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The head of the Cleveland Clinic stroke program and medical director of the Comprehensive Stroke Center sat down with Neurology Live for an in-depth discussion on stroke certifications, advanced treatment technology, and the ever-evolving concept of "time is brain."
Andrew Russman, DO
Ongoing advances in stroke management have set ablaze what was once a specialty self-limited by time and effective treatment options. The rapid evolution of stroke care over the past 25 years, including the expansion of the time-to-treatment window for intravenous tissue plasminogen activator (IV tPA) and the emergence of endovascular thrombectomy for the treatment of large vessel occlusion, has not only optimized outcomes for patients but also invigorated a class of providers who are now on the front line of health care innovation.
One of those providers leading the charge is Andrew Russman, DO, head of the Stroke Program and medical director of the Comprehensive Stroke Center at Cleveland Clinic in Ohio. For Russman, “time is brain” is a way of life, and he has dedicated his expertise to the perpetual reduction of time to treatment in stroke, whether that means advocating on the Hill for improvements to the stroke system of care or mobilizing Cleveland Clinic’s team of specialists on its groundbreaking mobile stroke unit.
There is always room for improvement, Russman told NeurologyLive in a recent interview, during which he detailed how the concept of time will continue to shape the future of stroke care in the United States.
Andrew Russman, DO: I think it’s really important to differentiate hospitals based on capability of services, and it’s important to provide standards and have people strive to improve, identify opportunities for improvement, and then develop performance improvement plans. To me, the most important aspects that the Joint Commission encourages are providing metrics of performance that should be goals. That is the only way that programs really get better over time; they stay up-to-date with changes and are always striving for improvement.
Although these performance metrics are all so closely looked at, they don’t necessarily always reflect the clinical care that you’re providing. It’s very hard to create institution-specific standards, and therefore there are a lot of insensitivities in some of the measures. For example, one of the things we’re tracking is our performance around the concept that “time is brain.” Time is such an important concept in stroke, and the minimization of time is something we need to always be striving for; however, every patient who arrives for treatment does not always qualify for that treatment at the time of arrival.
Stroke in and of itself is a dynamic process, but we are trying to apply a static measure, so developing dynamic measures based on the characteristics of the patient and the disease process is certainly an area we feel the Joint Commission and other organizations that are providing targets or goals should embrace and that national organizations that represent the care that neurologists or stroke specialists provide should advocate for.
In my position as vice chair for the stroke and vascular neurology section of the American Academy of Neurology, one of the things we’re going to focus on is advocacy related to these important issues, whether it’s the need for resources for acute stroke care or advocating for the importance of prehospital care and identification of disease severity for hospital destination. Regardless of the issue, I think advocacy is a major topic for us and helps us understand how we work with our colleagues in other areas. One of the most important things that the Joint Commission does is recognize that stroke care is not being provided by just 1 group. When you receive that stroke designation at the hospital, that’s not just 1 area of the hospital; it takes a village to take care of a stroke. It’s not just the acute care provider or the internal medicine physician or the neurologist; it’s the bedside nurse, the therapist, the laboratory staff, imaging—all the different areas that represent the importance of this multidisciplinary approach to taking care of the stroke patient. That to me is one of the most important things that the Joint Commission does for us; it really embraces the idea that we have to have this multidisciplinary team, and it provides standards for the multidisciplinary team.
Several years ago, the American Heart Association/American Stroke Association released Target: Stroke, a grouping of best practices surrounding acute stroke care, including going directly to CT [computed tomography] on arrival, performing a time-based assessment, activating stroke experts as soon as possible after arrival, as well as having IV tPA premixed for when the patient meets the clinical criteria and having prenotification occur. It’s important that institutions not only look at embracing a few of these but also really look at embracing their opportunities in all these areas. There have been really significant improvements in door-to-needle or door-to-door times since Target: Stroke was rolled out, and those improvements are directly tied to embracing these best practices, but we can continue to do a better job and redefine what those time targets are.
To me, there is no more important best practice then being ready for the patient, and the best way to be ready is prenotification. Prenotification is such an important issue. The elements of knowing time last known well and severity of disease are measures that not only let us know whether the patient may qualify for IV tPA but also understand what the right destination is for the patient.
Prehospital severity measures have been variably adopted nationally. In some states, legislation governs the requirement that emergency medical services and medical control authorities take on and adopt specific prehospital severity measures. Although the most commonly used measure nationally is the Cincinnati Prehospital Stroke Scale, it’s a simplified measure. You can expand that measure; you can use measures that have been validated to reflect the probability of identifying an emergent large vessel occlusion. If there’s knowledge and it’s appropriately performed in the prehospital setting, you can divert patients to a comprehensive stroke center or, better yet, just a center with thrombectomy capability.
