Check out the story from Ireland how over 60pc of stroke patients not arriving on time:

More than 60pc of people who suffer a stroke are not making it to hospital emergency departments in the ideal time frame, specialists warned yesterday.

The success of acute treatment of stroke is extremely time-dependent, the Oireachtas Health Committee was told.

The doctors called for a relaunch of the Act-FAST campaign, which raised awareness among the public about being aware of the symptoms of a stroke.

Prof Rónán Collins, Dr Diarmuid O'Shea and Prof Ken McDonald were appearing before the committee.

The doctors said that a "third to a half of all strokes may be prevented through lifestyle change, management of blood pressure and identification of an irregular heart rhythm".

A "nationwide approach to cardiovascular disease prevention is needed", they said.
Admission to a stroke unit is the foundation of all stroke care and reduces death and disability by 25pc.

"To achieve optimum patient outcomes, all acute stroke patients should be managed in an acute stroke unit," they said.

(Photo from leppre via Flickr)

Speed and the right place - more important than ever

Sooner the treatment, better the outcome.

You've read this before here - time is critical in getting a stroke patient to a stroke center hospital. Every minute counts.

You've also read about recent research on new stroke treatment. Now, read about how the new treatment calls for getting to the right place quickly:

That’s the implication of a study published Monday in the Journal of the American Medical Association that found that the sooner patients with severe strokes receive a thrombectomy, the less disabled they tend to be three months later.

Another tool for important tasks

I have a hammer. I also have an air compressor and a few nail guns.

So, which tool should I use to hang a picture on a wall?

On the other hand, I once had the need to place a piece of cedar siding around 24 feet above the ground. One hand held the siding, but using a hammer is a two-handed operation. Now which tool should I use?

So I see the importance of health professionals with more tools to do the important work of treating stroke patients. Check out the story on the FDA approving a clot-picker use with tPA:

Two Trevo clot retrieval devices were approved Friday by the FDA for use in conjunction with tPA thrombolysis in acute ischemic stroke patients.

Keys to survival include speed and expertise

Where are stroke centers? Click here for a map and a list, at least according to The Internet Stroke Center.

It stands to reason that stroke centers are the place to take stroke patients - as long as you can get to one relatively quickly. Read here about the question are stroke centers life savers?:

The odds of surviving a stroke are slightly better for patients treated at hospitals with a specialized stroke department, known as primary stroke centers, a new study finds.

But that benefit was only seen if stroke patients got to a stroke center in less than 90 minutes, the study authors said.

"Treatment of stroke is very time sensitive. As the saying goes, time is brain," said lead researcher Dr. Kimon Bekelis.

"So the faster you intervene, the faster the patient recovers," he said.

Sad but true facts about stroke patients, treatment and response

I was one of the fortunate - most people don't get to a hospital in time to be even considered for the primary treatment for stroke patients.

The treatment, tissue plasminogen activator (tPA) doesn't work all the time, and more treatments are being researched. Still, the drug has reduced the number of people who leave hospitals with little or no disability.

So, why so few people being treated? It's because, it seems, people don't get in a hurry to get to help with a stroke. And that's just not right. Know the symptoms. And get help F.A.S.T. Check out the story on how a medical team studies when an effective but sometimes risky stroke drug should be used:

God and time - he's got all that's needed for all of us

God has, quite literally, all the time in the world for each one of us.

-Philip Yancey

I'm a fan of time.

One of my favorite TV offerings is the program "Doctor Who" about an eccentric time traveler, with clever plots often revolving around time. And in real life, it's interesting to me how the timing of events have been so key in history and in my own life.

• A gifted, somewhat maverick, neurosurgeon winds up in a middle-size Southern city for a short time. In that small space of time, a family with a young child suddenly needs that surgeon to save the child's life.
• A woman facing Alzheimer's disease faces a move to be closer to one of her children. A facility just opens a new wing, offering as much independence as wanted but care if needed. As the disease progresses, the same facility builds an unparalleled skilled nursing facility next door. The woman is cared for in comfort close to a loving family in her last few months.

'Be strong and take heart'

Wait for the Lord; be strong and take heart and wait for the Lord.

-Psalm 27:14

Impatience - the story of my life.

I'm better than I used to be but still struggle with impatience. I avoid some things because of it - golf, for example. As an amateur woodworker, I use my hobby as a tool to teach myself patience. It's working, but slowly.

Impatience is a special challenge for many stroke survivors. I know it was (and is) mine. Struggling to read. Struggling for proper speech. Struggling to write clearly.

The best way I've found to conquer impatience is to read verses like this selection from Psalm. Timing is not always ours - often, timing is in God's time.

So think about that when you struggle with impatience. Use this time to build your inner strength - take heart and wait for the Lord.

One more way to potentially speed treatment

Speed, as you know, is key in treating stroke patients.

