CVA patients to wrong hospital, may cause legal action

[Ridryder 911]

Stroke victims are often taken to wrong hospital

Monday, May 09, 2005

By Thomas M. Burton, The Wall Street Journal

Christina Mei suffered a stroke just before noon on Sept. 2, 2001. Within eight minutes, an ambulance arrived. Her medical fate may have been sealed by where the ambulance took her.

Ms. Mei's stroke, caused by a clot blocking blood flow to her brain, occurred while she was driving with her family south of San Francisco. Her car swerved, but she was able to pull over before slumping at the wheel. Paramedics saw the classic signs of a stroke: The 45-year-old driver couldn't speak or move the right side of her body.

Had Ms. Mei's stroke occurred a few miles to the south, she probably would have been taken to Stanford University Medical Center, one of the world's top stroke hospitals. There, a neurologist almost certainly would have seen her quickly and administered an intravenous drug to dissolve the clot. Stanford was 17 miles away, across a county line.

But paramedics, following county ambulance rules that stress proximity, took her 13 miles north, to Kaiser Permanente's South San Francisco Medical Center. There, despite her sudden inability to talk or walk and her facial droop, an emergency-room doctor concluded she was suffering from depression and stress. It was six hours before a neurologist saw her, and she never got the intravenous clot-dissolving drug.

In a legal action brought against Kaiser on Ms. Mei's behalf, an arbitrator found that her care had been negligent, and in some aspects "incomprehensible." Today, Ms. Mei can't dress herself and walks unsteadily, says her lawyer, Richard C. Bennett. The fingers on her right hand are curled closed, and she has had to give up her main avocations: calligraphy, ceramics and other types of art. Kaiser declined to comment beyond saying that it settled the case under confidential terms "based on some concerns raised in the litigation."

Stroke is the nation's No. 1 cause of disability and No. 3 cause of death, killing 164,000 people a year. But far too many stroke victims, like Ms. Mei, get inadequate care thanks to deficient medical training and outdated ambulance rules that don't send patients to the best stroke hospitals.

Over the past decade, American medicine has learned how to save stroke patients' lives and keep them out of nursing homes. New techniques offer a better chance of complete recovery by dissolving blood clots and treating even more lethal strokes caused by burst blood vessels in the brain. But few patients receive this kind of treatment because most hospitals lack specialized staff and knowledge, stroke experts say. State and county rules generally require paramedics to take stroke patients to the nearest emergency room, regardless of that hospital's level of expertise with stroke.

Stroke care is positioned roughly where trauma care was a quarter-century ago. By 1975, surgeons expert at treating victims of car crashes and other major accidents realized that taking severely injured patients to the nearest emergency room could mean death. So the surgeons led a push to make selected regional hospitals into specialized trauma centers and to overhaul ambulance protocols so that paramedics would speed the most severely injured to those centers. Now, in many areas of the U.S., accident victims go quickly to a trauma center, and trauma specialists say this change has saved lives and lessened disability.

Eighty percent or more of the 700,000 strokes that Americans suffer annually are "ischemic," meaning they are caused by blockage of an artery feeding the brain, usually a blood clot. Most of the rest are "hemorrhagic" strokes, resulting from burst blood vessels in or near the brain. Although they have different causes, both result in brain tissue dying by the minute.

Several factors have combined to prevent improvement in stroke care. In some areas, hospitals have resisted movement toward a system of specialized stroke centers because nondesignated institutions could lose business, according to neurologists who favor the changes. In addition, stroke treatment has lacked an organized lobby to galvanize popular and political interest in the ailment.

A big reason for the backwardness of much stroke treatment is that many doctors know little about it. Even emergency physicians and internists likely to see stroke victims tend to receive scant neurology training in their internships and residencies, according to stroke specialists.

"Surprisingly, you could go through your entire internal-medicine rotation without training in neurology, and in emergency medicine it hasn't been emphasized," says James C. Grotta, director of the stroke program at the University of Texas Health Science Center at Houston.

Many hospitals don't have a neurologist ready to deal with emergencies. As a result, strokes aren't treated urgently there, even though short delays increase chances of severe disability or death. Even if doctors do react quickly, recent research has shown that many aren't sure what treatment to provide.

