When someone who may be having a stroke is brought by EMS to New Hanover Regional Medical Center, a specialized medical team meets the patient at the door and immediately starts to evaluate their symptoms and make decisions about the next steps of care.
That process, triggered by what’s called a Code Stroke, was launched a decade ago, and since then NHRMC has added specialists in neurointerventional surgery and been certified as a DNV-GL Comprehensive Stroke Center.
NHRMC, now part of Novant Health, continues to improve its care of stroke patients by increasing access to treatments and looking for more ways to get acute stroke patients treatments more quickly.
Most strokes occur when blood clots block blood flow to the brain. These are called ischemic strokes. So, for most stroke patients, vital treatment typically consists of two options—thrombolytics, a drug used to break up or dissolve blood clots, and/or physically removing a clot in a blood vessel through a thrombectomy procedure.
Receiving appropriate treatment quickly is critical. “During a stroke, as time goes on more brain cells die, and the goal is to restore blood flow so that you can save brain,” said Dr. Vinodh Doss, DO, an interventional neurologist and NHRMC’s medical director of Stroke and neurointerventional surgery. “The sooner you get that artery open, whether it’s with medication or mechanical thrombectomy, the better chance the patient has to recover because you’re saving brain.”
In April 2011, NHRMC launched Code Stroke, a process that involves a predetermined set of protocols and methods of care that can be rapidly carried out to reduce the amount of time it takes for a stroke patient to get evaluated and receive treatment. “With Code Stroke, the idea is to be very fast and efficient in our evaluation and treatment,” said Dr. Doss.
When “Code Stroke” is activated pre-hospital by emergency medical services (EMS) and by emergency department (ED) physicians, stroke team members, which include neurology providers, specially trained stroke nurses and pharmacists, as well as emergency department staff, quickly assemble and are ready to start diagnosis and treatment of potential stroke as soon as the patient arrives at the ED. The team quickly identifies patients who would benefit from thrombolytics, sometimes called “clot-busting drugs,” and administers the medication.
“Patients eligible for thrombolytics have a better chance of recovery from a stroke,” said Dr. Doss.
Dr. Doss said the percentage of patients NHRMC is treating with thrombolytics has dramatically increased over time. “Right now, more than half of our patients who are treated with thrombolytics get that within 30 minutes, which is among the best times in the country,” Dr. Doss said.
Improving Recovery Chances
While use of clot-busting medication has improved recovery, performing mechanical thrombectomy at NHRMC has been a game-changer for stroke care for the hospital and southeastern North Carolina.
“For a while giving thrombolytics was the most we could do for stroke patients,” said Kerry Lamb, administrator of neuroscience. “However, more research and clinical trials in the field of stroke showed that patients experiencing a large vessel stroke could have a better outcome if a specially trained physician retrieved that clot out of their brain through a procedure called mechanical thrombectomy.”
Dr. Doss was hired as NHRMC’s first interventional neurologist in 2017 and began performing this life-saving procedure, which involves feeding a catheter through an artery in the arm or leg into the head to remove a clot from an artery and restore blood flow to that part of the brain.
If a blood clot is removed through mechanical thrombectomy, patients with a large vessel stroke have a higher chance of recovery and avoiding life-long disability from the stroke. Prior to Dr. Doss’ arrival, stroke patients needing that high level of care were transferred to hospitals farther away.
In 2018 a second neurointerventionalist, Dr. Jeffrey Beecher, an endovascular neurosurgeon, joined NHRMC, further enhancing the hospital’s ability to treat more ischemic stroke patients plus patients experiencing hemorrhagic strokes, which occur when an artery in the brain bleeds.
Dr. Doss helped establish NHRMC’s Code ELVO (Emergent Large Vessel Occlusion) process in 2017 as part of the code stroke process.
Code ELVO is used to rapidly identify and treat patients with an ELVO or large vessel stroke. When a patient’s CT scan reveals a large vessel blockage in one of the large arteries in the brain, steps are quickly taken to remove the clot through a mechanical thrombectomy.