Recent news about telemedicine shortening door-to-needle time:

A mobile stroke treatment unit (MSTU) operated by Cleveland Clinic which uses telemedicine to connect emergency team members to a hospital-based vascular neurologist, reduced time to tPA treatment by more than 25 minutes in an analysis of the first 100 patients transported. ...

The phone number is easy to remember - but who's calling it?

A few posts ago, we looked at the hospital behavior after a stroke patient is hospitalized. And you have seen postings about how hospitals often take patients more seriously if they arrive via ambulance.

But who's calling for an ambulance ride? Here's an interesting look at how race and sex may influence who calls an ambulance for stroke symptoms:

With an average age of 71, half of the stroke patients were women and almost 70 percent were white. Almost 20 percent were black, 8 percent were Hispanic and 3 percent identified as Asian.

Training stroke patients for the just-in-case scenario

Photo from Thomas Hawk via Flickr

Learning is generally a good thing.

Ever been hospitalized? If so, it's likely you went through a discharge process, received some instructions and signed some papers. In my experience, most instructions are semi-helpful at best. Now, here's an idea that might be an upgrade for in-hospital instructions - educating stroke survivors helps them spot another stroke faster:

Stroke survivors who receive extensive stroke education are much more likely to recognize symptoms of another stroke and seek immediate treatment, a new study shows. ...

From biblical times to modern hospitals, timing can make all the difference

From Flickr by Sean MacEntee

Starting out in left field here. One of my favorite books in the Bible is Acts. Why? Because a lot of important events are happening quickly, and timing is critical. The order of events is part of a grand plan there.

I like timing things in life, too. I'm not as good as God with timing, but when my sequence of actions works, it gives me a great deal of satisfaction.

So, I'm interested in this recent story about how workflow processes can be a success, showing how clot busters can be delivered in an hour, even with an MRI:

Two centers -- one academic, one community -- that use MRI as part of an NIH study dropped their median DTN [Jeff's note: DTN stands for door-to-needle, or the time between the patient enters the hospital to the time of stroke treatment] time from 93 to 55 minutes after focusing their workflow processes, Amie Hsia, MD, of MedStar Washington Hospital Stroke Center, and colleagues reported online in Neurology.

Are hospital patients with stroke 'hiding in plain sight?'

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We're all told: Time is brain. And in a recent posting, even the newly developed tools to battle strokes work better when there's no delay.

So, it's a little distressing to find that time is still a problem - for patients who are already in a hospital. Even delays in imaging to determine best treatment. You'd think if the patient was already in the hospital, that would not be a problem.

But it is.

Read about recent research showing that imaging is delayed when a stroke strikes within a hospital:

Best stroke outcome still comes down to speed, it seems

When the drug tissue plasminogen activator (tPA) came along, we've heard time and again that speed is vital for improved outcomes for stroke patients.

Now, with other tools becoming available, it seems that the rule of speed still applies. The most recent example comes from an article about three keys to blazing fast thrombectomy:

Reduced disability with mechanical clot removal for large-vessel ischemic strokes -- as consistently seen across recent trials -- gave a clear mandate for use but also re-emphasized the need for speed.

"It's all about timing," said Patrick Lyden, MD, director of the stroke program at Cedars-Sinai in Los Angeles.

Read the whole story about the three keys. And remember - if you or someone you care about exhibit stroke signs, get to care. Fast.

Living too far away from stroke centers

Too far, too long.

Rural America is especially hard hit when it comes to stroke centers "over an hour away" for one third of Americans:

"Even under optimal conditions, many people may not have rapid access to comprehensive stroke centers, and without oversight and population level planning, actual systems of care are likely to be substantially worse than these optimized models," says Dr. Mullen.

Levels of access to care also varied in different geographical areas. Worryingly, access to care was lowest in an area often referred to as the "Stroke Belt" - 11 states where stroke death rates are more than 10% higher than the national average, predominantly situated in the southeast of the US.

"Reduced access to specialized stroke care in these areas has the potential to worsen these disparities," says Dr. Mullen. "This emphasizes the need for oversight of developing systems of care."

So the people who are most likely to need the care are also the most likely to be too far from care. We can - and must - do better.

Note to self: If you're going to have a stroke, schedule it

This week, I took a friend to a hospital's emergency room after normal business hours. This isn't the only visit that confirmed my belief that health care suffers after hours.

Now, from Denmark, a new study looks at that weekend effect:

Overall, death within 30 days was 15% more common among patients presenting to Danish hospitals on weekend, evening, or night-time hours compared with those admitted during regular business hours, Nina Sahlertz Kristiansen, MHSc, of the Centre for Quality in Middelfart, Denmark, and colleagues found.