For example, a survey published in 2000 in the journal Stroke showed that 66 percent of hospitals in North Carolina lacked any protocol for treating stroke. About 82 percent couldn't rapidly identify patients with acute stroke.

As with other life-threatening conditions, stroke patients are better off going where doctors have had a lot of practice addressing their ailment. A seven-year analysis of surgery in New York state in the 1990s showed that patients with ruptured blood vessels in the brain were more than twice as likely to die -- 16 percent versus 7 percent -- in hospitals doing few such operations, compared with those doing them regularly. A national study published last year in the Journal of Neurosurgery showed a similar disparity.

Another major shortcoming of most stroke treatment, according to many neurologists, is the failure to use the genetically engineered clot-dissolving drug known as tPA. Short for tissue plasminogen activator, tPA, which is made by Genentech Inc., has been shown to be a powerful treatment that can lessen disability for many patients. A study published in 2004 in The Lancet, a prominent medical journal, showed that the chances of returning to normal are about three times greater among patients getting tPA in the first 90 minutes after suffering a stroke, even after accounting for tPA's potential side effect of cerebral bleeding that can cause death. But several recent medical-journal articles have found that nationally, only 2 percent to 3 percent of strokes caused by clots are treated with tPA, which has no competitor on the market.

Some authors of studies supporting the use of tPA have had consultant or other financial relationships with Genentech. Skeptics of the drug point to these ties and stress tPA's side-effect danger. But among stroke neurologists, there is a strong consensus that the drug is effective.

One reason why many patients don't receive tPA is that they arrive at the hospital more than three hours after a stroke, the time period during which intravenous tPA should be given. But many hospitals and doctors don't use tPA at all, even though it has been available in the U.S. since 1996. The dissolving agent's relatively high cost -- $2,000 or more per patient -- is a barrier. Medicare pays hospitals a flat reimbursement of about $5,700 for stroke treatment, regardless of whether tPA is used.

Glender Shelton of Houston had an ischemic stroke caused by a clot at Los Angeles International Airport on Dec. 30, 2003. In full view of other holiday travelers, Ms. Shelton, then 66, slumped over, and an ambulance was called. It was 4:45 p.m.

By 5:55 p.m., she arrived at what now is called Centinela Freeman Regional Medical Center, four miles away in Marina del Rey. Hospital records show that doctors thought Ms. Shelton had suffered an "acute stroke." But she didn't get a CT scan, a recommended initial step, until 9 p.m. By then, she was already outside the three-hour window for safely administering intravenous tPA. Records also say she didn't receive the drug "due to unavailability of a neurologist until after the patient had been outside the three-hour time window."

Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of the prestigious stroke unit at the University of Texas Health Science Center at Houston. Ms. Shaw says that at her unit, her mother would have had a CT scan within five minutes of arriving, and tPA probably would have been administered 30 or 35 minutes after that.

Today, according to her daughter. Ms. Shelton often can't come up with words or relatives' names, can't take care of her finances, and can't follow certain basic commands in neurological tests.

Kent Shoji, an emergency-room doctor at Centinela Freeman who handled Ms. Shelton's case, says, "She was a possible candidate for tPA," but a CT scan was required first. "The order was put in for a CT scan," Dr. Shoji says. "I can't answer why it took so long."

A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage with our CT scan, and we had to call a technician to come in. That's pretty common with a community hospital." The hospital has since been acquired by a larger health system and now does have 24-hour CT capability.

A hospital-accrediting group has begun designating hospitals as stroke centers, but that is only part of what is needed, stroke experts assert. They say hospitals typically have to come together to create local political momentum to change state or county rules so that ambulances actually take stroke patients to stroke centers, not the nearest ER. New York, Maryland and Massachusetts are moving toward creating stroke-care systems, and Florida recently passed a law creating stroke centers. But in many places, short-term economic interests impede change, some doctors say.

"There are still very parochial interests by hospitals and physicians to keep patients locally even if they're not equipped to handle them," says neurosurgeon Robert A. Solomon of New York-Presbyterian Hospital/Columbia. "Hospitals don't want to give up patients."

