Mayo Clinic Stroke Programs: Providing Acute Care in the Community and Beyond

The term "brain attack" has never really caught on in the public imagination. This is unfortunate because "stroke" often fails to invoke the sense of medical urgency, of life-and-death drama that "heart attack" does. Yet timely treatment for stroke is just as critical. Every minute counts. The initial symptoms of stroke—a slight tingling in the hand, a transient bout of slurred speech, for example—can be subtle and may not be recognized for what they are. And it is difficult for the public to comprehend the potentially devastating consequences of damage to the brain.

Even within the medical community, acute stroke may not translate into rapid intervention. For example, the administration of tissue plasminogen activator (t-PA) in the first 3 hours can limit the amount of brain tissue injured in an ischemic stroke. According to the American Stroke Association, of those eligible, an average of only 5% to 10% receive it. Administration of t-PA is one of 10 quality-of-care indicators Mayo Clinic in Arizona tracks in compliance with the American Stroke Association's "Get With the Guidelines-Stroke" (GWTG-Stroke) program. For the past 3 years, 100% of their eligible patients received t-PA within the first 3 hours after onset.

Rapid Response: The Critical First Hour

There is a box, referred to as the "clot box," in the emergency department (ED) at Mayo Clinic Hospital in Phoenix, Arizona, that contains everything needed to administer intravenous t-PA. In that same ED is a large poster on the wall—a minute-by-minute timeline for acute stroke care. An ideal aspired to, it quickly became a reality as Mayo's stroke team shaved 20 minutes off the time from ED arrival to appropriate intervention (the "door to needle" response time). It required the formation and dedication of a rapid-response team, one that includes the very first persons on the scene—the emergency medical services (EMS) responders. Neurologists and emergency physicians from Mayo Clinic helped the Phoenix and Scottsdale fire departments set up the Stroke Alert System and then trained their EMS personnel to evaluate stroke in the field and call in the diagnosis en route.

The minute the call comes in, a triage nurse at Mayo Clinic Hospital activates a single phone number that simultaneously pages all members of the stroke team, alerts radiology to prepare for an urgent CT scan, and notifies lab technicians and stroke team nurses. The patient must be seen within 10 minutes of arrival. The on-call stroke neurologist must be present within 20 minutes, the CT scan done within 25 minutes, and lab studies done and interpreted within 45 minutes. The goal is to deliver t-PA intravenously, if appropriate, within 60 minutes of the patient's arrival, a goal that has been met in 100% of cases since 2004. The same timeline applies for inpatients with acute stroke. Nurses and technicians throughout Mayo have been trained to recognize the symptoms and to call the coactivated page number.

Dedicated stroke care beyond the first hour includes delivery and monitoring of necessary medications (eg, lipid-lowering agents, antihypertensive treatments, antiplatelet medications, anticoagulants); providing speech, swallowing, physical, and occupational therapy as needed; and providing stroke education and counseling. Finally, it includes a follow-up visit with the neurologist within 4 to 6 weeks to help the patient sort through life changes, assess the need for continued services, and reiterate stroke prevention guidelines.

This level of dedication earned Mayo Clinic designation as a Phoenix Primary Stroke Center (PSC) in April 2003 and certification as a Joint Commission (JC) PSC in May 2006. With more than 85% compliance with GWTG-Stroke, it was 1 of approximately 30 hospitals in the country awarded the American Stroke Association Annual Performance Achievement Award last year. St. Luke's Hospital, a Mayo Clinic facility in Jacksonville, Florida, is also a JC-certified PSC. Hospitals at Mayo Clinic in Minnesota are awaiting a JC site visit for final approval.

Mayo Clinic Arizona's Stroke Program

The stroke team, directed by Bart M. Demaerschalk, MD, includes neurologists Maria I. Aguilar, MD, David W. Dodick, MD, and Timothy Ingall, MD, PhD. One team member is on call 24 hours a day, 7 days a week. An endovascular surgical neuroradiologist, Brian W. Chong, MD, provides such treatments as mechanical clot retrieval and intra-arterial t-PA, offered also at Mayo Clinic's other sites and a select number of other facilities in the country.

Reflecting the complex nature of stroke, the stroke program at Mayo Clinic in Arizona is guided by an interdisciplinary committee that includes members of the departments of neurology, neurosurgery, neuroradiology, vascular surgery, emergency medicine, internal medicine, critical care medicine, physical medicine and rehabilitation, and cardiology. Stroke patients are preferentially admitted to a specific ward with nurses who have expertise in neurologic and neurosurgical care and receive state-of-the art treatments such as intravenous thrombolytic therapy, intra-arterial thrombolysis, clot retrieval, stents, coils for aneurysms, and new drugs and interventions that are in clinical trials.

Reaching Out to the Community

Beginning in 1998, Dr Ingall and physicians and health care providers at other institutions helped establish the Phoenix Metropolitan Matrix of Primary Stroke Centers to ensure designated, hospital-based stroke care coverage in all areas of Phoenix. Bentley J. Bobrow, MD, a Mayo emergency medicine physician, and Dr Demaerschalk collaborated to develop ASPIRE, a program that tracks the response to and outcome of every patient with acute stroke called in by an EMS provider. Overall, these community efforts have resulted in a 20-fold increase in the timely delivery of t-PA to patients in the Phoenix area since 1998.

Stroke patient telemedicine consultation

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Stroke Telemedicine for Arizona Rural Residents (STARR) allows Mayo neurologists to provide diagnostic consultation to patients in the rural communities of Yuma and Kingman through a telemedicine program funded by the Arizona Department of Health Services. Via Internet access, Mayo physicians have site-independent, 2-way audio-video capability and can control a remote camera to conduct an examination and consultation with patients and ED physicians in rural emergency settings. CT scan images and lab reports can be reviewed, helping an on-site physician provide interventions such as t-PA in a timely manner. Patients who need services that are unavailable can be air-lifted to Mayo. "Before this program, this level of acute stroke care was in the exclusive domain of large metropolitan and academic centers. This is a community service that extends Mayo's care outside those areas," explains Dr Demaerschalk. "If it succeeds, it is hoped that the state will extend funding to new areas, improving stroke care throughout Arizona."