Beaufort News

Would proposed protocols save more stroke patients?

  • In South Carolina, the state with the nation's fifth-worst stroke mortality rate, a group of specialists and lawmakers wants to change the way the most severe stroke patients are treated.
  • The specialists, who submitted a 165-page report to state legislators this month, want many acute patients to get urgent treatment at Charleston's Medical University of South Carolina, the state's only top-rated stroke hospital and the only one where stroke-specific surgical intervention is always available.

    The S.C. Department of Health and Environmental Control approved the new guidelines last year. They were distributed to some EMS departments in November, but Beaufort County has not been told to make the change, according to Beaufort County EMS training officer Julie Williams. Legislation to make the protocols law has been suggested, but not yet introduced.

    The S.C. DHEC approved the new guidelines last year, they don't become mandatory unless the legislature votes in favor of them.

    State Sen. Darrell Jackson, a Richland Democrat who sits on the Senate Medical Affairs committee, has said his aides were finalizing the bill.

    Patients who have experienced symptoms for more than three hours before an ambulance arrives should be taken directly to MUSC if they are within an hour's drive of the Charleston hospital, the new protocols say.

    Symptoms of a stroke include:

  • sudden numbness or weakness in the face, arm or leg, especially on one side of the body
  • sudden confusion, trouble speaking or understanding
  • sudden trouble seeing in one or both eyes
  • sudden dizziness, loss of balance or coordination
  • sudden severe headache with no known cause.
  • For acute patients more than an hour from Charleston, the new protocols may mean going to a local hospital as a stopover before quickly being transferred to MUSC by helicopter or ambulance.

    Beaufort County hospital officials say they already transfer many severe stroke patients to MUSC, but they also say they have neurologists on staff to treat stroke patients. One local hospital official believes legislation is unnecessary and would contradict national efforts to get stroke patients to a hospital as soon as possible.

    WHERE TO GO?

    MUSC stroke center director Robert Adams and research director Edward Jauch leaders of the new effort to provide fast intervention for severe stroke patients.

    Under the proposed protocols developed after a yearlong study, EMS workers would determine when a stroke began before deciding where to take the patient.

    The protocols, similar to those used for trauma patients, call for patients to go to the hospital best able to treat them rather than to the nearest hospital, Jauch said.

    In some cases, patients should bypass level-two stroke centers -- such as Coastal Carolina Hospital in Hardeeville -- to get to MUSC,the proposed protocols say.Beaufort Memorial and Hilton Head hospitals are not stroke-certified.

    Williams, of Beaufort County EMS, said her department is aware of the new protocols but will follow the county's current stroke protocol until DHEC requires it to change.

    Williams said the results of neurological and physical exams and a pre-hospital fibrinolytic check sheet dictate the hospital that's best for the patient.

    "Our goal with stroke patients is the same as that with our (heart attack) and trauma patients, which is to transport to a facility that can provide the most appropriate care for the patient's needs," Williams said. "Deviation from transporting to a preferred facility will depend on the current condition of the patient."

    She said stroke patients' locations within the county also is a factor in where they will be treated.

    Coastal Carolina is the first choice for patients in southern Beaufort County, Williams said.

    Paramedics also may opt to transport them to Memorial University Medical Center in Savannah, rather than MUSC, she said. The Savannah hospital is a primary stroke-care center, according to The Joint Commission , which rates hospitals ability to treat stroke patients.

    Northern Beaufort County patients destinations' depend on the results of the physical exam and fibrinolytic check sheet, which helps doctors determine whether the patient can receive a drug that will dissolve their clot, Williams said. The medication is available at Beaufort Memorial Hospital.

    If the evaluation reveals the patients cannot receive a medication for the stroke, they will be transported by ground or air to a stroke facility, she said.

    The closest level-one stroke facility, where doctors can surgically remove blood clots that restrict blood flow to the brain and cause strokes, is MUSC.

    HOSPITALS RESPOND

    Bill Masterton, CEO of Hardeeville's Coastal Carolina Hospital, said administrators at Coastal Carolina and Hilton Head Hospital -- both owned by Tenet Healthcare -- are reviewing the report to gauge the impact of the recommendations on services at both hospitals.

    Although both have neurologists available to evaluate patients, Masterton said both hospitals support sending the most critical stroke patients to MUSC.

    Helicopter transport to Charleston, which takes about 20 minutes, can be expensive, but it usually is covered by insurance, he said.

    Even if Coastal Carolina patients are not transported to MUSC, they may still be treated by a neurologist there.

    Coastal Carolina is involved in a "tele-medicine" program that allows doctors to consult by remote video camera with MUSC experts, a program that has expanded to 11 hospitals in two years.

    MUSC doctors might make recommendations such as transporting patients to their hospital for more advanced treatment, according to Sheila Traficante, RN and Coastal Carolina's stroke program coordinator.

    Advanced treatment can include surgery, but only a fraction of patients require such treatment, she said.

    "Having this arrangement helps us save time," Traficante said. "When patients arrive at the emergency room, they are already being evaluated and can begin receiving necessary, lifesaving treatment before they are transported."

    Patients might receive a tissue plasminogen activator, or t-PA, a drug that can break up the blood clot and restore blood flow, oxygen and nutrients to the brain. The faster the clot is broken up, the better the odds of full recovery.

    "The important thing to remember is, if you have any stroke symptoms, you must get to the hospital within 60 minutes of the first symptoms," Traficante said.

    Dr. Paul Mazzeo, Beaufort Memorial Hospital's chief of staff, said addressing stroke care through legislation is misguided. The only instance in which an acute stroke patient would benefit from transfer to MUSC would be in the instance of a brain hemorrhage, he said.

    About 85 percent of all strokes are non-bleeding. Many of the remaining 15 percent do not require surgery, and those that do already are transferred to MUSC and other hospitals where surgery is available, Mazzeo said.

    "Legislation is not needed to interfere in this decision-making process," Mazzeo said. "Every minute that passes without intervention using clot-busting medication is associated with the death of millions of brain cells. The legislation also would encourage a degradation of the skills of local physicians from lack of use when these skills may be called upon to assist our patients."

    Mazzeo said legislation also would counter a national campaign that encourages patients with stroke symptoms to get to the nearest hospital right away because "time is brain."

    Neurologists at Beaufort Memorial often give patients MRIs in the emergency room if they arrive with stroke symptoms, and the hospital also has a comprehensive Acute Rehabilitation Unit to aid in restoring functional independence in stroke patients, he said.

    "We've participated in numerous national clinical research trials in treating acute stroke," he said. "In my opinion, the value of rapidly treating a stroke patient and rehabilitating that person in a setting where they can be supported by their loved ones cannot be underestimated."

    Mazzeo added that asking EMS or an emergency room physician to take the time to evaluate a patient, determine that they're having a stroke and then arrange transport to MUSC is treatment time lost that increases the risks of permanent disability.

    There's also a matter of finding available transport to MUSC.

    "Over the course of my 16 years of practicing in Beaufort, there have been many times when I've had to request transfer to MUSC but found that the helicopter was not flying due to weather conditions or that a bed was simply not available at MUSC to accept the patient," he said.

    The (Charleston) Post & Courier contributed to this report.

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