The University of California at San Diego runs one of the leading stroke hospitals in the country. It and others in the area that are well prepared to treat stroke patients have sought for a decade to set up a regional system, but there has been little progress, says Patrick D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting losing stroke business," he says. "We have the same political crap as in most communities. Paramedics still take people to the local ER."

Among the opponents of the stroke-center concept during the 1990s was Richard Stennes, then ER director at Paradise Valley Hospital south of San Diego. In various public debates, Dr. Stennes recalls, he argued that many apparent stroke patients would be siphoned away from community hospitals even if they didn't turn out to have strokes. Also, he argued that tPA might cause more injury than it prevents. And then there was the economic issue: "Those hospitals without all the equipment and stroke experts," he says, "would be concerned about all the patients going to a stroke center and taking the patients away from us." Dr. Stennes has since retired.

"All hospitals and clinicians try to deliver the right care to patients, especially those with urgent medical needs," says Nancy E. Foster, vice president for quality of the American Hospital Association, which represents both large and small hospitals. "Community hospitals may be equally good at delivering stroke care, and it would be important for patients to know how well prepared their local hospital is."

Stroke experts aren't proposing that every hospital needs to specialize in stroke care but instead that in every population center there should be at least one that does. In Atlanta, Emory University's neuro-intensive care unit illustrates the special skills that make for top care. Owen B. Samuels, director of the unit, estimates that 20 percent to 30 percent of patients it treats received poor initial medical care before arriving at Emory, jeopardizing their futures or even lives. Brain hemorrhages, for example, are commonly misdiagnosed, even in patients who repeatedly showed up at emergency rooms with unusually severe headaches, Dr. Samuels says.

The Emory unit has 30 staff members, including two neuro-critical care doctors and five nurse practitioners. A team is on duty 24 hours a day. The unit handles about two dozen patients most days, keeping the staff busy. On the ward, nearly all patients are unconscious or sedated, so it's eerily silent. Patients generally need to rest their brains as they recover from stroke or surgery.

After a hemorrhagic stroke, blood pressure in the cranium builds as blood continues to seep out of the ruptured vessel. Pressure can be deadly, cutting off oxygen to the brain. Or escaped blood can cause a "vasospasm," days after the original stroke, in which the brain reacts violently to seeped-out blood. In the worst case, the brain herniates, or squeezes out the base of the skull, causing death. To avoid this, nurses at Emory constantly monitor brain pressure and temperatures. They put in drain lines. They infuse medicines to dehydrate, depressurize and stop bleeding.

Since Emory launched the neuro-intensive unit seven years ago, 42 percent of patients with hemorrhagic strokes have become well enough to go home, compared with 27 percent before. Fewer need rehabilitation -- 31 percent versus 40 percent -- and the death rate is down.

Damica Townsend-Head, 33, gave the Emory team a scare. After surgery last fall for a hemorrhagic stroke, her brain swelling was "really out of control," Dr. Samuels says, raising questions about whether she would survive. The staff put a "cooling catheter" into a blood vessel, which allowed the circulation of ice water to bring down the temperature in her blood and brain. They intentionally dehydrated her brain to lower pressure. A month later, she woke up and recovered with minimal disability. She still walks with a cane and tires easily, but her speech is normal and she hopes to return soon to work. "I consider her what we're in business for," Dr. Samuels says.

The public's low awareness of stroke symptoms -- and the need to respond immediately -- can also hinder proper care. Ischemic strokes, those caused by clots or other artery blockage, cause symptoms such as muscle weakness or paralysis on one side, slurred speech, facial droop, severe dizziness, unstable gait and vision loss. People with this kind of stroke are sometimes mistaken for being drunk. In addition to intense head pain, a hemorrhagic stroke often leads to nausea, vomiting or loss of balance or consciousness. Still, many people with some of these symptoms merely go to bed in hopes of improving overnight, doctors say. Instead, they should go immediately to a hospital and demand a CT scan as a first diagnostic step.

The well-funded American Heart Association, established in 1924, has made many people aware of heart attack symptoms and thereby saved many lives. In contrast, the American Stroke Association was started only in 1998 as a subsidiary of the heart association. The stroke association spent $162 million last year out of the heart association's $561 million overall budget.

