In Los Angeles County, a 4,752–square-mile urban–suburban sprawl that is home to an estimated 10 million people, no one knows exactly how many acute strokes occur each year or how well they are managed. Nationwide, stroke is the number-three cause of death; stroke-related medical costs in 2010 are estimated at $73.7 billion. 1
Since the debut of the Los Angeles Stroke Center System in November 2009, however, the county has been poised not only to know exactly how many acute stroke patients it is delivering to hospitals, but how quickly and efficiently they are being treated. Most important, patients are more likely to get the care that they need. Radiology, of course, has a key role to play.
Fernando Vinuela, MD, says, “We deal with a stroke as soon as possible because for each minute, a person loses 2 million brain cells.” Vinuela is professor of radiology, interventional neuroradiology division, at the Ronald Reagan University of California–Los Angeles (UCLA) Medical Center.
UCLA Medical Center is one of 20 hospitals in Los Angeles County that have earned certification as primary stroke centers from the Joint Commission. This designation enables hospitals to apply to Los Angeles County’s Emergency Medical Services (EMS) Agency for inclusion in the Los Angeles Stroke Center System, which initially included only nine hospitals.
Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine and director of the UCLA Stroke Center, says, “The American Heart Association (AHA) has been a driver in this process. It helped design a process to bring all stakeholders to the table.”
Saver has played an integral role in the development of the stroke system in Los Angeles County and was the recipient of an award from the AHA for his continuing volunteer work for the organization. UCLA Medical Center created a prehospital stroke-screening scale, and UCLA Medical Center’s physicians used it to train the county’s paramedics to identify strokes. This ensures that a stroke patient will be taken to the nearest stroke center (instead of to the nearest emergency department).
Bill Koenig, MD, is medical director of the Los Angeles County EMS Agency, which enrolls hospitals in the stroke system and is in the process of building a database to monitor the benefits of the system. No one in the EMS Agency knows exactly how many emergency vehicles are deployed by the county and by the 88 cities (and many unincorporated areas) that constitute the most populous county in the United States. In fiscal year 2008–2009, more than half a million people were transported to county emergency departments. An estimated 2,000 to 3,000 of those patients were having strokes.
“The care of the patient is a continuum that starts in the field,” Koenig says. The benefit of having more hospitals in the stroke system is that EMS personnel don’t have as far to travel when transporting a stroke patient.
The stroke system began with a one-tier network of primary stroke centers, but it is evolving into a two-tier system that will include comprehensive stroke centers, Saver says. Primary stroke centers are the first-choice locations for diagnosing a stroke, and they are able to deliver recombinant tissue plasminogen activator (tPA) intravenously.
If the stroke-care team at a primary stroke center decides that a patient requires endovascular delivery of tPA or needs neurosurgery, however, the patient is transferred to a comprehensive stroke center. Comprehensive stroke centers offer vascular surgery and neurosurgery, and ideally, each would support five to 10 primary stroke centers.
In 2005, the Brain Attack Coalition2 recommended key capabilities that comprehensive stroke centers should have. These include the presence of health-care personnel with specific expertise in neurosurgery and vascular neurology; advanced neurological-imaging capabilities, including MRI and various types of cerebral angiography; microsurgical and endovascular techniques, including clipping and coiling for intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and other infrastructure and programmatic elements, such as an ICU and a stroke registry.
Of US hospitals, 1,200 are certified by the Joint Commission as primary stroke centers, Saver says. He estimates that the cost of running a stroke program can range anywhere from $8,000 to $150,000, depending on a hospital’s existing staff and technology.