Off-hours admissions were associated with a lower likelihood of meeting even eight out of 10 performance measures, but that difference diminished over time, particularly from 2003 to 2011 after a national quality improvement program, the group reported online in Stroke.

The key factor in the mortality difference appeared to be stroke severity, they noted.

If only strokes followed a calendar and time clock - only Monday through Friday, 9 to 5.

Reducing time can improve outcomes

You've heard here and elsewhere that time is so critical in stroke treatment. Even though stroke treatment is far from ideal, speed can often improve the outcome.

I ran across an interesting article that laid out ideas that experts propose to reduce time in treating strokes:

Because the absence of blood flow to the brain results in the ongoing death of brain cells and continued loss of functionality, “every minute of delay in administering t-PA is worth 1.8 days of disability-free life,” he said. “Years ago, we were treating 4 percent of patients nationwide with t-PA, which has grown to 8 percent and even 10 percent in New Jersey thanks to greater awareness by both hospitals and patients. But with a theoretical goal of administering it to 30-40 percent of all stroke patients someday,” he said, “we’ve got a long way to go.”

To help close that gap, Gizzi advocates further streamlining the process by which stroke victims are treated during transport to the hospital through a series of new practices, many of which require a physician’s greater trust in, reliance on, and collaboration with the emergency medical services personnel and paramedics who are first on the scene.

Most of us have seen delays in treatment of all kinds of ailments in hospitals and other locations. For stroke patients, delays can mean death or disability. The need for speed must be taken seriously.

It's global: Telemedicine can make a difference

Telemedicine is important in rural America. I've been through lots of small towns with few or no specialists who can make the difference between proper treatment and permanent disability or death.

Now, a study in Germany shows the impact telemedicine in that country:

During the same interval, the proportion of patients receiving thrombolytic therapy rose from 2.6% to 15.5%.

"The main findings of 10-year experience of TEMPiS showed that this type of telemedical stroke unit network is sustaining, offers state-of-the-art acute stroke care by increasing access to stroke units and improving thrombolysis service, and is associated with long-term improvement in terms of quality indicators of acute hospital care," Muller-Barna and colleagues wrote.

Telemedicine -- the use of modern teleconferencing technology to evaluate patients remotely and to recommend treatment strategies -- has increasingly been adopted in developed countries as a way to bring specialist care to rural areas where it is otherwise scarce or unavailable.

In the stroke setting, it involves putting stroke neurologists located mainly in urban tertiary care centers on call to evaluate patients brought into community hospitals in distant towns.

Time, as mentioned in this blog before, is key in stroke response. Using the combination of technology and medicine can decrease that time and improve outcomes.

On the road - with stroke treatment

It's known that the quicker the treatment, the better chances for better outcome for a stroke patient.

Now, one hospital is taking this one step further, taking stroke treatment on the road:

The unit -- a standard ambulance equipped with a CT scanner and stocked with clot-busting tissue plasminogen activator (tPA) -- overcomes the limitation of having to wait until a patient arrives at the hospital to confirm that the stroke is ischemic, which can drastically delay administration of the proven treatment.

The hope is that bringing the imaging and the tPA to the point of first medical contact out in the field will restore blood flow to the brain faster, save neurons, and ultimately improve patient outcomes, according to James Grotta, MD, director of stroke research for the Clinical Institute for Research & Innovation at Memorial Hermann-Texas Medical Center.

'Everything beautiful in its time'

He has made everything beautiful in its time. He has also set eternity in the human heart; yet no one can fathom what God has done from beginning to end.

-Ecclesiastes 3:11

It's a new year: A time for new starts, a time to look forward to hope.

Time can also be tricky. It can fly. It can drag. People - despite their best efforts - can't control time.

Yet time can be precious. Consider the words in Ecclesiastes - "He has made everything beautiful in its time." In its time. Not every thing is beautiful all the time. But in its time... .

Happy new year, everyone.

Quicker treatment, better outcomes

A couple of days ago, I posted a note about how hospitals increasingly give powerful clot-buster for stroke. A related item, showing the importance of early treatment shows that the quicker the treatment, the better chances of a better outcome.

A study indicates that ultra-early treatment reduces disability after stroke:

... [T]he new study found that when these clot-busting drugs were administered even sooner -- within 90 minutes of the appearance of stroke symptoms -- patients had little or no disability after three months compared with patients who got the drugs later.

"Despite the time window of 4.5 hours to give clot-busting drugs, there are clear differences between patients treated ultra-early -- within 90 minutes -- and those treated later," said lead researcher Dr. Daniel Strbian, an associate professor of neurology at Helsinki University Central Hospital in Finland."

Stroke is the leading cause of disability in the United States, so quicker treatment to reduce these outcomes should be a high priority. I'll end this with the same note I ended the last posting: It's vital that a stroke patient get help quickly. Recognize the signs of a stroke and don't hesitate in getting aid!