Justin Zivin, another University of California at San Diego stroke expert, says the stroke association "is a terribly ineffective bunch. When it comes to actual public education, I haven't seen anything."

The stroke association counters that it is buying television and radio ads promoting awareness, similar to ones produced in 2003 and 2004. The group also sponsors research and education, including an annual international stroke-medicine conference.

It's not just the general public that fails to recognize stroke symptoms. Often, emergency-room doctors and nurses don't, either. Gretchen Thiele of suburban Detroit began having horrible headaches last May, for the first time in her life. "She wasn't one to complain, but she said, 'I can't even lift my head off the pillow,' " recalls her daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain one night and suffered blurred vision. When the pain recurred in the morning, she went to the emergency room at nearby St. Joseph's Mercy of Macomb Hospital. Ms. Mazero says that during the six hours her mother spent there, she was given a CT scan, but not a spinal tap, which could definitively have shown she had a leaking brain aneurysm, meaning a ballooned and weakened artery in her brain. After the CT, Ms. Thiele was given a muscle relaxant and pain medicine and sent home, her daughter says.

Two months later, the blood vessel burst. Neurosurgeons at William Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms. Thiele suffered massive bleeding and died. Ali Bydon, one of the neurosurgeons at Beaumont, says a CT scan often is inadequate and that her condition could have been detected earlier with a spinal tap, also called a lumbar puncture. "Had she had a lumbar puncture and perhaps an operation earlier, it might have saved her life," says Dr. Bydon. "In general, a person who tells you, 'I usually don't get headaches, and this is the worst headache of my life,' is something that should alarm you."

In addition, he says Ms. Thiele "absolutely" was experiencing smaller-scale bleeding in May that foreshadowed a more serious rupture. If doctors identify this kind of bleeding early, he says, chances of death are "minimal." But when a rupture occurs, he says, "25 percent of patients never make it to the hospital, 25 percent die in the hospital and 25 percent are severely disabled."

A St. Joseph's hospital spokeswoman says the hospital has "very aggressive standards for treatment, and we met this standard," declining to elaborate.

Paramedics did the right thing after Chuck Toeniskoetter's stroke, but only because of some extraordinary intervention. Mr. Toeniskoetter, then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los Angeles. He had just finished a run at 3:30 p.m. when, in the snowmobile shop, he began slurring his words and nearly fell over. Kathy Snyder, the nurse in the ski area's first-aid room, quickly diagnosed stroke. She called a helicopter and an ambulance.

Ms. Snyder says she knew the closest hospital with a stroke team was Sutter Roseville Medical Center in Roseville, Calif. The helicopter pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms. Snyder says she stood on the helicopter runners, demanding the patient go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to Sutter, where he promptly received tPA. Today, he has no disability and is back running a real estate-development business in the San Jose area. "Trauma patients go to trauma centers, not the nearest hospital," he says. "Stroke victims, too, require a real specialized sort of care."

One-third of all strokes are suffered by people under 60, and hemorrhagic strokes in particular often strike young adults and children. Vance Bowers of Orlando, Fla., was 9 when he woke up screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001. Malformed blood vessels in his brain were bleeding. He was in a coma by the time an ambulance delivered him at 1:57 a.m. to the nearest emergency room, at Florida Hospital East Orlando.

Emergency-room doctors soon realized Vance had a hemorrhagic stroke. But neurosurgery isn't performed at that hospital. A sister hospital-- minutes away by ambulance, Florida Hospital Orlando, did have neurosurgical capability. But in part because of administrative tangles, Vance didn't get to the second hospital until 4:37 a.m., more than two hours after his arrival. Surgery began at 6:18 a.m. "This delay may have cost this young man the possibility of a functional survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said in a letter to the hospitals' joint administration.

Florida Hospital, an emergency-medicine group and an ER doctor recently agreed to settle a lawsuit filed against them in Orange County, Fla., Circuit Court by the Bowers family. The defendants agreed to pay a total of $800,000, court records show. Monica Reed, senior medical officer of the hospital, says the care Vance received was "stellar" and that any delays weren't medically significant. Vance's stroke, not the care he received, caused his injuries, she said.

