State eyes faster treatment for stroke

State health officials will require hospitals treating stroke patients to meet strict new quality standards this fall in the nation's first statewide effort to prevent needless brain damage and paralysis resulting from slow or inadequate emergency treatment.

Under the plan, which will be phased in starting in October, ambulances will take suspected stroke victims only to hospitals that can prove they will give prompt care to stroke victims, requiring around-the-clock availability of brain-scanning equipment and radiologists and neurologists to interpret scans.

Stroke is the nation's third leading cause of death and the leading cause of serious disability, but the effort to reduce that toll in Massachusetts could be undermined if more hospitals do not agree to become stroke centers. Twenty-six of the state's 67 acute-care hospitals have not yet applied, including both on Cape Cod, leaving the Department of Public Health short of its goal of having a center within an hour's drive of every Massachusetts resident.

Speed is crucial to stroke treatment, especially when it comes to administering a drug that can reduce brain damage if given within three hours of the start of symptoms, such as sudden numbness or inability to speak. Fewer than 5 percent of patients who might benefit receive the drug, called t-PA, either because patients wait too long to seek help or because the hospital doesn't act quickly enough when victims arrive.

Massachusetts hospitals that want to continue treating stroke victims must be able to quickly evaluate whether a patient should get t-PA, a high-stakes choice since the drug can cause dangerous internal bleeding in the minority of patients whose stroke is caused by a broken blood vessel.

"Older people fear stroke more than heart attack, because they'd rather be dead than sitting there paralyzed or unable to speak," said Dr. Peter Moyer, medical director of Boston Emergency Medical Services and a prime mover behind the stroke initiative, which he said could reduce long-term disability in an extra 100 or more stroke patients annually.

The stroke initiative is part of a growing effort in Massachusetts to funnel patients to the best emergency care rather than simply the closest. The state long ago designated a few hospitals to take the lead in treating victims of car accidents, gunshot wounds, and other traumas, and, this year, Boston paramedics began taking certain heart attack patients only to hospitals that could immediately perform angioplasty to reopen their clogged arteries.

"It's really been terrific," said Dr. Chris Cannon, a cardiologist at Brigham and Women's Hospital who is playing a lead role in the heart attack program. He said that all seven Boston hospitals that do angioplasty get at least three quarters of patients to the operating room within an hour of arrival while the two that don't do the surgery, Carney and Faulkner hospitals, have been gracious about patients being diverted from their doors.

Compared with care for heart attacks, good-quality stroke treatment requires less equipment and specialized staff, and state officials say that even the smallest hospital could probably qualify as a stroke center if officials made the commitment.

Officials at Cape Cod Hospital in Hyannis and Falmouth Hospital, neither of which has applied to be a stroke center, say they are interested. But they're studying whether they can keep the extensive records required by the new standards.

"We do know this is an important service, particularly with the [elderly] population on the Cape," said David Reilly, a spokesman for Cape Cod Healthcare, which owns both hospitals. "We do hope to pursue it down the road."

Other hospitals may be holding back because they are apprehensive about providing the aggressive treatment the state wants. Many smaller hospitals do not have 24-hour access to neurologists to diagnose the cause of strokes or ready access to neurosurgeons who can operate if there is extensive internal bleeding from t-PA treatment.

But leaders of the state stroke-center initiative say that stroke is too important a disease, striking 11,800 residents a year and killing 3,600, for many hospitals to only care for patients who arrive by their own transportation.

"We've got to get out of this 'treatment nihilism' on stroke," said Dr. Lee Schwamm, associate director of acute stroke services at Massachusetts General Hospital, which has offered to make doctors available to consult with smaller hospitals to help them decide on administering t-PA to patients.

However, Schwamm said he was encouraged at the level of hospital participation. He said it guarantees that treatment of strokes and the long recovery that follows would not be left to a handful of teaching hospitals, which already are much more aggressive in treating strokes. Boston teaching hospitals use t-PA twice as often as the national average.

Stroke has lagged far behind the nation's other two leading killers, heart disease and cancer, in both available treatments and public understanding. Most victims still wait hours before seeking medical attention, largely because most people don't recognize stroke symptoms or don't realize that, where strokes are concerned, "time lost is brain lost."

Treatment delays became more pressing in 1996 when the US Food and Drug Administration approved t-PA, tissue plasminogen activator, the first treatment that can actually dissolve the blood clots that cause ischemic strokes. Such strokes account for about 80 percent of the total, and studies have shown that t-PA improves the odds of these patients having minimal or no disability three months later by about 30 percent.

Suzi Reynolds, 33, became what Schwamm called "a hallelujah case" for the benefits of t-PA when she suffered a stroke in November 2000 while watching election returns at home with her former boyfriend, Peter Reynolds. "I really was in a total dream state: no fear, no pain, nothing but la-la," she recalled. "My whole right side was paralyzed. . . . I knew what was going on, but I couldn't speak."

Because Peter Reynolds immediately recognized signs of a stroke and because the couple lived near Mass. General, she received t-PA within 45 minutes of her symptoms appearing. Almost immediately, she began getting sensation back in her right foot, and more gradually she regained her ability to speak, stand, and move. Today, the only lingering effect is occasional difficulty saying multisyllable words.

But, for every Suzi Reynolds, whose stroke was caused by a blood clot, many doctors in emergency medicine fear that a patient given a clot-dissolving drug might die or be accidentally hurt if that person's stroke was caused by a blood vessel rupture. T-PA can make the internal bleeding worse when given to patients who suffer such hemorrhagic strokes.

Partly as a result, a number of hospitals, such as North Adams Regional Hospital, are taking a wait-and-see approach about becoming a stroke center. "It's something we're looking at," said North Adams spokesman Paul Hopkins. "It hasn't been decided yet if we'll be participating." He explained that the hospital needs to know that it has the resources to satisfy the state requirements.

State officials hope that tiny 24-bed Martha's Vineyard Hospital can serve as a model that helps other hospitals realize that they can be stroke centers, even if they do not have neurosurgeons or neurologists on duty. Emergency room director Alan Hirshberg installed a telemedicine monitor several years ago that allows Mass. General neurologists to review brain scans of Martha's Vineyard patients to determine the stroke's cause and talk to patients before advising the island hospital's doctors about use of t-PA.

"It's almost like going to visit the doctor," he said.

Ultimately, the state's heightened emphasis on stroke care goes beyond the emergency to include proper tracking of patients' rehabilitation to giving them blood-thinners that could prevent strokes in the future.

"It's the creation of a system that tracks the patient through the hospital stay [and beyond] that makes the difference," said Dr. Allan Ropper, chief of neurology at Caritas St. Elizabeth's Medical Center.

State officials say the benefits to patients of treatment at a stroke center are so clear that they hope the holdouts will reconsider. "Our goal is for every hospital to be a center," said Paul Dreyer, director of health care quality at the Department of Public Health.

Scott Allen can be reached by email at allen@globe.com.