Is this true?

[prankster]

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so i've heard that certain states are now requiring neurologists to be on site whenever a stroke patient comes to the hospital for that hospital to be considered a stroke center. I've also heard that this may become the norm in the future. Anyone else heard of this? That could really make for some rough call nights if you have to go to the hospital whenever a stroke patient comes in....

 

[typhoonegator]

I would think of it another way. Lets say your mom has a stroke, and shows up in the ED of your "stroke center" 2 hours after onset. The ED physician does her exam, then calls the on-call neurologist, at home. She says the stroke scale is "6-ish", but she isn't sure if the patient could understand her questions. The CT scan gets done, and per the musculoskeletal radiologist who is taking call that night, it looks negative. So the ED doc gives tPA. Patient doesn't get better. Goes to CTA which shows a right M1 cutoff. Patient then goes for STAT MRI with perfusion imaging. The ED doctor calls the neurologist back, wanting to know if she should activate the cath lab for MERCI clot extraction. It's now been 5 hours since your mother's stroke. The musculoskeletal radiologist reading the MRI thinks there is a big mismatch, but the neurologist can't tell if he is talking about the MTT or CBF imaging. Oh wait, now the ED doc thinks the patient might be improving. How the heck is the stroke neurologist supposed to appropriately decide these things over the phone?

I don't know about you, but if my mom showed up with a stroke to a "stroke center", then there had better be a stroke neurologist performing an exam and reviewing her imaging within an hour of arrival. There is just too much lost in translation over the phone, and too many decision points to make a phone conversation workable.

Stroke neurology has fortunately become a specialty where acute management can make a difference, and that management can take several forms. You can't run a trauma center without a trauma surgeon on-call, and in my opinion you can't run a stroke center without a stroke neurologist on call.

Where I work, there are 4 neurology residents in house every night, along with an in-house neurocritical care fellow, and the on-call stroke attending still comes in for every acute stroke within the time window for any therapy. It's the only way to really know what is going on.

 

[prankster]

makes sense, was just trying to find out if i had heard correctly. Thanks!

 

[GopherBrain]

I have to disagree. I'm not going to get into the regulatory issues of what you need to be a "stroke center", as those decisions are usually administrative rather than medical; I just want to disagree with the notion that physical attending oversight is needed (or even that beneficial) when giving TPA. As long as a good NEUROLOGY resident is on hand, the right things will happen.

At my program, there is often one neurology resident in house overnight. At most, we will have 2 residents on site. No fellows. Certainly no attendings. If your mom comes in with a stoke, the ED pages me. I run there, clinically evaluate her, send her off to the CT scanner for a CT/CTA ASAP, and then call the stroke fellow. The stroke fellow and I speak on the phone and make a decision about IV TPA based on history, presentation, and non-con imaging findings (the fellow can see the imaging from home on his computer). I communicate that decision to the ED team, and they begin mixing up the TPA. The CTA happens as part of our standard protocol. If there is a vessel cut-off in an accessible area, the cath lab is activated for AG and MERCI after IV TPA (presuming we are in the time window). If we are out of the MERCI window, we process the CT perfusion data and consider an off-label MERCI. In either case, is only at that point that we are contemplating MERCI that an attending has to become involved, and even then we just speak on the phone.

I don't have the data, but I can assure you that my co-residents and I aren't going around giving TPA inappropriately, or frittering away the time window... Unfortunately, this kind of resident autonomy may be on the decline, as regulations like specialty center certification demand greater attending oversight.

 

[eddieberetta]

I would think of it another way. Lets say your mom has a stroke, and shows up in the ED of your "stroke center" 2 hours after onset. The ED physician does her exam, then calls the on-call neurologist, at home. She says the stroke scale is "6-ish", but she isn't sure if the patient could understand her questions. The CT scan gets done, and per the musculoskeletal radiologist who is taking call that night, it looks negative. So the ED doc gives tPA. Patient doesn't get better. Goes to CTA which shows a right M1 cutoff. Patient then goes for STAT MRI with perfusion imaging. The ED doctor calls the neurologist back, wanting to know if she should activate the cath lab for MERCI clot extraction. It's now been 5 hours since your mother's stroke. The musculoskeletal radiologist reading the MRI thinks there is a big mismatch, but the neurologist can't tell if he is talking about the MTT or CBF imaging. Oh wait, now the ED doc thinks the patient might be improving. How the heck is the stroke neurologist supposed to appropriately decide these things over the phone?

I don't know about you, but if my mom showed up with a stroke to a "stroke center", then there had better be a stroke neurologist performing an exam and reviewing her imaging within an hour of arrival. There is just too much lost in translation over the phone, and too many decision points to make a phone conversation workable.

Stroke neurology has fortunately become a specialty where acute management can make a difference, and that management can take several forms. You can't run a trauma center without a trauma surgeon on-call, and in my opinion you can't run a stroke center without a stroke neurologist on call.

Where I work, there are 4 neurology residents in house every night, along with an in-house neurocritical care fellow, and the on-call stroke attending still comes in for every acute stroke within the time window for any therapy. It's the only way to really know what is going on.