Vance, now 13, survived but is mentally handicapped and suffers daily seizures, his mother, Brenda Bowers, says. Once a star baseball player, he goes by wheelchair to a class for disabled children. He speaks very slowly but not in a way that many people can understand. "He remembers playing baseball with all of his friends," his mother says, but they rarely come around any more. "He really misses all that."

Food for thought,

Ridryder 911

[Guest]

Interesting article, Brings up the question of taking Pt's to the closest appropriate facility. I had a AMI "the widow maker" I had a choice a small ER 4 beds that would have to fly the pt or a Hospital that has Cardiac Cath, I chose the ER with the Cardiac Cath, The pt died enroute to the ER, I followed ACLS protocols to the tee. The choice I made taking the pt to the closet appropriate er saved me a lawsuit.

[emt_hound]

Very interesting, but I don't like some of the assumptions raised in the article about what happened in these cases versus what could have happened.

I hate the presumption of negligence, but it sounds like the issue here is remedial training on stroke diagnosis and treatment for ER staff, not on revamping the transport protocols for EMS.

[Richard B the EMT]

As a BLS provider, I concur. This should be protocol for all ERs.

Admittedly, we have "Stroke Centers" here in NYC, but it should be the ER Crews should all be trained, not a transportation decision that I always seem to be getting questioned on by the ER Docs at the local hospital so designated.

Our Paramedics follow the same "Stroke Center" patient designation.

[RichmondMedik]

I tell people on my rig the closest "APPROPRIATE" facility -- may not be the one the patient wants and I explain out how they will have to be transported a second time to go to the right facility -- it is usually recieved pretty well when explained properly

Paul

[JennaEMT]

I hate the presumption of negligence, but it sounds like the issue here is remedial training on stroke diagnosis and treatment for ER staff, not on revamping the transport protocols for EMS.

Maybe I read the article differently, but I disagree...

The current ischemic stroke guidelines, put out by the American Stroke Association, recommend a CT scan to rule out hemorrhagic stroke, followed by tPA, within a window of three hours from the onset of symptoms. They also say that CT should be available 24/7 for stroke evaluation; if a pt arrives who is suspected to be having a CVA and CT is not available then the pt should be transferred.

In the article, they say, "Kent Shoji, an emergency-room doctor at Centinela Freeman who handled Ms. Shelton's case, says, "She was a possible candidate for tPA," but a CT scan was required first. "The order was put in for a CT scan," Dr. Shoji says. "I can't answer why it took so long."

A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage with our CT scan, and we had to call a technician to come in. That's pretty common with a community hospital."

So it sounds like the doctor did follow the protocols; the hospital just wasn't set up to follow the time-line for tPA.

I'd have to agree with the writer of the article, this pt should have been taken to a hospital that had a CT available - like the stroke center 17 miles away, instead of the community hospital 13 miles away. Paramedics & EMTs need to be allowed to take pts where they will receive appropriate care - and I say we are well-trained to make that determination in the field. You wouldn't take a woman in labor to a hospital that had no L&D; you wouldn't take a major trauma to a hospital that had no trauma services. I'd back mcad's decision ("Interesting article, Brings up the question of taking Pt's to the closest appropriate facility. I had a AMI "the widow maker" I had a choice a small ER 4 beds that would have to fly the pt or a Hospital that has Cardiac Cath, I chose the ER with the Cardiac Cath"). So, if the hospital that is fully prepared to manage CVA in the 3-hour window is only a few more miles, we should go there.

But don't get overly excited about this article; it has some spin in it. For example, it says, "For example, a survey published in 2000 in the journal Stroke showed that 66 percent of hospitals in North Carolina lacked any protocol for treating stroke. About 82 percent couldn't rapidly identify patients with acute stroke." What the hospitals lack is a written "stroke plan," a document that goes in the pt's chart and that all disciplines, from ED to rehab, use to plan for and to chart the pt's progress. It does NOT mean that 66% of NC hospitals can't treat CVAs. And the 82% they refer to was a poll of lay people - 82% of the general public couldn't identify stroke sxs. The way it was written, you'd think that 82% of NC hospitals couldn't identify a stroke. Reporters :evil: Some days that rank right up there with lawyers.

