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City lacks certified stroke programs
Web Posted: 06/01/2008 01:21 AM CDT
By Don Finley
Express-News
Frustrated by their efforts to build a system of stroke care in San Antonio as good as its trauma system, local emergency medical officials are starting to point fingers — blaming an absence of physician leadership and hospital inertia for the lack of progress.
San Antonio lacks even a single hospital certified to offer basic emergency care to stroke patients — unlike other large Texas cities that have several, and many smaller towns that have at least one.
“It is surely a tragedy and an embarrassment to our community that San Antonio is the worst city in which to suffer a stroke, regarding acute care, of any city its size,” said Dr. Robert Hart, a stroke expert and professor of neurology at the University of Texas Health Science Center.
A local committee of doctors, hospital administrators and emergency medical personnel responsible for organizing San Antonio's emergency stroke care halted deliberations in February for 90 days while its members worked out differences within their own institutions.
On May 23, Dr. Ronald Stewart, a trauma surgeon and chairman of the regional advisory council that oversees the committee, e-mailed invitations to physicians who treat stroke patients to attend the committee's next meeting Monday.
“In spite of more than a year of discussions and meetings with all the major health care systems and a number of physicians, little progress has been made in establishing a functional stroke system,” Stewart wrote. “San Antonio acute stroke patients have been transferred to a wide number of different areas, including Kerrville, Austin and McAllen, because of the lack of care available here in San Antonio. In my opinion, this situation is unacceptable.”
While neurosurgeons and neurointerventionalists (a subspecialty that performs advanced procedures on stroke patients) are in short supply and often unwilling to be on call for after-hours emergencies, the larger problem, observers say, is that hospitals are reluctant to build state-of-the-art stroke programs without the help of neurologists — who are skilled in diagnosing and treating stroke patients. Most neurologists have busy office practices and see little reward in leaving their crowded waiting rooms to rush to the hospital.
“The tricky thing is taking call, being available at a moment's notice,” said Dr. Alan Halliday, a San Antonio neurologist and president-elect of the Texas Neurological Society.
“The places that have successful stroke centers — although there are some community-based ones in really tight communities — are usually at places like medical schools, where there are on-staff, salaried physicians, lots of residents and fellows who are right there 24/7. Not calling some guy to get out of bed to race in to assume malpractice risk with little reimbursement.”
But University Hospital, the primary teaching hospital for the health science center, recently broke up its acute stroke team after several years. The neurologists pulled out, saying they couldn't afford to maintain 24-hour coverage for only a handful of patients.
Badly overtaxed with trauma patients and the uninsured, University closes its emergency room doors to medical patients about 75 percent of the time, with ambulances diverted to other hospitals. A new surgical tower is planned at University to ease the crunch, but it isn't scheduled for completion until at least 2012.
And while San Antonio's stroke care problems mirror those across the country, other places have managed to overcome them — largely through physician leadership, said Stewart, chairman of the Southwest Texas Regional Advisory Council for Trauma, which the state has charged with building a stroke system on the framework of the regional trauma system.
“This is a travesty — especially when one looks at the progress other, much smaller cities have made,” Stewart said. “There are many factors responsible for this lack of progress, but the two largest factors are a lack of physician leadership and a lack of beds at University Hospital.”
‘Just criminal'
A new voice in the debate belongs to Suzanne Hildebrand, founder and former president of the local chapter of Mothers Against Drunk Driving. Her husband, 68-year-old Ray Hildebrand, was found April 16 collapsed on a restroom floor at the Bexar County district attorney's office, where he works as a criminal investigator.
He was rushed to Baptist Medical Center, where the doctor told his wife he had suffered a brain hemorrhage and would have to be transferred to another hospital.
“I said, ‘Why can't you take care of him?'” And he said, ‘Because we're not a stroke unit.'”
More than seven hours later, after multiple calls to find a stroke center that would admit him, a helicopter delivered Hildebrand to Brackenridge Hospital in Austin, the closest facility that would accept him. When his wife saw him last in San Antonio he was speaking slowly but clearly and could move his right arm and leg. By the time he reached Austin, those functions were gone. The Austin surgeon told her it was too late to operate.