“With a large vessel blockage, you expect to have a large volume stroke,” Dr. Doss said. “But if we restore blood flow, we can save brain so patients don’t have a large stroke. The goal is to save enough brain to help get the patient back to normal or able to undergo rehab so they can return to normal or very close to normal function.”
In the decade since NHRMC implemented Code Stroke, it has been activated more than 5,700 times. During the same period, nearly 500 ELVOs (large vessel blockages) were treated; over 1,000 patients were given thrombolytics to dissolve their clots; and the time from arrival to treatment was reduced from greater than one hour to approximately 20 minutes.
“We have some of the best times in the country because of the standard work we have in place,” said Dr. Doss. “The process at NHRMC allows you to have a much better chance of recovery, and it speaks volumes to the program and to the work EMS does with triaging and getting the patients to us.”
Certified Comprehensive Stroke Center
The combined specialized skills of Dr. Beecher, NHRMC’s director of cerebrovascular and endovascular neurosurgery, and Dr. Doss have enabled NHRMC to strengthen care available for people who experience a stroke. “Between Dr. Doss and Dr. Beecher, we have been able to provide 100 percent coverage for any patient that comes to our hospital experiencing stroke and stroke-like symptoms,” said Lamb.
In 2019 NHRMC became certified as the first DNV Comprehensive Stroke Center in North Carolina.
“DNV Comprehensive Stroke Center certification validates that we are meeting or exceeding high quality national standards and outcomes in our care of patients that are experiencing an acute stroke,” said Tom Curley, RN, stroke center manager. “Comprehensive stroke centers provide intensive care and interventional procedures that other stroke centers and hospitals can’t.”
NHRMC is the region’s only hospital that delivers advanced neuroscience care 24 hours a day, seven days a week. Patients experiencing stroke symptoms are transferred to NHRMC from nine surrounding counties.
“We are excited to have come so far in stroke care in just a few years,” said Lamb. “We’ve also received many awards along the way and national recognition for advances we’ve had in quality outcomes and decreasing our treatment times. There are so many things the stroke team is doing so well.”
Regional Stroke Collaborative and Artificial Intelligence
The NHRMC Stroke team continues to look for and implement ways to further improve stroke care for stroke patients across the region.
“We have launched a regional stroke collaborative with our partner hospitals to identify stroke patients with intracranial hemorrhage or large vessel occlusion (LVO) that really need to come to a comprehensive stroke center,” said Dr. Doss. “We’ve done great work here in Wilmington, and we can talk about how great our numbers are, but it’s only as good as how we help the region, not just Wilmington or New Hanover County.”
Through the collaborative, NHRMC’s stroke team seeks to help other regional hospitals improve stroke care and reduce the amount of time between when patients arrive at their hospitals and are transferred to NHRMC for treatment.
Artificial intelligence is another tool NHRMC is using to further reduce the amount of time patients must wait before they receive critical stroke treatment. “Through the partnership with Novant Health, we will be implementing artificial intelligence in the triage of stroke,” said Dr. Doss. “With Brunswick Medical Center we’ve been using Viz.ai, a cloud-based imaging platform to identify stroke and large vessel occlusion.”
Lamb said the goal is to install Viz.ai at NHRMC’s 17 Street location in Wilmington in June, followed by NHRMC-Emergency Department North and NHRMC Orthopedic Hospital.
The technology gives Dr. Doss and Dr. Beecher immediate access to CT and CTA imaging on their phones, allowing them to evaluate imaging scans of patients in real time and detect large vessel occlusions and blood in the brain, helping to quickly coordinate care. “Without this, there are significant delays as outside hospitals try to reach us by phone,” said Dr. Doss. “If we can implement A.I. technology it cuts down times, improves communication, and thereby improves patient care. It’s the leverage of technology to get patients the best care possible as fast as possible.”
For more information on NHRMC Neuroscience, visit: Neuroscience.