[Ace844]

Hi All,

You may want to consider talking to th ER/neuro docs in your area. Alot of the major hospitals in the NE are doing intra-arterial, isolated vessel TPA in angio. Meaning in short that the Neuro MD and the interventional radiologist take the patient to angiography (some cases MRA) and thread a cath via the neck to the basalar arteries. They inject the Dye, isolate the clot and thread a cath to that vessel, then release small amounts of TPA to "alleviate" the clot. This therepy has expanded the "CVA thrombolysis/lytic" window up to 6-8 hrs post sx onset. I respecfully submit it may be beneficial to yuo and your patients to find where/when/if they are doing this in your practice area.

Ace

[NR_Paramedic]

The whole problem with this argument is that class 1 pts. (trauma excluded) MUST go to the closest ER, if you pass 2 community ER's w/ a pt. having an active MI and the pt. dies before you get the cath. lab hosp. then you are liable b/c the community ER can still administer thrombolytics etc... Most systems that I am aware of do not have protocols saying that stroke pts. go to stroke centers, cardiac pts. go to cardiac centers etc...I believe they should be in place but they are not. Guess that keeps the SCT/CCT guys in business. The Idea that a paramedic can be liable for taking a class 1 pt. to the closest ER is scary. Esp. for more suburban or borderline rural EMS systems where its not a 2 min. difference. If they want to sue anyone they should sue whoever wrote the protocols. The paramedic just has to follow his standing orders.

[Ace844]

Hello Everyone,

Here's some more recent data on this topic...

Hope this Helps,

ACE844

Objectives: To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period.

Methods: The authors obtained data from the 1992–2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435.

Results: From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%).

Conclusions: Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.

(Place of Death After Stroke—United States @ 1999-2002

JAMA. 2006;295:2717-2718.

MMWR. 2006;55:529-532)

1 figure, 1 table omitted

Stroke is the third leading cause of death in the United States.1 Successful acute stroke intervention depends on early recognition of symptoms, prompt emergency transport, and rapid in-hospital treatment. However, approximately half of stroke decedents die before admission to the hospital.2 During 1990-1998, the proportion of stroke deaths that occurred in hospitals declined, and the proportion occurring before transport to hospitals increased.3 This report summarizes trends in the place of death among all stroke decedents, the proportion of stroke deaths occurring before emergency assistance arrives, and characteristics associated with place of death. Among 162 672 persons who died of stroke in 2002, 49.2% died pre-transport, 0.4% were dead on arrival (DOA), 3.3% died in emergency departments (EDs), and 47.0% died after admission to a hospital. Early patient and bystander recognition of stroke symptoms and timely action in calling for emergency assistance might reduce the number and proportion of stroke deaths. In addition, improving timely arrival of emergency care and appropriate treatment of stroke patients can reduce the proportion of pre-transport deaths and serious sequelae that lead to severe disabilities.

National mortality statistics in this report were based on death-certificate information from all 50 states and the District of Columbia (DC) that was reported to CDC. Demographic data (eg, race/ethnicity, sex, and age) and place of death on death certificates were provided by funeral directors or family members. The death certificate item on where death was pronounced was used as a proxy source of information for place of death. Stroke-related deaths were defined as those for which the underlying cause reported on the death certificate by a physician, medical examiner, or coroner was classified according to International Classification of Diseases, Tenth Revision (ICD-10) codes I60–I69. These include hemorrhagic (I60–I62), cerebral infarction (I63), unspecified (I64), occlusion and stenosis (I65–I66), other cerebrovascular deaths (I67–I68), and deaths with cerebrovascular sequelae (I69). Place of death was defined as pre-transport death (death pronounced in a nursing home or at home or other place), post-transport death (death pronounced in the ED or hospital), DOA, or unknown. The distribution of place of death among stroke decedents in the United States was assessed during 1999-2002 and the percentage change was assessed from 1999 to 2002.