“I'm angry,” said Suzanne Hildebrand, her voice breaking. “I don't understand why, when we can pass these venue taxes, when we say we've got the best medical center in South Texas — and we don't have a stroke center? Give me a break.”
Hildebrand is recovering in a San Antonio long-term care hospital, unable to speak clearly or stand without help. His wife plans to raise the issue with lawmakers and go before Bexar County Commissioners Court.
“Nobody wants to take responsibility,” she said. “Nobody wants to have to get up in the middle of the night and go down there. And this is just criminal.”
Stroke is the third-leading cause of death in the United States, after heart disease and cancer. An estimated 780,000 Americans will suffer a stroke this year and 150,000 of them will die from it. As many as 30 percent of survivors will be permanently disabled.
More than 80 percent of strokes are ischemic, caused by a blood clot in the brain. The rest are hemorrhagic, caused by bleeding.
Not simple
In 2000, a national group of experts, advocates and government officials called the Brain Attack Coalition published recommendations for hospital-based stroke programs. The idea was to build a system of stroke care modeled on the nation's trauma system. Primary stroke centers would stabilize and provide emergency care, while comprehensive stroke centers would handle the most complicated cases.
The Joint Commission, the national accrediting body for hospitals, began certifying primary stroke centers in 2002. The criteria for certifying comprehensive stroke centers are still being hammered out.
The Texas Legislature in 2005 created a stroke committee to oversee the creation of a statewide stroke system, using the framework of the 22 trauma regions in Texas. No funding is available for hospitals or communities to participate.
“I think several of the (local hospital) systems are very interested and committed to designating as stroke centers, but appear to lack adequate physician coverage for such an undertaking,” said Eric Epley, executive director of the South Texas Regional Advisory Committee, and chairman of the stroke committee.
“University Hospital has some physician support but is handicapped by a critical bed shortage. The population of possible stroke patients is quite large, and if only one hospital in the city designates as a stroke center, it will become the default destination for all of those patients,” Epley said. “The added load of patients is concerning, but not nearly as concerning as not having the commitment of the physicians that are required to take care of critical stroke patients.”
A powerful drug, tissue plasminogen activator, or tPA, can limit the disabling after-effects of clotting strokes if given within three hours after symptoms begin — although neurointerventionalists are able to thread a catheter closer to the brain and give the drug beyond three hours. For bleeding strokes, quick access to a neurosurgeon is required.
To qualify for even basic or primary certification, a stroke center has to have an acute stroke team available around the clock to evaluate within 15 minutes any patient suspected of having a stroke. A neurosurgeon must be available within two hours. And tPA must be offered.
It would seem simple, but it's not. Although neurologists aren't the only doctors who can administer tPA, they are the most familiar and comfortable with it. TPA is a powerful drug and even when given correctly causes bleeding in about one in every 16 patients, Hart said — adding drug companies have so far failed to come up with a better and safer alternative.
Many emergency medicine physicians have been skeptical of tPA. The American College of Emergency Physicians' policy on the drug calls for “an institutional commitment” from the hospital and all specialty groups involved before it's made available.
In reality, hospitals prefer it be given by a neurologist. And there lies the problem, Halliday and others said.
“The neurologists learned that for hospital privileges they had to take call, which means you're available 24/7,” said Halliday, chief of neurology at Brooke Army Medical Center. “For neurosurgeons to take call, the hospitals started reimbursing them: ‘Here's $1,000 a day, $3,000 a day, just to carry your beeper. Neurologists, you get nothing. But you have to come in here in the middle of the night for an indigent, noninsured patient for which you'll never get reimbursed, and you do assume risk for taking their care.'”
Recognizing that neurologists now treat most patients in their offices, the American Academy of Neurology is recommending that they be paid extra for being on call for emergency consultations, in addition to whatever patient fees they generate.
