Improving systems

Developments to improve outcomes for stroke, cardiac patients

Eloise Ogden/MDN Dr. Jeffrey Sather, Trinity Health’s chief of medicine and medical director for the Emergency Trauma Center in Minot, also is medical director for the North Dakota Department of Health’s Division of Emergency Medical Systems.

Stroke and cardiac systems of care across the state are having successes and changing people’s lives.

Since the creation of the North Dakota cardiac and stroke systems of care task forces, nurses, doctors, hospitals, EMTs, governments and other agencies in the state have been working to improve stroke and cardiac care outcomes.

Dr. Jeffrey Sather was a presenter at The North Dakota Stroke and Cardiac Conference held in Fargo in early October.

Sather is Trinity Health’s chief of medicine and medical director for the Emergency Trauma Center in Minot. He’s also medical director for the North Dakota Department of Health’s Division of Emergency Medical Systems.

The conference brought together people across the state who are working to improve the systems of care, education and training, Sather said. He said the conference was started several years ago as part of a grant from the Harry B. and Leona M. Helmsley Trust.

The conference has continued now under the N.D. Department of Health and is part of the Stroke and Cardiac Systems.

Sather, in an Oct. 24 interview, said the two-day conference is designed for basically all levels of care – including ambulance personnel, hospital nursing staff and other hospital paraprofessionals to the physicians. It is designed around education specifically toward stroke and cardiac.

The cardiac and stroke systems started around 2010 and 2011 when the grant was received and has been developing since.

“We’ve seen a lot of work going into system development, not just focusing on what happens in the hospital, for example, focusing on what happens from point of contact from a patient all the way through their hospital stay. It involves public education, it involves ambulance pre-hospital personnel, emergency medical dispatch, the rural critical access hospitals and all the way to the larger tertiary hospitals,” said Sather.

He said both stroke and cardiac are time-sensitive diagnosis. This, he said, means it makes a big difference from the onset of symptoms to how quickly a person gets the proper treatment.

He said North Dakota has six larger hospitals in the state – Trinity in Minot, two Bismarck hospitals, two in Fargo and one in Grand Forks -designated as primary stroke centers with more advanced capabilities in dealing with strokes. He said those six hospitals also are primary cardiac centers with cardiologists and cath labs.

This, he said, leaves a big gap in the rural areas in the state. “You take away the six and the majority of our hospitals are critical access level hospitals,” Sather said.

“We have through system development worked with all of those hospitals in getting protocols around dealing with heart patients – how to properly treat people having an acute MI or heat attack,” Sather said. He said the state-recommended protocols have been developed using national guidelines.

“We have a task force and have had consensus amongst the cardiologists to develop a set of state recommended treatment protocols,” he added.

“The patients should feel better that there’s really a set system coming into play within the state that your treatment should be. Obviously, it’s going to be a little bit different based on where you’re at, but you’re coming into a statewide system that’s going to give you the best available care for the area that you’re in,” Sather said.

Part of what has been developed in this system is the recommended treatment for people having what is called an ST Elevation MI – the kind of heart attack where there’s sudden complete blockage of an artery, Sather said.

“The recommended treatment if it’s available is to go right to a cath lab to get your artery open as soon as possible,” Sather said. “The current guidelines say if that can be done within 120 minutes, it’s the best treatment.”

“What we’ve been able to do through system development is actually look at what areas of the state where that’s possible,” he said.

For example, someone in Rugby right now who calls 911, the ambulance’s protocol (is) the ambulance can do the EKG, he said.  “Actually we’re one of the only states in the country where every ambulance has the ability to do that and that was through the Helmsley Trust that was made possible.”

“If they identify that type of heart attack in Rugby, they don’t take you to the Rugby hospital. They’ll come right here to Minot because it’s been proven through literature and research that the best treatment is to go right to the cath lab,” Sather said. “Further, if you come right here to Minot with enough notification, you don’t even stop in our emergency room. You go right from the ambulance to the cardiac cath lab and see the cardiologist and get your artery opened up because that’s the best treatment for the best outcomes.”

Sather said they are looking closely at the data. “We’ve looked at not only local data but statewide data and multistate data where these type of systems are being put into place,” he said. “In using North Dakota, South Dakota and Minnesota, we’re seeing a speed from identification of a problem to having that artery open. We’ve decreased that time by about 15 minutes in total time for patients that enter the system that way through ambulances. So by using that ambulance education we’ve been able to speed that time the patients get into the cath lab and get the artery open.”

“Further, we’re seeing a decrease in the amount of time it takes for a patient to be transferred from a rural hospital into one of the cardiac centers for that same type of heart attack. Patients that present to outside hospitals are getting sent in quicker and treated quicker as well, and we’re starting to see that actually will improve outcome for patients meaning their survivability, their chances of death are less and their chances of being discharged without any significant problems with their heart is becoming less.

“We’re actually starting to see a movement in the outcomes of patients as well- (of) that speeding them through to the proper treatment,” he said.

“Stroke is also time sensitive,” said Sather.

He said a couple of treatments are available for stroke, with TPA, a clot-busting drug, the main one that most everybody knows about nowadays.

He said TPA has some specific guidelines to use it, including it needs to be within three hours of the onset of their symptoms.

“There’s a big education piece that we’ve been trying to push across the state teaching people if you’re having a stroke, you need to seek treatment right away because if you come in a day later, the ability for us to do a lot in the way of treatment is not there. It’s really, really a time-sensitive treatment,” Sather said.

He said some people realize right away they are having symptoms but many times people do not realize they are having a stroke. “That’s real time sensitive in that if it’s over a certain amount of time, you can’t give the drug for it,” he said.

“Hospitals really have to have three things in place to do that. They have to have a CAT scan available that they can quickly get a CAT scan done and have it read because that’s one of the tests that has to be done before this can be given. They also have to have the drug (TPA) available and have the ability to give it, and they have to have protocols in place for giving it,” he said.

Some other treatments can be done that can extend that time slightly. “But most of those timeframes are really within a small window so this is really a time-sensitive condition,” he said.

As a state, Sather said a task force has worked on a statewide recommended protocol. Through the N.D. Department of Health, they have started designating hospitals as being stroke-capable facilities.

“We’re just in that process of that first round of designation. This is going to be a big change for a few areas because there are some hospitals that won’t be able to be designated. There’s a handful of hospitals in the state that don’t have CAT scanners so because of that they can’t be designated as stroke centers,” he said.

He said they anticipate a minimum of about six hospitals won’t be stroke centers.

“What that means is the ambulance in that area within a relatively short time, probably by sometime next year, will be required to bypass those hospitals for stroke patients because it really just puts a delay in the care of those patients. They’ll have to take them to a stroke-ready hospital which could be one of the other smaller hospitals or to one of the primary stroke center hospitals which is one of the six larger hospitals in the four cities.

Trinity Hospital in Minot is a primary stroke center.

“The designation of primary stroke center which Trinity has as well as the other five larger hospitals in the state is a Joint Commission on accreditation of hospitals designation,” he said.

He said it is very exciting for all this to be happening “because we’re seeing outcomes improve for patients.”