In 2002, a total of 162 672 deaths from stroke occurred among US residents, with an age-adjusted death rate of 56.2 per 100 000 population. Of these stroke-related deaths, 49.2% occurred pre-transport (35.4% in a nursing home and 13.8% in the decedent's home or other place), 0.4% were DOA, 50.3% occurred post-transport (3.3% in EDs and 47.0% after admission to a hospital), and information was unknown for <0.1%. The proportion of pre-transport deaths among stroke decedents in 2002 increased among successive age groups, particularly for deaths occurring in nursing homes. For example, the proportion of deaths that occurred pre-transport was 14.4% among stroke decedents aged <45 years (11.8% at home or other place and 2.6% in nursing homes), compared with 65.2% among those aged 85 years (15.3% at home or other place and 49.9% in nursing homes). The proportion of pre-transport deaths was higher among females than males, among whites than other races, and among non-Hispanics than Hispanics. However, the proportion of stroke-related deaths that occurred in EDs was higher for blacks than other racial groups and higher for Hispanics than non-Hispanics. Asians/Pacific Islanders had the highest proportion of post-transport stroke deaths that occurred in a hospital compared with all racial groups.

The highest proportion of pre-transport stroke deaths was observed among persons who died of sequelae of cerebrovascular diseases (72.1%) or other cerebrovascular conditions (69.5%), followed by unspecified stroke (54.5%), cerebral infarction (53.2%), and hemorrhagic stroke (14.2%). Those who died of a hemorrhagic stroke had the highest proportion of deaths in EDs (5.9%) and hospitals (79.6%).

The US age-adjusted stroke death rate steadily decreased from 61.6 per 100 000 population in 1999 to 56.2 per 100 000 population in 2002. However, minimal change was observed in the distribution of place of death and characteristics associated with place of death among stroke decedents from 1999 to 2002. The place of death did not change from 1999 to 2002 for groups defined by age, sex, or race/ethnicity. The relative increase from 1999 to 2002 in the proportion of stroke decedents dying pre-transport was 3.4% for all strokes, 8.5% for hemorrhagic strokes, 7.1% for other cerebrovascular deaths, 4.9% for cerebral infarctions, 4.3% for cerebrovascular sequelae, and 3.4% for unspecified strokes.

Reported by:

C Harris, MPH, C Ayala, PhD, JB Croft, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

CDC Editorial Note:

The findings in this report indicate that overall national trends and characteristics associated with place of death among stroke decedents did not change from 1999 to 2002. In 2002, approximately half of all stroke deaths occurred pre-transport. A substantial proportion of pre-transport stroke deaths occurred in nursing homes rather than at home or another place, and a greater proportion of post-transport deaths occurred after hospital admission rather than in EDs. Pre-transport stroke deaths increased with successive age groups and occurred more frequently among females than males, whites than other racial groups, non-Hispanics than Hispanics, and those who died with sequelae of cerebrovascular diseases than other stroke subtypes. These proportions and characteristics of pre-transport stroke deaths remain consistent with previously published data, which indicated that 49.5% of all stroke deaths in 1998 occurred in hospitals, 46.1% occurred pre-transport, and 0.6% of persons were DOA.3 However, the results from this report and the 1998 report are not directly comparable because of changes in ICD coding from the ninth to the tenth revisions.

Sex differences noted in pre-transport stroke deaths could be attributed in part to differences in emergency response time. One study indicated that during a stroke, women might have a longer delay time in reaching the hospital than men.4 Although delayed emergency response might partially explain the disparity between males and females, the findings in this report indicate that approximately 40% of stroke deaths in females occurred in a nursing home. In 1999, women accounted for approximately 70% of the nursing home population5; in addition, women aged 80 years or any hospital patients admitted from a nursing home are more likely to have do-not-resuscitate orders than men aged 80 years, younger women, or hospital patients admitted from home.6 Blacks, compared with Hispanic and non-Hispanic whites, might be more likely to use emergency medical services (EMS) for transport to the hospital, thus reaching the hospital earlier4 and supporting the finding that a smaller proportion of blacks die pre-transport than whites. In addition, one study observed that blacks and Hispanics also might be less likely to have do-not-resuscitate orders than whites, regardless of age.6

