MUSC awarded Joint Commission certification as Comprehensive Stroke Center

It’s a pit crew like no other.

“Time is brain,” said Raymond Turner, M.D., director of cerebrovascular surgery at the Medical University of South Carolina, which recently met the Joint Commission’s standards for becoming a Disease-Specific Care Comprehensive Stroke Center. This means that MUSC is part of an elite group of about 100 hospitals nationwide and the first one in the state with this status.

A sense of urgency and excitement fills the air as doctors Turner, Christine Holmstedt, D.O., and Aquilla Turk, D.O., celebrate the news and discuss how the team has succeeded in getting patients faster and higher quality care. “We all have the same passion,” Holmstedt said. “I think we’re all super passionate about what we do.”

No one needs to tell them what’s at stake when it comes to stroke. An estimated two million brain cells die every minute during stroke, increasing the risk of permanent brain damage, disability or death.

The Comprehensive Stroke Center certification recognizes those hospitals that have state-of-the-art infrastructure, staff and training to handle patients with the most complex forms of all strokes. It also recognizes the driving ambition of MUSC Health Stroke Program team leaders to relentlessly provide care that maximizes the chance for patients to make the best recovery possible.

Take the measurement of door-to-needle times, for example. There’s a critical window of time for patients who are having a stroke and are eligible to receive the intravenous tissue plasminogen activator tPA, which is a clot-busting medication, to have the best outcomes. It’s called the door-to-needle time.

Turner explained the national standard for door-to-needle is 60 minutes. MUSC hit that. “And we didn’t stop when we hit 50 minutes or 45 minutes and go, ‘Oh, that’s good enough.’ We said, ‘Let’s see if we can get it less than 30 minutes.’”

Turner compared the team’s accomplishment to that of a finely-tuned pit crew all working together. “It’s driving those metrics. It’s not just checking a box and saying, ‘We can get there.’ We don’t accept substandard outcomes. We don’t accept hitting a standard and being average.  We’re all driving and continuously trying to get better and better and push the envelope to improve the outcomes.”

The door-to-needle time is just one part of the race. Another is access to a certain level of care – the type that can make a radical difference in a person’s ability not only to survive but also to have the best quality of life possible.

Understanding that there are different types of hospitals equipped for different levels of care shows why comprehensive status matters, said Holmstedt, who is the medical director of MUSC’s Clinical Stroke and Telestroke programs.

“We have acute stroke-ready hospitals across South Carolina, which are the hospitals that can stabilize a stroke patient, potentially treat them with IV tPA if they need it, but then typically they have to ship them on either to a Primary Stroke Center or a Comprehensive Stroke Center.”  Without access to stroke expertise by telemedicine, stroke patients in these parts of the state would otherwise not be treated.

Primary Stroke Centers are hospitals that can do everything that an acute stroke-ready hospital can do, as well as admit and monitor acute stroke patients who have received the clot-busting medication in a dedicated stroke unit. Then there’s the top comprehensive tier, the certification level MUSC recently received, that means a hospital can handle the most complex of stroke patients and provide the most advanced level of care achievable.

Complex stroke patients range widely, from “those patients who may require endovascular procedures, such as clot removal, those who require securing of an intracranial aneurysm or those that require neuro-critical intensive care, and emergent neuro-surgical evaluation and treatment,” Holmstedt said.

“To be comprehensive, you have to be able to provide those services 24 hours a day, 365 days a year. And, it’s not just offering the services. We have to monitor our outcomes and demonstrate true quality of care.  We actually monitor our discharged patients at 90 days post-discharge to monitor their clinical outcomes and make sure we’re doing the right thing.”

Stroke Belt

Sunil Patel, M.D., chairman of neurosurgery at MUSC, remembers 10 years ago when he became chairman, making stroke the No. 1 priority for the state given that it had the highest stroke mortality rates in the country. MUSC, in partnership with the state of South Carolina, made a commitment to hire the right specialists and coordinate the right teams, he said.

“We have very high incidence of stroke and an even higher rate of death compared to other states. MUSC is moving to provide better health for the population it serves, to touch all lives. In keeping with this, we think stroke is very important for us to be very good at and to provide even better outcomes for these patients. We owe it to the people of South Carolina.”

It has taken a dedicated effort spanning multiple disciplines to reach this elite comprehensive status.

“Stroke is a very general term. There are all kinds of blood vessel conditions that occur in the brain, from hemorrhages to ischemia,” he said. “Many different specialties are involved not only in the diagnosis, but in the treatment and early evaluation and rehabilitation of these patients. It spans eight to nine different specialties in medicine from surgical to radiology to neurology and emergency medicine. That’s why it takes a village to get the comprehensive status.”

Dr. Bruce Ovbiagele, M.D., chairman of neurology, agreed, adding that the comprehensive status is a stamp of approval for MUSC and its ability to treat stroke patients, which is critical since people in both Carolinas and Georgia are four times more likely to die from a stroke compared to many other states in the country. According to the Centers for Disease Control and Prevention, on average, one American dies from stroke every four minutes.

“Unfortunately, the outcomes for stroke in our region could be much better. We have been providing this type of high-level comprehensive stroke care for a while. This recognition from the Joint Commission will make awareness of our profound stroke expertise much better known in the region, thereby allowing more patients to benefit from disability-preventing and life-saving therapies.”

One aspect of this excellence is MUSC’s Stroke Recovery Research Center, one of a handful of such centers in the nation dedicated to improving the quality of life for those who have had strokes. The center has 33 active grants that focus on stroke recovery, 23 investigators with funded stroke recovery research projects and 250 stroke survivors enrolled in the center’s Registry for Stroke Recovery called RESTORE.

