Time is Brain: How our Stroke Team is working to improve systems across Wyoming
By Kristy Bleizeffer May 11, 2018
Life-saving stroke care is measured in minutes. Time is brain, the saying goes, and the faster doctors open the blocked blood vessel, the better the chance of survival and recovery.
Treating stroke involves almost every clinical department at Wyoming Medical Center, starting with emergency responders. Our multidisciplinary stroke team meets every month to analyze the latest data, collaborate on best care practices and troubleshoot areas that need improvement.
Neurologist David Wheeler, M.D., Ph.D., F.A.A.N., is medical director of WMC’s Primary Stroke Center, the only center in Wyoming certified by the Joint Commission. In this interview, he explains the work of the Stroke Steering Committee and how we are reaching out to provide this life-saving stroke care to patients across the state.
Who is on the stroke team?
The most important component is the emergency medical personnel – paramedics, EMTs and emergency room nurses – who are now engaged in evaluating the patient in the field and alerting the team that a stroke patient is coming. By recognizing stroke symptoms and activating the stroke team while the patient is on the way to the hospital, we are able to start treatment much faster and save more brain cells.
I am the medical director of the stroke team and lead the team of neurologists who take stroke call. Melody Bowar, R.N., B.S.N., C.N.R.N., S.C.R.N., is the Stroke Center coordinator and ensures that every patient with stroke gets the best possible care. She is also responsible for making sure the quality of our program is the best it can be and ensures we are recognized by the certifying agencies for the work we do.
Other members of the team include the emergency room physicians who are often the first point of contact when the patient arrives and our radiologists who help interpret the studies and are involved in doing interventions if they are necessary. We also have nursing from ICU and the neurological unit along with representatives from the therapy disciplines – physical therapy, occupational therapy and speech.
What happens in these monthly meetings?
It is a continual process improvement group. So, we review the performance of the program, identify areas for improvement and develop strategies for overcoming those deficits or problems as we see them. There has never been a meeting where there was not something we were concerned about that we thought we could do better. That has been true since we started meeting monthly in 2006, when hospital administration asked me to help develop a program for stroke care. At the time, we embarked on becoming certified by the Joint Commission as a stroke center and used American Heart Association’s Get with the Guidelines program.
What are some of the big milestones in stroke care at WMC since 2006?
First and foremost, we just got a lot better at recognizing as a team acute stroke and putting systems in place to respond to it. The next big change came between 2010-2013 and was recognizing that a larger population of stroke patients would benefit from intravenous tPA, the clot-busting medication, than we were treating. So we expanded the time window for treatment and changed the exclusion criteria so that more people were able to be treated effectively. Right from the beginning, we were doing intra-arterial tPA occasionally but not consistently, a couple times a year.
In about 2015, the first studies started coming out showing profound benefits for mechanical thrombectomy – or using the stent retriever devices to pull blood clots from the blocked vessel in the brain. Right away, we began figuring out how we could deliver that service effectively. That was a big process change for us and something that we are still working on: making sure that we are able to assemble the team rapidly, always have the equipment that we need and, more importantly, identifying early which patients may be candidates for that treatment. Early identification, even before patients arrive at the hospital, will have an impact on how you are going to triage them and how quickly you can get them treated.
Now, we are currently working on getting the right patient to the right facility in Wyoming as quickly as possible. Our focus is developing a statewide system of care. Newer data just released in the last couple of weeks shows that some patients may benefit from mechanical thrombectomy up to 24 hours after their symptoms start (as opposed to previous guidelines of about 6 hours). So, the next phase is figuring out how to get these patients to the place where they can be evaluated for the extended time window and then get that treatment. Practically, Wyoming Medical Center can do the mechanical thrombectomy, but we have to get the patient here in a timely manner to determine if it is the right course of treatment.
What does that mean for Wyoming patients?
To put it simply, it means if you have a stroke in WMC’s catchment area, your odds of having a good outcome after a stroke are significantly better. Stroke is the fifth leading cause of death and the leading cause of long-term disability, so its economic and personal impacts are incalculable. With aggressive treatment, many patients are now able to resume their normal lives within a relatively short period of time. That is only true because we are setup to recognize stroke quickly and assemble the team required to fix the problem quickly.
We still are relying on people recognizing the symptoms of stroke and calling 9-1-1. That is, I think, still our biggest area for potential improvement. Then, we are still trying to develop the best strategies for helping people in more distant regions. So, how do we combine the expertise of their local hospital without getting in the way of the care that they need?
What are you doing with other hospitals around the state to improve this system?
First and foremost, we are trying to help all of our sister facilities become experts in recognizing acute stroke and giving clot buster medication as quickly as possible. The next phase is to recognize which patients might benefit from mechanical thrombectomy and getting those candidates onto that next level of care as quickly as possible. Sometimes, that means bypassing the local ER and coming straight to Wyoming Medical Center as quickly as possible.
We do personal visits either in person or using teleconferencing technology to interact with hospital administration and providers that are at our other facilities. We provide feedback on patients that they send to us for care, letting them know how things turned out and what we think might have helped make things go better. We work with organizations like the American Heart/Stroke Association to make them aware of educational opportunities through webinars and local conferences.
There is a significant desire out there to do better with acute stroke care across the state, and I think there is an eagerness to collaborate on delivering that care between the organizations. I am sure that we have a lot of work to do in terms of teaching people about the mechanical thrombectomy aspects of this and extended time windows, because that is all really new.
Are you surprised at how stroke treatment has progressed in your career?
Yes. When I was a resident, the treatments only worked maybe 1 in 10 times that you had a really amazing outcome. Then, every once in a while you would see kind of a miraculous improvement with the intra-arterial tPA, but it was not a normal thing. In the last couple years, when we get the clot out with mechanical thrombectomy, the majority of patients walk away unscathed which is astonishing.
What are your closing thoughts on the WMC stroke team?
I am proud of the work that this team has done at Wyoming Medical Center. I think it is really remarkable that so many people work so diligently all the time to keep making this better. I have been on a lot of committees, but I have never been part of one that so reliably brings so many people to the table who are engaged. And the results speak for themselves.
I am inspired by the amazing dedication that these people show to doing it well and doing it well every single time. This whole facility is just really engaged when it comes to doing the right thing for people and that is what keeps me here. The people who work here in this hospital are incredible.
Dr. David B. Wheeler is a neurologist at Wyoming Neurologic Associates.