Ohio hospitals differ over use of stroke ambulances

Local hospitals could not agree about how best to evaluate and care for patients in the immediate aftermath of a stroke

By Ben Sutherly
The Columbus Dispatch

TOLEDO, Ohio — Last year, a specially equipped ambulance began taking stroke care beyond hospital walls and into greater Cleveland. This month, a similar vehicle will begin to do the same in parts of the Toledo metro area.

OhioHealth announced last week that it is working with Columbus fire officials to operate a similar type of ambulance, equipped and staffed to deliver the clot-busting drug tPA to stroke patients.

But other local hospitals, caught off-guard by the announcement, are not yet on board.

On Tuesday, a news release prepared by OhioHealth quoted Mayor Michael B. Coleman as saying that the new partnership "will greatly benefit the citizens of Columbus."

In contrast, by late Friday, Ohio State University’s Wexner Medical Center issued a statement that read, in part, "We’re pleased that the city has indicated that they’re placing the proposal on hold until we can bring all parties together in a collaborative way to determine what’s the best way to serve stroke patients in central Ohio."

Columbus Public Safety Director George Speaks also issued a statement late Friday: “Public Safety is reaching out to all our great health-care providers in hopes that the mobile stroke-treatment concept is a collaborative project. A joint collaboration and funding will better ensure this concept comes to fruition for the betterment of our community."

As planned, the ambulance initially would have operated within a 7-mile radius of OhioHealth Riverside Methodist Hospital, where it would be based.

Strokes strike nearly 800,000 people annually nationwide and are Ohio’s fourth-leading cause of death, killing 5,690 people in 2013. OhioHealth officials say they want to reduce that number and lessen strokes’ power to disable, thereby improving patients’ long-term quality of life.

In some cases, that quality of life hinges on quick delivery of the tPA drug.

"What we’re going on is the basic premise that ‘time is brain,’ " said Dr. Janet Bay, a neurosurgeon and OhioHealth’s vice president and lead physician for neuroscience. "As it stands right now, very few hospitals in the country are able to get the tPA treatment to the patient in the first hour that they’re showing symptoms."

OhioHealth’s announcement came after local hospitals could not agree about how best to evaluate and care for patients in the immediate aftermath of a stroke. Interviews with hospital and public-safety officials suggest that the disagreement has its roots in both unresolved clinical questions and financial concerns.

The approach that OhioHealth took in announcing the stroke ambulance also was greeted with skepticism.

"Central Ohio health-care providers have a long history of collaboration in delivering the best care for our community," said Dr. Richard Streck, Mount Carmel’s executive vice president and chief clinical-operations officer. "We would like to continue that longstanding heritage of collaboration in developing and deploying stroke care."

Streck said he didn’t think OhioHealth’s announcement was in keeping with that tradition.

A lack of consensus hasn’t kept mobile stroke ambulances from deploying in other parts of the state.

Mercy Health in northwestern Ohio plans to start a mobile stroke-treatment unit this month that will serve most of the western half of Lucas County, which is home to Toledo.

"I think stroke care is where cardiac (care) was about 10 years ago," said Julie Georgoff, service-line administrator for orthopedics and neuroscience at Mercy. The mobile unit is the next step, she said.

The Cleveland Clinic began operating a similar vehicle in Cleveland in summer 2014.

Cleveland’s experience has mirrored research published earlier that year in The Journal of the American Medical Association. In that study, German researchers found that, among patients receiving tPA, the time needed to administer clot-busting drugs was decreased by 25 minutes when using a mobile stroke-treatment vehicle — without increasing the number of adverse events.

However, the article said that more research was needed to determine more conclusively the effect of a mobile stroke-treatment vehicle on the health of patients.

Cleveland’s mobile stroke crew administers tPA an average of 40 minutes faster than the standard treatment, said Dr. Peter Rasmussen, director of the cerebral vascular center at the Cleveland Clinic.

The Cleveland unit provides coverage to about 500,000 people. Its geographic reach has expanded from its initial base in Cleveland into six of the city’s southern suburbs.

Each ambulance equipped for stroke care should be able to serve about 800,000 to 1 million people, Rasmussen said. For the first 11 months of this year, the Cleveland Clinic’s mobile stroke unit transported 280 patients.

"I’m sure you would find some naysayers, but the vast majority of stroke (experts) in the city of Cleveland have bought into the mobile stroke concept," Rasmussen said.

But, as in Columbus, the discussion in northeastern Ohio about whether to take patients with certain severe strokes directly to hospitals’ comprehensive stroke centers instead of the closest hospital remains a source of sensitivity.

"A lot of hospitals are not on board with this," said Dr. Cathy Sila, director of the comprehensive stroke center at Cleveland’s University Hospitals Case Medical Center. "The mobile stroke-care transitions into being more of a marketing tool and a market-share tool. ... The patient is more likely to go to the facility that owns the mobile stroke unit."

Mobile stroke care remains a research project, Sila said. "It is not a standard of care."

Such units might come in handy in East Coast cities where major traffic jams regularly snarl ambulances for long periods of time, and they might make a difference in rural areas. But in many large Ohio cities, where there is a concentration of hospitals capable of high-quality stroke care nearby, Sila questions the usefulness of an ambulance capable of stroke care.

"The answer is different depending on the city," Sila said. "If you’re in a city like Columbus or Cleveland, where there may be two or three minutes’ difference, ... I don’t think that’s going to make a difference for people."

(c)2015 The Columbus Dispatch

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