By Don Finley
San Antonio Express-News
SAN ANTONIO — For the first time, San Antonio Emergency Medical Services has issued rules for paramedics on where to take stroke patients and how to evaluate and treat them en route — a major step in building a regional system of emergency stroke care.
The order, issued Nov. 1, requires that patients suspected of having a stroke be taken by EMS to “the closest appropriate stroke center” if symptoms began less than eight hours earlier.
The order lists all five Baptist Health System hospitals and all Methodist Healthcare System hospitals except Methodist Specialty and Transplant Hospital.
“We didn’t necessarily have a stroke criteria, if you will,” said Dr. Craig Manifold, medical director of San Antonio EMS, who issued the directive. “Hospital marketing influenced some of the decisions” on where to transport patients.
“Now it may be that we’re not taking them to the patient’s request as often, but what we want to do is make sure we’re getting them to the most appropriate hospital in order to provide that service, just as we do with trauma care,” Manifold said.
The order comes several months after the hospitals and other area EMS systems joined the Stroke Alert system. Manifold said the delay was mainly because San Antonio EMS was working to iron out differences among hospitals on how quickly patients should be evaluated and treated.
Time is critical in treating stroke. A powerful clot-busting drug, tPA, can reduce the damage caused by certain strokes if given within three hours, although some recent research suggests that window can be stretched to 41/2 hours. And certain procedures that involve snaking catheters through blood vessels to reach the clot can sometimes be effective a short time beyond that.
All the Baptist hospitals were certified in June as stroke centers by the Joint Commission, the national accrediting body for hospitals. Of the Methodist facilities, only the flagship Methodist Hospital was certified at the same time, although three other hospitals in the system are in the certification process.
That bothers one local advocate for stroke patients, Suzanne Hildebrand, who has argued that only certified hospitals should be on the list. “My position is that until a hospital achieves the certification, regardless of levels, they should not be listed. Saying that they are going to get their certification is not good enough. What happens if they fail it for some reason?”
“Metropolitan Methodist Hospital, Methodist Stone Oak Hospital and Northeast Methodist Hospital are all participating in completing the certification process,” Geoff Crabtree, senior vice president of the Methodist system, said in an e-mail. “While we do not know when the Joint Commission will arrive, we are hopeful that within six months they will provide the appropriate certification for the hospitals mentioned. In the meantime, the public can be assured of the clinical excellence of stroke care within these hospitals.”
Local officials began trying to build the regional system two years ago, before any local hospital was certified, and for months it looked as though no hospital was willing or capable of putting the procedures in place and having the staff to implement them.
“Now that there are stroke-certified hospitals in San Antonio, of which there are six - five at Baptist and one being main Methodist - I think there’s a higher level of care in the city now,” said Michael Zucker, chief development officer for the Baptist system. “As for what EMS decides and where they’re routing patients, it’s truly their decision.”
Eric Epley, executive director of the Southwest Texas Regional Advisory Council for Trauma and chairman of its stroke committee, said the leaders of both hospital systems on the list signed letters of attestation before joining the Stroke Alert system, promising to meet national standards for hospital stroke programs and to seek certification.
“Overall, I think (the stroke system) has been a tremendous success,” Epley said. “Major health care systems have stood up, raised their hands and done the right thing. They’ve made investments in resources and personnel and education. And overall, patients are not being stranded like they were two years ago. Patients are accepted many times quicker than they used to be. Nothing’s perfect. But it’s been a tremendous step forward.”
New EMS rules for stroke
* Suspected stroke patients with symptoms that began less than eight hours earlier will be taken to the closest approved stroke center, which includes the five Baptist Health System Hospitals and all Methodist Healthcare System hospitals except Methodist Specialty and Transplant Hospital.
* Symptoms include sudden onset of one-sided weakness or facial droop, abnormal speech or vision, confusion or unconsciousness, new or repeated seizures and headache.
* Ambulance should be on the scene in 20 minutes or less and the hospital notified as quickly as possible of a stroke alert. Patient’s airway, breathing and circulation should be supported, blood sugar tested and treated if necessary, and EKG performed to detect atrial fibrillation (a stroke risk factor) or other heart rhythm abnormality.
Copyright 2009 San Antonio Express-News