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Return to Stroke Care Fastest by Ambulance, but Rates Haven't Risen in a Decade Overview

More on Stroke Care Fastest by Ambulance, but Rates Haven't Risen in a Decade

Research and Clinical Trials

Return to Stroke Care Fastest by Ambulance, but Rates Haven't Risen in a Decade Overview

More on Stroke Care Fastest by Ambulance, but Rates Haven't Risen in a Decade

Stroke Care Fastest by Ambulance, but Rates Haven't Risen in a Decade

NEW YORK (May 1, 2012)

Since the approval of the clot-busting medication tPA (tissue plasminogen activator) in 1996, physicians have had an important tool at their disposal to treat patients suffering from ischemic stroke (the kind caused by a blood clot in an artery in the brain). The bad news is that doctors cannot administer tPA to patients who have had stroke symptoms for more than 4.5 hours, so patients with stroke must arrive at the hospital quickly. Unfortunately, it appears that people with stroke symptoms do not call for an ambulance – by far the quickest way to get to the hospital – more frequently than they did before the availability of tPA.

The JAMA Study

This is the conclusion of a recent study by Hooman Kamel, M.D., and Babak Navi, M.D., both neurologists at NewYork Presbyterian/Weill Cornell Medical Center, whose research letter published in the March 14, 2012 issue of the Journal of the American Medical Association (JAMA) analyzed 12 years of data from around the country. They found that, despite a decade of educational efforts about the symptoms of stroke and the importance of prompt treatment, half of people who are having a stroke still don't call 911 and immediately seek care. The reseachers gathered data on 1,605 cases, and found that only 51% of patients with stroke arrived at the emergency department via ambulance, a proportion that did not change significantly between 1997 and 2008.

Hooman Kamel, M.D.
Hooman Kamel, M.D.

"Both disability and mortality from stroke have improved over the past few decades, so in general we're making very good progress in treating this disease," said Dr. Kamel. Since the approval of tPA there's even more reason for patients to immediately seek medical attention for a stroke, and calling 911 and arriving by ambulance rather than by car or public transportation will allow patients to get this drug much faster, he said. "With this drug every minute counts. Brain cells are dying every minute, and the faster you receive the drug the better."

Know the Signs, Seek Care Immediately

Patients, family members, bystanders, and the public should learn to recognize the signs of a stroke so they can seek medical attention as soon as possible if they or someone they are with begins having symptoms. They include: sudden difficulty speaking, understanding other people, trouble moving or using one side of the body, numbness on one side of the body, and loss of vision. "Those kinds of symptoms should be assumed to be a stroke," Dr. Kamel said, "and you should let your doctors determine whether you are having a stroke or not." Even patients who know the symptoms of stroke may have behavioral barriers to calling 911, he added. "People sometimes know what is happening and still don't call. Sometimes it's difficult to acknowledge that these symptoms could be a dangerous warning. And often people do not want to inconvenience their family or bystanders. But given the high stakes we think it is better to call 911 and receive urgent evaluation in case you are having a stroke."

The 4.5-hour window for tPA treatment begins when patients' family members, friends, coworkers, or patients themselves can objectively confirm they were last perceived to be normal. "The faster people take action the more likely it is that we can provide treatment, and the more likely the treatment will help," he said. "This is not a situation in which you should wait a few hours to see if you feel better, or to call your primary care doctor and make an appointment for later in the day."

Neurologist Randolph Marshall, M.D., Chief of the Stroke Division at NewYork Presbyterian/Columbia University Medical Center said, "The lack of ambulance use is a marker of a lack of knowledge about stroke and the importance of immediate care." While ambulance usage doesn't tell the whole story, he said, the study shows that there is still a lot more to be done to improve acute stroke care.

Major Centers Doing Better

Randolph S. Marshall, M.D.
Randolph S. Marshall, M.D.

Stroke remains the leading cause of disability, but in the last year stroke dropped from the third leading cause of death to the fourth. "The improvement in outcomes is a reflection of the way that major centers such as NYP have made a multifaceted effort to improve stroke care. We're actually delivering better and more efficient stroke care – and it's showing up in our numbers," he said.

Over the last four years doctors at NYP/Columbia have tripled the rates of treating patients with IV tPA, and in the last year doubled those rates. "So while ambulance usage is a component of delivering effective acute stroke care, it's equally important that when patients do get to the emergency room, they're treated efficiently and effectively," said Dr. Marshall. "We've done a better and better job each year doing that and our total number of tPA treatments has really skyrocketed. And that is due in large part to the efforts of the emergency department staff, our stroke team, and stroke nurse coordinators, in organizing and educating our staff and faculty about acute stroke."

Dr. Marshall added, "In the final analysis we have to keep working on all aspects of acute stroke care, including educating the public and primary care physicians about calling 911 to get an ambulance to bring them to the hospital as soon as possible, and continuing to work on the processes in the emergency room to deliver the best and most efficient stroke care."

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