People suffering a stroke in San Luis Obispo County may have a better chance of avoiding death or serious disability now that every hospital in the region has met strict criteria to become nationally certified as a Primary Stroke Center.
In late May, the Joint Commission — the nation's leading hospital accreditation agency — issued the certification to French Hospital Medical Center in San Luis Obispo, and Arroyo Grande Community Hospital and Marian Regional Medical Center in Santa Maria, which operate under the same license. All three are owned by Dignity Health.
Sierra Vista Regional Medical Center got the certification in 2011 and has been renewed twice; Twin Cities Community Hospital in Templeton was certified in November. Both are owned by Tenet Healthcare.
For a hospital to get Primary Stroke Center certification, it must meet a long list of requirements.
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Among them: having a designated stroke unit or beds with round-the-clock medical staff trained in stroke care; appropriate diagnostic equipment and specific treatment capabilities; neurosurgery services either on-site or available within two hours; regular staff training in stroke treatments; and more.
“The benefit to the public is that no matter where they live and no matter where they go, they will get the same standard of care or better,” said Dr. James Malone, vice president for medical affairs at French Hospital. “People should take comfort in that.”
Partnering with paramedics
The certification by all four hospitals in the county will help “solidify a system-wide approach” for hospitals and paramedics to work together to quickly identify stroke patients, get them to a hospital where a trained stroke team will be waiting for them, and then provide the right care that can be tracked for accountability, said Kathy Collins, interim director of the county’s Emergency Medical Services.
Collins said she is meeting with stroke team coordinators at all of the hospitals to review how they communicate with paramedics transporting stroke patients, the hospitals’ internal policies for those patients, and their methods for collecting data to track patient outcomes.
She said that standardized data collection will help identify gaps or delays in the system, and track how many patients are subsequently transferred to higher-level treatment centers outside the county and why.
The hospital certifications and collaboration among agencies improves patients’ chances for survival and recovery, she said. “I wouldn’t say they necessarily got bad care (before), but they get better care now,” Collins said.
'Time lost is brain lost'
The accreditations come after a sobering statewide analysis two years ago that showed San Luis Obispo had the highest rate of age-adjusted deaths from stroke among all California counties.
The 2013 County Health Status Profiles study by the California Department of Public Health looked at average number of stroke deaths from 2009 to 2011, taking age into account in comparing counties. At that time, Sierra Vista was the county’s only certified stroke center.
Locally, some physicians questioned the study’s rankings, which used data from death certificates that may not be filled out the same in every county.
Still, during that period, the stark reality is that about 206 people died in San Luis Obispo County, with stroke listed as the cause. No figures tell the story of how many others suffered serious, permanent disability.
Stroke occurs when a blood vessel in the brain ruptures or becomes blocked. About 87 percent are ischemic strokes — caused by a blood clot that blocks blood flow to part of the brain and kills cells there. Stroke is the fifth leading cause of death and the number one cause of adult disability in the United States. Experts universally emphasize that “time lost is brain lost” in stroke treatment.
The move to establish certified stroke centers to improve medical care and survival rates began in 2000 and today, about one third of hospitals nationwide are certified, according to the American Stroke Association. The program is so well regarded that in some areas of the country, paramedics only take stroke patients to hospitals with the certification and bypass hospitals without it.
'We learned a lot'
Malone said French Hospital “was well on the path” to seeking certification when the 2013 study came out.
“We’d been talking about it for a year and a half or two years,” he said. “It was a nine- to 12-month process of preparing ourselves” for the Joint Commission inspection in May.
He said the hospital had the equipment and staff to meet the commission’s requirements, but went through a lengthy process reviewing its procedures, training all stroke team staff and reorganizing some duties to make sure the hospital could meet specific time-to-treatment goals such as getting a CT scan of the head within 45 minutes and, if appropriate, an intravenous clot-busting drug within an hour or two.
“It really causes you to scrutinize all the little moving parts,” Malone said. “It can be a demanding process but for us it was really fun. We learned a lot.”
To get and maintain certification, hospitals are required to adopt national stroke treatment protocols and provide ongoing staff training, which Malone said was especially important for small hospitals like those in SLO County that see only 100 or 200 stroke patients a year and don’t get the daily practice that big hospitals do.
Sierra Vista sees about twice as many stroke patients per year as other hospitals in the county, according to state data. Dr. Thomas Clark, medical director of Sierra Vista’s stroke program, said the certification by all hospitals in the county will benefit residents.
“It’s great. That’s how it should be done,” Clark said. “The bottom line is, if someone has a stroke it shouldn’t matter where they go. They should get the same rapid treatment.”
Going through the certification process, he said, “has led to much more timely and effective stroke care throughout the region” although whether that will be reflected in the next batch of state data is unclear for now.
Don’t wait, call 911
Even with the certification, the hospitals will still need to send some stroke patients elsewhere for advanced care.
The Joint Commission also issues a Comprehensive Stroke Center certification for research hospitals that can receive transferred stroke patients and handle multiple complex cases, and have neurosurgeons and other staff able to do immediate advanced treatments. The closest Comprehensive Stroke Center hospitals to San Luis Obispo are in Los Angeles and San Jose.
Cottage Hospital in Santa Barbara also provides some treatments unavailable locally, said Clark, who also is regional stroke director for the Stroke & Neurovascular Center of Central California, a Santa Barbara medical practice.
In cases where patients have a blood clot but can’t receive tPA (tissue plasminogen activator), the intravenous clot-busting drug, another emergency procedure called mechanical thrombectomy can be done.
In that case, a catheter is threaded up to the brain to grab the clot and pull it out to restore blood flow. Studies show that procedure needs to be done within 6 ½ hours for a good outcome, Clark said.
“The closest place that provides that service is Cottage Hospital in Santa Barbara,” he said.
Clark, Malone and Collins all emphasized that while the hospitals and paramedics are working to provide fast, appropriate stroke treatment, the clock starts ticking while patients are still at home.
At the first symptom of stroke, they advise, call an ambulance so that treatment can start en route and a stroke team will be waiting at the emergency room door.
"If someone thinks they’re having a stroke they should call 911,” Malone said. “It can make a significant difference in survival or permanent disability.”
SYMPTOMS OF STROKE
If you or someone else shows any of these symptoms, call 911
- Sudden numbness or weakness of the leg, arm or face
- Sudden confusion or trouble understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause.
FAST is a simple way to remember the signs of stroke:
F - Face. Ask the person to smile. Does one side of the face droop?
A - Arm. Ask the person to raise both arms. Does one arm drift downward?
S - Speech. Ask the person to repeat a simple phrase. Is their speech slurred or strange?
T - Time. If you observe any of these signs, call 911.
Source: American Stroke Association