“The ideal thing would be to have a group of hospitals get together and work something out so that maybe during a given time, all acute stroke patients who are eligible for (tPA) went to one facility, and the volume of patients then would justify putting together on-call teams,” Hart said. “That's never happened.”
‘We will work this out'
And individual hospitals are working on other solutions. The Baptist Health System sometimes uses telemedicine so that emergency room doctors can consult with neurologists in remote cities. And they plan to hire staff neurologists within the next few months, said Michael Zucker, chief development officer of the Baptist system, who thinks that offering first-rate stroke care can be profitable.
The Baptist system also is in discussion with health science center neurosurgeons to work at St. Luke's Baptist Hospital — which might seek certification as a comprehensive center, as University also hopes to do. With a little creativity, Zucker said, officials would like to see all of the Baptist hospitals certified at least as basic, or primary, stroke centers.
“The city doesn't have anything right now,” Zucker said. “Access is a big challenge in this community. A patient shows up and the level of service isn't available, and we have to transfer them to where that is. I don't know that everybody can be a comprehensive center and I don't think we're going to see that. But certainly we can have one or two, just like we have several trauma centers.”
Christus Santa Rosa hospitals have no immediate plans to seek certification. “Currently, we do not have all of the components necessary to seek designation,” a spokeswoman said. “Working with the medical community, we would like to be in a position to seek such status at some point in the future.”
Methodist Hospital, which includes a facility it calls the Texas Neurosciences Institute, was less forthcoming. “We're working on it,” said spokeswoman JoAnn King. The hospital did not respond to requests for elaboration.
At University, officials are trying to figure out how to improve stroke care given the unavailability of beds and neurologists, said Nancy Ray, chief nursing officer and associate administrator of the hospital.
“Much of stroke care can be done through protocols: Given these symptoms, given this CT scan, given this blood work, this is what you do. And the key to following these protocols is that you do it very rapidly. And so maybe a combination of neurology and other faculty such as our emergency medicine faculty and our hospitalists can step up in an organized way to create a system and a program.
“Every physician is committed to doing this,” Ray said. “Nobody is proud of this. So we will work this out.”
Web Posted: 06/01/2008 01:21 AM CDT
By Don Finley
Express-News
Frustrated by their efforts to build a system of stroke care in San Antonio as good as its trauma system, local emergency medical officials are starting to point fingers — blaming an absence of physician leadership and hospital inertia for the lack of progress.
San Antonio lacks even a single hospital certified to offer basic emergency care to stroke patients — unlike other large Texas cities that have several, and many smaller towns that have at least one.
“It is surely a tragedy and an embarrassment to our community that San Antonio is the worst city in which to suffer a stroke, regarding acute care, of any city its size,” said Dr. Robert Hart, a stroke expert and professor of neurology at the University of Texas Health Science Center.
A local committee of doctors, hospital administrators and emergency medical personnel responsible for organizing San Antonio's emergency stroke care halted deliberations in February for 90 days while its members worked out differences within their own institutions.
On May 23, Dr. Ronald Stewart, a trauma surgeon and chairman of the regional advisory council that oversees the committee, e-mailed invitations to physicians who treat stroke patients to attend the committee's next meeting Monday.
“In spite of more than a year of discussions and meetings with all the major health care systems and a number of physicians, little progress has been made in establishing a functional stroke system,” Stewart wrote. “San Antonio acute stroke patients have been transferred to a wide number of different areas, including Kerrville, Austin and McAllen, because of the lack of care available here in San Antonio. In my opinion, this situation is unacceptable.”
While neurosurgeons and neurointerventionalists (a subspecialty that performs advanced procedures on stroke patients) are in short supply and often unwilling to be on call for after-hours emergencies, the larger problem, observers say, is that hospitals are reluctant to build state-of-the-art stroke programs without the help of neurologists — who are skilled in diagnosing and treating stroke patients. Most neurologists have busy office practices and see little reward in leaving their crowded waiting rooms to rush to the hospital.
“The tricky thing is taking call, being available at a moment's notice,” said Dr. Alan Halliday, a San Antonio neurologist and president-elect of the Texas Neurological Society.
