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Hospitals improve ER stroke care

Massachusetts health department data show increased use of drug that improves recovery

By Liz Kowalczyk
Globe Staff / December 12, 2011
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Massachusetts hospitals have substantially improved care for stroke patients in the emergency room, although some have lagged behind in using a potentially life-saving drug, new state health department data show.

During 2009 and 2010 combined, 80 percent of stroke patients who were eligible for the drug - which can dissolve the blood clots that trigger most strokes - received it. That was up from 71 percent in 2008 and 2009.

Eight hospitals, however, ranked significantly below average in the most recent period, suggesting that they did not give the drug - called intravenous tissue plasminogen activator, or tPA - to patients who could have benefited from it. Studies have shown that when given soon after a stroke, the drug can improve a patient’s recovery.

Dr. Madeleine Biondolillo, director of the state Bureau of Health Care Safety and Quality, said officials are working with hospitals whose “tPA administration rates are below levels targeted by the department,’’ but she is pleased with the overall progress.

When the Department of Public Health began a push to improve stroke care in 2004, only about one-third of patients eligible for tPA - considered the gold standard in emergency stroke care - got it. As part of the initiative, the department publicly posts on its website hospital performance data on the percentage of patients receiving tPA.

“Massachusetts hospitals have made excellent strides in improving care to those suffering from acute stroke,’’ Biondolillo said in an e-mail, “and this is a very important step we are taking to maximize the quality of care in the Commonwealth.’’

More than 10,000 Massachusetts residents each year have strokes, and many die or are left with devastating disabilities. About 80 percent of the strokes are caused by a clot that blocks blood flow in one of the brain’s blood vessels. This is called an ischemic stroke, and only patients with this type of stroke are eligible for tPA.

To get the best results, doctors generally must give tPA to these patients within three hours of when their stroke symptoms began, but most patients arrive at the emergency room too late to qualify for treatment.

The state’s analysis of emergency stroke care looked just at patients who arrived at the hospital within two hours of the start of symptoms, leaving an hour for diagnosis and the start of treatment. It looked at patients seen in 2009 and 2010, the most recent data available.

Patients had a greater chance of getting the drug if they went to a hospital in metropolitan Boston or in the western part of the state, to one with 200 or more beds, or to a teaching hospital, according to the new data. Hospitals in Southeastern Massachusetts gave tPA to a smaller percentage of the eligible patients.

In hospitals with low rates of use, doctors may not be diagnosing patients fast enough in the emergency room, perhaps because of overcrowding or not having immediate access to CT scanners and neurologists, specialists said.

And because tPA’s risks include excessive bleeding, some emergency room doctors may be hesitant to use it.

“Hospitals that are doing well have taken a coordinated, multidisciplinary approach that is supported by hospital leadership. They are running performance reports and someone is really reviewing the data,’’ said Dr. Lee Schwamm, director of acute stroke services at Massachusetts General Hospital. “Those who are struggling may not have uniform consensus in their ER or the resources to access stroke expertise.’’

At Cape Cod Hospital, one of the eight institutions that ranked below average, just 49 percent of the patients eligible for tPA received the drug in 2009 and 2010. Spokesman David Reilly said it was “really a documentation issue as opposed to a quality of care issue.’’

He said emergency room doctors did not always write down why certain patients were ineligible for tPA - if a patient had a medical condition that raised the risk of bleeding, for example - making it look like patients should have gotten the drug when they actually did not qualify. So far in 2011, he said, all patients who should have gotten tPA received the drug.

Dr. Nancy Edwards, a member of the stroke committee at the Southcoast Hospitals Group, which includes Charlton, St. Luke’s, and Tobey, also blamed poor record keeping. At St. Luke’s, 51 percent of eligible stroke patients received tPA, while 58 percent of patients received it at Charlton. The health department did not release data for Tobey, because the number of patients was too small.

“We feel, based on thorough review of our patient records, that the clinical decisions made by our providers are appropriate,’’ Edwards said in an e-mail.

Doctors rely on imaging, usually a CT scan, of the brain to help determine whether a patient is having an ischemic stroke; patients with the other type of stroke, caused by a burst blood vessel, can be harmed if treated with tPA. Even for ischemic stroke patients, the drug can cause fatal bleeding into the brain.

The health department requires hospitals to adopt specific plans for assessing and treating stroke patients, and to educate the public about the warning signs of stroke. Hospitals must also submit detailed data on how fast they treat patients and how many receive tPA. In return, hospitals that comply are permitted to market themselves as “primary stroke services.’’

Health officials have not tried to revoke primary stroke service designation of hospitals that have fallen below average in tPA use, Biondolillo said.

“We hope that continued public reporting and data release will help drive improvements in quality and afford consumers the opportunity to make informed choices about where to receive emergency care,’’ she said.

Residents should ask their doctors and hospitals about their performance and what can be done to improve it, said Schwamm, who has consulted for the state on the initiative. “We don’t want to decertify hospitals. We want every hospital to provide very good care,’’ he said.

Liz Kowalczyk can be reached at

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