Interesting scenario. So are there a lot of hospitals that on the one hand have interventional stroke therapy (whether provided by a neuroradiologist or someone else) ready to roll 24/7 but on the other hand have no neuroradiologist available to evaluate acute stroke imaging (and to remind the neurology team that perfusion datasets should be acquired as part of the CTA study, and that delaying the decision by getting an MR is no longer state-of-the-art in most situations)??? I apologize -- am giving you a hard time because as someone who just comlpeted radiology residency and am going into neuroradiology, I take offense at the implication that the on call radiologist will not be familiar with stroke imaging -- this is bread and butter radiology that our residents are extremely competent at.

This is a complex issue dependent on the availability of a number of highly skilled individuals. When they are not available, health care systems must decide whether it is better to optimize timeliness of care or expertise level of the operators.

I think it would be best if all stroke centers had a neurologist, radiologist and interventionalist available 24/7, but is this practical? How much delay will result from added transportation time to centers where this is the case?

If we remove the need for IA therapy, many other centers have the needed expertise, but it is unrealistic for such places to expect their neurologist to come in for every "query" stroke case (which is basically the only way the neurologist will be able to be on-site for the few actual "real-deal" cases without delaying therapy for them).

It will be interesting to see how this plays out.

 

[typhoonegator]

Yeah, I totally agree that IV tPA is a real no-brainer once you've had even a little training. I also agree that most of the things that happen once an acute stroke hits the ED are pretty protocol-ized and don't require much independent thinking. I was really addressing the original post with an eye toward community hospitals without a seasoned neurology resident in house. I would have no problem with my mom (or anyone else) showing up in your tertiary medical center and getting treated without direct attending oversight. In fact I would applaud it. I would have a problem with my mom showing up at "Outside Hospital" with a moonlighting IM fellow in the ED, a moonlighting chest radiologist in the back, and a fresh "Stroke Center" accreditation in the window, with no neurologist in sight.

For IV tPA at one of our hospitals, the decision is made between the junior resident and the stroke fellow, who is in-house anyway because they are running the neuro-ICU. The attending gets called, and they generally come in and leave a note at some point during the night, even though the tPA has already been given. At the other hospital, there is no fellow in-house overnight, so the in-house senior calls the attending directly, and the decision is made over the phone.

Once the IV has been given, any further IA therapy really requires that the attending be directly involved. I'm impressed that your interventionalists will come in without a neurology attending being directly involved, but at our institutions, the attitude is such that if you're going to wake-up the interventionalist, the neurology attending had better be there making that decision. This is true even in simple small stroke, big area-at-risk, obvious cutoff cases. Deciding on taking the patient to IA at our facility is usually a fairly complicated discussion, and certainly not as simple as cutoff + time window = IA. Once in the cath lab, there is an ongoing dialog between the neuroIR attending and the stroke attending regarding the ongoing case.

At our hospitals, another big reason for the attending presence is the large number of interventional research protocols, and numerous non-interventional protocols that need to be decided on and get patients enrolled into in the acute setting. The attendings and fellows usually manage this side, because we don't feel that the residents need to be burdened with questions like "can we give hyperoxia therapy and still enroll the patient in protocol X?"

Another issue for us is volume. There is this "tele-stroke" system at our hospitals, and this means that anyone with a suspected stroke anywhere in the general vicinity of Boston can call us and talk with a fellow over this video-conferencing system to decide on tPA. Once given, the patient is typically shipped to us by chopper for IA decision making. The result of this is that the volume of acute neurology can get pretty hairy overnight. With a junior resident in the ED seeing typically 20+ patients per night, they simply don't have the time to babysit a stroke through the post-tPA decision imaging and IA decision-making process. So the fellows and attendings act as a sort-of safety valve to take over once the immediate management has been decided in the ED.

 

[typhoonegator]

One thing I forgot.

Our attendings come in because acute stroke management is actually really fun -- once the junior resident has weeded out the garbage consults. Our attendings generally want to come in and get involved, and I think that's awesome.

 

[eddieberetta]

I think we are on the same page.

For IV, probably do not need a neurologist in house, but should have them available for hi tech conference, along with appropriate ED and radiology support.

For IA, need more of a team set up, neurologist should be very involved in decision making, probably on site in most cases to examine patient and help decide risk/benefit.

The question is, should all query stroke patients go to a center that can provide IA? It would be nice but is it realistic?

 

[typhoonegator]

That is a great question. I don't think we have the resources (or the efficacy data) to really push every "query stroke" to an IA center. We would be inundated with a very low signal/noise ratio, and the costs would be enormous.

I think telemedicine has a lot to offer in this area, by having the stroke neurologist be able to conduct an exam over a teleconference, then help the ED physician at the OSH decide on IV therapy. If needed, the patient could then be transferred to the tertiary center for IA considerations and post-tPA monitoring. I don't think much is lost in this exchange; if the patient qualifies, you get the tPA in the patient ASAP, and still have options for IA thereafter.