“The places that have successful stroke centers — although there are some community-based ones in really tight communities — are usually at places like medical schools, where there are on-staff, salaried physicians, lots of residents and fellows who are right there 24/7. Not calling some guy to get out of bed to race in to assume malpractice risk with little reimbursement.”
But University Hospital, the primary teaching hospital for the health science center, recently broke up its acute stroke team after several years. The neurologists pulled out, saying they couldn't afford to maintain 24-hour coverage for only a handful of patients.
Badly overtaxed with trauma patients and the uninsured, University closes its emergency room doors to medical patients about 75 percent of the time, with ambulances diverted to other hospitals. A new surgical tower is planned at University to ease the crunch, but it isn't scheduled for completion until at least 2012.
And while San Antonio's stroke care problems mirror those across the country, other places have managed to overcome them — largely through physician leadership, said Stewart, chairman of the Southwest Texas Regional Advisory Council for Trauma, which the state has charged with building a stroke system on the framework of the regional trauma system.
“This is a travesty — especially when one looks at the progress other, much smaller cities have made,” Stewart said. “There are many factors responsible for this lack of progress, but the two largest factors are a lack of physician leadership and a lack of beds at University Hospital.”
‘Just criminal'
A new voice in the debate belongs to Suzanne Hildebrand, founder and former president of the local chapter of Mothers Against Drunk Driving. Her husband, 68-year-old Ray Hildebrand, was found April 16 collapsed on a restroom floor at the Bexar County district attorney's office, where he works as a criminal investigator.
He was rushed to Baptist Medical Center, where the doctor told his wife he had suffered a brain hemorrhage and would have to be transferred to another hospital.
“I said, ‘Why can't you take care of him?'” And he said, ‘Because we're not a stroke unit.'”
More than seven hours later, after multiple calls to find a stroke center that would admit him, a helicopter delivered Hildebrand to Brackenridge Hospital in Austin, the closest facility that would accept him. When his wife saw him last in San Antonio he was speaking slowly but clearly and could move his right arm and leg. By the time he reached Austin, those functions were gone. The Austin surgeon told her it was too late to operate.
“I'm angry,” said Suzanne Hildebrand, her voice breaking. “I don't understand why, when we can pass these venue taxes, when we say we've got the best medical center in South Texas — and we don't have a stroke center? Give me a break.”
Hildebrand is recovering in a San Antonio long-term care hospital, unable to speak clearly or stand without help. His wife plans to raise the issue with lawmakers and go before Bexar County Commissioners Court.
“Nobody wants to take responsibility,” she said. “Nobody wants to have to get up in the middle of the night and go down there. And this is just criminal.”
Stroke is the third-leading cause of death in the United States, after heart disease and cancer. An estimated 780,000 Americans will suffer a stroke this year and 150,000 of them will die from it. As many as 30 percent of survivors will be permanently disabled.
More than 80 percent of strokes are ischemic, caused by a blood clot in the brain. The rest are hemorrhagic, caused by bleeding.
Not simple
In 2000, a national group of experts, advocates and government officials called the Brain Attack Coalition published recommendations for hospital-based stroke programs. The idea was to build a system of stroke care modeled on the nation's trauma system. Primary stroke centers would stabilize and provide emergency care, while comprehensive stroke centers would handle the most complicated cases.
The Joint Commission, the national accrediting body for hospitals, began certifying primary stroke centers in 2002. The criteria for certifying comprehensive stroke centers are still being hammered out.
The Texas Legislature in 2005 created a stroke committee to oversee the creation of a statewide stroke system, using the framework of the 22 trauma regions in Texas. No funding is available for hospitals or communities to participate.
“I think several of the (local hospital) systems are very interested and committed to designating as stroke centers, but appear to lack adequate physician coverage for such an undertaking,” said Eric Epley, executive director of the South Texas Regional Advisory Committee, and chairman of the stroke committee.