Turk said while what the stroke team physicians do is important, they are very grateful to have such a strong Stroke Recovery Research Center that is advancing post-stroke treatment options. “Between the time the patient is discharged three to seven days after their stroke, there’s another two-and-a-half months' worth of work, and that’s obviously a very critical time for them. Rehabilitation is a huge component of how well these patients do functionally because that’s the bottom line. If we didn’t have that involvement, then our outcomes would not be nearly as good as they are.”

It’s not only in rehabilitation where MUSC is making a mark. One huge success story is its telestroke outreach. MUSC had a record-breaking year in 2015 with more than 1,800 consults. MUSC acts as the hub of stroke expertise that now has grown to serve 22 sites, ensuring that almost all state residents are within 60 minutes of having access to expert stroke and cerebrovascular care.

Holmstedt said it speaks to the team’s commitment to reducing health disparities and providing everyone – not just those living near a large hospital – with high-quality care through the telestroke program in association with the South Carolina Telehealth Alliance. “We now have made stroke care available to 96 percent of South Carolinians within a 60-minute drive so they can get access to expert stroke care. This is all about improving access to care around the state of South Carolina and addressing disparities.”

That may mean just a telestroke consult or it also may involve a transfer to either a primary stroke center or to MUSC. Physicians are on call 24/7 to help make that determination.

Turk said it takes a highly-trained team to identify and evaluate patients, some of whom are arriving via helicopter. “When they come in, they go straight to the CT scanner. Physicians are coming to them rather than the patients waiting on the physicians. It’s about the process. It’s about time and efficiency.”

Doctors use CT scans to check blood vessels for blockages and perform specialized perfusion imaging to determine what brain tissue is still viable to know what treatment options remain that still can preserve brain function.

Holmstedt said it’s not just the doctors who are racing the clock, it’s the entire stroke team, including nurses, pharmacists, radiology technicians and others.

“There’s a nurse who comes from the neuroscience ICU who’s with the patient for the entire acute stroke care transition, helping move the patient through the system. These nurses know the patient from the time they arrive in the ED all the way until they get admitted to the neuro-critical care unit. Having a stroke-trained critical care nurse with the patient improves care area transitions for patients. The Joint Commission felt that having a brain attack nurse escort the patient was novel and considered this 'best practice for Comprehensive Stroke Care.'"

Patients also get specialized stroke treatment because strokes differ in how they are caused and how they might respond to treatment. Turner said it goes well beyond just treating a blocked blood vessel that can be one cause of a stroke.

“The same holds true with aneurysms, intracerebral hemorrhages and vascular malformations. It’s so much more than just an ischemic stroke. That’s why it’s comprehensive.”

Global Reach

Part of being a comprehensive center is doing research that improves stroke treatment. MUSC is among the leading hospitals nationally and internationally conducting clinical stroke research. Holmstedt said MUSC is known for its robust research program. “We have world-class research going on here in stroke. So it’s not just about treating the patients in our state, but addressing stroke patients all over the world,” she said. 

“Just since last year, our combined group has published 98 papers. Many of those were scientific journals and guidelines for stroke care. We have a clinical trial for nearly every patient who comes through our stroke program, and that’s really to offer patients options. It’s something we’re really proud of. We’ve built a huge stroke research algorithm.”

For example, according to guidelines suggested by clinical trials, the time window to get a thrombectomy, or the removal of a blood clot, is within six hours of a stroke. Turk said MUSC uses a different approach.

"We use imaging to make personalized judgments about whether a patient still might benefit even past that six-hour window. That’s what comprehensive centers do, and that’s what the MUSC stroke team does. We set the standards," Turk said.

“To me, the role of academic centers is to push the envelope and try to understand if we should be doing things that are outside the recognized norms. In order to be appropriate and push those boundaries, you need to track your data, you need to publish your data, you need to publish how you’re doing, why you’re doing it and what your outcomes are.”

MUSC also leads in the testing of the latest in medical devices being manufactured to treat stroke. Turner said many of the new devices and drugs to treat stroke that are being used all around the world came through MUSC early in the testing stages.

“If you look at a typical day at MUSC, we’re treating maybe five new stroke patients through our surgeries, and we may be treating another five through our medical therapies. But if you look at the reach of what we’ve been able to do with all these new therapies, we’re treating hundreds, if not thousands, of patients all around the world every day. That’s reach that’s impacting stroke care not just in Charleston, but around the world.”

The other important component is getting that research and access to quality care out to the public. Turner said the race against time begins with the patient. There’s a lack of public awareness about stroke.

It’s important to know the symptoms of stroke and to understand the difference in hospitals in terms of level and quality of care, Holmstedt said.

“The bottom line is, if you’re having a stroke, you need to get expert care fast and know who the partners are in the state, know who’s treating stroke, know where to go, know the signs and symptoms of stroke and know that strokes are preventable,” Holmstedt said.

Turner agreed. “You will be making life-and-death decisions based on where you go, and that’s the reality of it. If you’re having a bad stroke, there’s a significant risk of death, and where you go and where you get your first level of care is critical.”

Going to the right hospital the first time is critical because having to be transferred to another hospital takes time. That loss in time sometimes means a condition no longer remains treatable, he said. “Every step of the process of treating patients, we’re saying, ‘Hey, can I save one minute there and two minutes here, because it really does matter. Every minute matters.”