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Stroke Services Gain Stamp of Approval


Neurologists Eric Aldrich, left, and Rafael Llinas have merged the stroke programs at Hopkins Hospital and Hopkins Bayview.
Last spring over a birthday dinner with all the family around the table, Alice, a 75-year-old woman from Gaithersburg, Md., began slurring her speech. One side of her face drooped. Thinking she would be better in the morning, her children put her to bed. That was a mistake. Alice was actually suffering from a stroke caused by a blood clot in an artery feeding her brain.

The next morning, she arrived at Hopkins Hospital, too late to administer an intravenous drug that would have dissolved the clot. She was admitted to the brain rescue unit where a full complement of specialists would start her on what looked to be a very long road to recovery.

Failure to recognize symptoms and late arrival at the hospital are factors that can hinder proper stroke care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in conjunction with the American Stroke Association, has developed a nationwide certification program that evaluates the stroke care hospitals provide. Those that make exceptional efforts to foster better outcomes—that have a variety of experienced stroke specialists, a dedicated hospital unit and superior nursing—are designated “primary stroke centers.”

This year, both Hopkins Hospital and JH Bayview Medical Center qualified as primary stroke centers. “For five or six years, people in multiple departments have been working toward improving our stroke service, so certification is sort of the icing on the cake,” says Eric Aldrich, assistant director of the stroke service at Hopkins Hospital. “What is particularly gratifying, though, is that everyone’s embraced the fact that both hospitals are two parts of the same whole. That’s the big achievement.”

Aldrich, along with colleague Rafael Llinas, stroke director at Hopkins Bayview, helped merge the two programs. The collaboration cuts across departmental lines, pulling in neurologists, cerebrovascular neurosurgeons, neurointensivists and interventional neuroradiologists. The result is a comprehensive program with enough patients to conduct high-quality clinical trials.

Between them, the centers treat some 700 stroke cases a year. About 500 are “ischemic,” caused by a blocked artery; the rest are “hemorrhagic,” resulting from burst blood vessels in or near the brain. The centers also treat hundreds more cerebrovascular conditions, including aneurysms and transient ischemic attacks (TIAs), and have rare expertise treating strokes in children.

“For the most part, the services are entirely merged, financially and administratively,” says Llinas. He and Aldrich rotate between the hospitals and spend a month attending at each. At both centers, residents and fellows rotate and take call, and a stroke team is on duty 24/7. And yet, “each institution has its own neighborhood and personality,” says Robert Wityk, director of the stroke service at Hopkins Hospital. Hopkins Bayview, for instance, sees more strokes caused by hypertension and smoking; JHH, more caused by drug abuse and HIV.

In 1996, Wityk was among the first to use intravenous tPA, the clot-breaking drug. He soon brought together an acute stroke team to treat patients arriving at the hospital’s ED. In 2000, he and the nursing staff opened the inpatient brain rescue unit (BRU) on Meyer 7. At Hopkins Bayview, an acute stroke team was established and inpatient management standardized.

The units have fostered collaboration among doctors and nurses. Now nurses have expertise in stroke management, and an exceptionally high number are certified in neuroscience, says Robin Wantz, nurse manager of Hopkins Hospital’s BRU, now on Meyer 9.

Many hospitals, Aldrich notes, have sought to model their stroke services on the rapid response procedures of trauma centers. They want stroke victims to go to stroke centers much like accident victims go to trauma centers. Taking this notion one step further, Hopkins Hospital and Hopkins Bayview aim to create stroke centers akin to heart or cancer centers, where all the physicians and therapists are brought together for the patient.

Once it certifies primary stroke centers (currently about 100 nationwide), JCAHO plans a second round of evaluations to certify “comprehensive” stroke centers. When their new, two-year certifications come up for review, Hopkins Hospital and Hopkins Bayview will seek this expanded designation—and more. “We’re working toward a comprehensive stroke program for all of Johns Hopkins and its affiliates,” says Aldrich. “Our dream is to become a model of an integrated stroke program across an entire health care system.”

—Neil A. Grauer

 

 

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