“University Hospital has some physician support but is handicapped by a critical bed shortage. The population of possible stroke patients is quite large, and if only one hospital in the city designates as a stroke center, it will become the default destination for all of those patients,” Epley said. “The added load of patients is concerning, but not nearly as concerning as not having the commitment of the physicians that are required to take care of critical stroke patients.”
A powerful drug, tissue plasminogen activator, or tPA, can limit the disabling after-effects of clotting strokes if given within three hours after symptoms begin — although neurointerventionalists are able to thread a catheter closer to the brain and give the drug beyond three hours. For bleeding strokes, quick access to a neurosurgeon is required.
To qualify for even basic or primary certification, a stroke center has to have an acute stroke team available around the clock to evaluate within 15 minutes any patient suspected of having a stroke. A neurosurgeon must be available within two hours. And tPA must be offered.
It would seem simple, but it's not. Although neurologists aren't the only doctors who can administer tPA, they are the most familiar and comfortable with it. TPA is a powerful drug and even when given correctly causes bleeding in about one in every 16 patients, Hart said — adding drug companies have so far failed to come up with a better and safer alternative.
Many emergency medicine physicians have been skeptical of tPA. The American College of Emergency Physicians' policy on the drug calls for “an institutional commitment” from the hospital and all specialty groups involved before it's made available.
In reality, hospitals prefer it be given by a neurologist. And there lies the problem, Halliday and others said.
“The neurologists learned that for hospital privileges they had to take call, which means you're available 24/7,” said Halliday, chief of neurology at Brooke Army Medical Center. “For neurosurgeons to take call, the hospitals started reimbursing them: ‘Here's $1,000 a day, $3,000 a day, just to carry your beeper. Neurologists, you get nothing. But you have to come in here in the middle of the night for an indigent, noninsured patient for which you'll never get reimbursed, and you do assume risk for taking their care.'”
Recognizing that neurologists now treat most patients in their offices, the American Academy of Neurology is recommending that they be paid extra for being on call for emergency consultations, in addition to whatever patient fees they generate.
“The ideal thing would be to have a group of hospitals get together and work something out so that maybe during a given time, all acute stroke patients who are eligible for (tPA) went to one facility, and the volume of patients then would justify putting together on-call teams,” Hart said. “That's never happened.”
‘We will work this out'
And individual hospitals are working on other solutions. The Baptist Health System sometimes uses telemedicine so that emergency room doctors can consult with neurologists in remote cities. And they plan to hire staff neurologists within the next few months, said Michael Zucker, chief development officer of the Baptist system, who thinks that offering first-rate stroke care can be profitable.
The Baptist system also is in discussion with health science center neurosurgeons to work at St. Luke's Baptist Hospital — which might seek certification as a comprehensive center, as University also hopes to do. With a little creativity, Zucker said, officials would like to see all of the Baptist hospitals certified at least as basic, or primary, stroke centers.
“The city doesn't have anything right now,” Zucker said. “Access is a big challenge in this community. A patient shows up and the level of service isn't available, and we have to transfer them to where that is. I don't know that everybody can be a comprehensive center and I don't think we're going to see that. But certainly we can have one or two, just like we have several trauma centers.”
Christus Santa Rosa hospitals have no immediate plans to seek certification. “Currently, we do not have all of the components necessary to seek designation,” a spokeswoman said. “Working with the medical community, we would like to be in a position to seek such status at some point in the future.”
Methodist Hospital, which includes a facility it calls the Texas Neurosciences Institute, was less forthcoming. “We're working on it,” said spokeswoman JoAnn King. The hospital did not respond to requests for elaboration.
At University, officials are trying to figure out how to improve stroke care given the unavailability of beds and neurologists, said Nancy Ray, chief nursing officer and associate administrator of the hospital.
“Much of stroke care can be done through protocols: Given these symptoms, given this CT scan, given this blood work, this is what you do. And the key to following these protocols is that you do it very rapidly. And so maybe a combination of neurology and other faculty such as our emergency medicine faculty and our hospitalists can step up in an organized way to create a system and a program.
“Every physician is committed to doing this,” Ray said. “Nobody is proud of this. So we will work this out.”
That's scary for a city of that size!
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