Two state program priorities for CDC's National Heart Disease and Stroke Prevention Program are to increase public awareness of signs and symptoms of a stroke and to improve emergency response for stroke. State efforts might have increased the capacity of EMS response to acute stroke. For example, Texas has adopted the Emergency Health Care Act, which mandates creation of a stroke committee, a statewide stroke emergency transport plan, and stroke facility criteria with the intent to construct an emergency treatment system in Texas so that stroke victims can be identified quickly and transported to appropriate stroke treatment facilities.7

The finding in this report indicate that hemorrhagic stroke patients were less likely to die before reaching the hospital, which supports previous findings that hemorrhagic stroke patients use EMS services more frequently8 and are seen earlier by the neurologist than other stroke subtype patients.4 Persons dying of cerebrovascular sequelae, followed by other cerebrovascular conditions and unspecified stroke deaths, had the highest proportion of pre-transport deaths, which could indicate that they had comorbidities or do-not-resuscitate requests and might have been less likely to seek further medical attention or use EMS services.9 Further investigation is needed to clarify the impact that do-not-resuscitate requests in homes, nursing homes, and end-state disease care settings have on the high proportion of pre-transport stroke deaths.

The findings in this report are subject to at least two limitations. First, death-certificate data are subject to error in the certification of the underlying cause of death.1 Second, death-certificate place of death data are based on where the decedent is pronounced dead and not necessarily where the decedent died. Therefore, the difference in reported place of death and actual place of death could result in either overestimates or underestimates in the proportion of stroke deaths that occurred in a specified location. However, the quality of place of death data has been investigated, with results indicating the consistency for reporting deaths in a hospital is 88.3% and is 92.9% for reporting deaths in either nursing homes or personal-care homes.10 Because approximately 80% of deaths in this report were classified as occurring in hospitals or nursing homes, bias likely did not affect the results of this analysis.10

The substantial proportion of pre-transport stroke deaths in the United States continues to illustrate the need for early recognition of stroke signs and symptoms followed by expeditious transport of stroke victims to hospitals, preferably hospitals recognized as stroke centers and treatment facilities. Policies and stroke emergency transport plans should be in place for all EMS systems in every state. Such plans should mandate stroke as an emergency event and should have protocols for identifying, transporting, and treating stroke patients to reduce the proportion of pre-transport stroke deaths.

REFERENCES

1. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. Natl Vital Stat Rep. 2004;53:1-115. PUBMED

2. CDC. State-specific mortality from stroke and distribution of place of death—United States, 1999. MMWR. 2002;51:429-433. PUBMED

3. Ayala C, Croft JB, Keenan NL, et al. Increasing trends in pre-transport stroke deaths—United States, 1990-1998. Ethn Dis. 2003;13(2 Suppl 2):S131-137. PUBMED

4. Menon SC, Pandey DK, Morgenstern LB. Critical factors determining access to acute stroke care. Neurology. 1998;51:427-432. ABSTRACT

5. Jones A. The National Nursing Home Survey: 1999 summary. Vital Health Stat 13. 2002;152:1-116. PUBMED

6. Zingmond DS, Wenger NS. Regional and institutional variation in the initiation of early do-not-resuscitate orders. Arch Intern Med. 2005;165:1705-1712. FREE FULL TEXT

7. Emergency Health Care Act of 2005. Texas state bill 330, 79® (June 17, 2005).

8. Schroeder EB, Rosamond WD, Morris DL, Evenson KR, Hinn AR. Determinants of use of emergency medical services in a population with stroke symptoms. Stroke. 2000;31:2591-2596. FREE FULL TEXT

9. Chang KC, Tseng MC, Tan TY. Prehospital delay after acute stroke in Kaohsiung, Taiwan. Stroke. 2004;35:700-704. FREE FULL TEXT

10. Poe GS, Powell-Griner E, McLaughlin JK, et al. Comparability of the death certificate and the 1986 National Mortality Followback Survey. Vital Health Stat 2. 1993;(118):1-53. No abstract available. PUBMED

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Here's a great TIA article:: http://www.charite.de/ch/neuro/forschung/t...weih.stroke.pdf

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