We want to identify disease severity prehospital because we want to get patients to the right destination the first time; we don’t want to do second transfers for the patients. Time is brain. But to do that, you need prehospital scale assessments. We need to embrace this nationally and bring every state online with having legislation that requires medical control authorities to adopt the hospital’s stroke severity measures in order to determine the right destination for the patient the first time.
The Joint Commission’s expansion of certification to the thrombectomy-capable level is a key step, and we need to encourage those primary stroke centers that have thrombectomy capability to apply for that additional certification so we can differentiate hospitals based on that capability. I think this all starts with a commitment on the part of the medical control authorities, and to get them organized, we have to continue to advocate around the need for this legislation because there is a big differentiator between states that have prehospital stroke scale requirements with hospital bypass legislation and those that don’t.
Mobile stroke, to me, is the ultimate elevation of the prehospital concept. We arrive on scene with the prehospital provider. We perform a sophisticated prehospital assessment that includes a CPC [cerebral performance category], we give tPA in the field in 20 minutes or less, and we can perform CT angiography on the mobile stroke unit, identify a large vessel occlusion, and take the patient directly to thrombectomy when they qualify. These next-generation capabilities in an advanced stroke system of care are critically important to understanding where the field should be moving, which is [toward being] more efficient. Mobile stroke not only teaches us how being efficient is important but also improves the care for the patient. Patients do better when we’re able to treat them sooner. Most mobile stroke units are somewhere around 30 minutes or so faster than you could treat people in the average emergency department. That makes a significant difference in disability for the patient; it makes a difference in whether they’re going to go home from the hospital or require ongoing rehabilitation. There are a lot of intangible benefits to less disability and return to function. We can do things more efficiently on the mobile stroke unit because it’s a specialized team; not just that, but we’re doing it at the patient’s doorstep and cutting out the transport time. You can’t replicate that [in a traditional hospital setting]. However, there’s a cost to that, and you maximize that benefit when you’re providing care frequently. So if you’re in a rural area where the unit’s not being utilized frequently and it’s a long transport time to get to the patient’s doorstep, it may not be as valuable and may not have as much benefit.
Past studies looked at specific population density measures, and those measures show whether it’s beneficial, likely, to have a mobile stroke unit in an individual community. Large cities, and I would say most medium-sized cities, have the population density to operate not only a mobile stroke unit but in some cases more than 1. For example, the city of New York could have a dozen, whereas Cleveland could accommodate 3 mobile stroke units.
But it really comes back to reimbursement. I think that mobile stroke care provides a paradigm shift in the “time is brain” concept that you can’t replicate elsewhere. However, it’s at a cost, and the current cost-to-reimbursement ratio is not sustainable to the expansion of mobile stroke. There’s no way to grow it dramatically without that capability. There’s a whole different category involved in mobile stroke because of the services provided, so there should be an appropriate bundle of payment from insurers to basically support that activity because it’s beneficial for patients and reduces disability. Looking at the cost of care overall, we think it’s really going to be cost-effective. Even if you just look at things like the reduced transports—we [Cleveland Clinic] went 2 or 3 years without transporting a patient a second time because we’re taking patients to the right destination the first time. The only reason we’re able to do that is because of the capabilities on that unit, and there is a significant cost savings just from not having to do a second transport. But there isn’t a clear understanding from Medicare even though they’re open to new ways of how we bill for services. There’s a bundle of things that happen in the mobile stroke environment, and to support this service, you have to bundle the payments just as you would for someone coming to an emergency department. This recognition is just a lack of forward thinking on the part of CMS [Centers for Medicare & Medicaid Services]; innovations in care, for them to really expand, have to be supported with appropriate levels of reimbursement for the care that’s being provided.
I do think that the quality of the care is so important. Regardless of the type of procedure, if you perform that procedure regularly, you will be more skilled at that procedure. Pretty much in every condition that’s treated, you can look at the literature and see that outcomes are better and there are fewer complications of care when [the procedure] is done by an experienced provider. The Joint Commission has appropriately come out and said providers should be doing a minimum number of these procedures; if you perform
1 thrombectomy every 6 months, you’re not maintaining your skill set. They have said there’s a minimum standard of 15 thrombectomies per year; I don’t think that’s based on some specific evidence that 15 is a magic number, but it is implying there is a minimum number of thrombectomies [to maintain a high level of skill].
Not only can inexperienced providers not perform that procedure as well, but the brain is a different circulation than the heart or the belly; there has to be an understanding or recognition that it’s a different set of vessels, that they’re much more fragile, and they’re substantially smaller. I think the basis is that you have to be formally trained, perform that procedure regularly, monitor your performance, and identify and monitor complications and look for opportunities for improvement; those are the hallmarks of a good program.
If you said there may be a time difference between going to a hospital with a less experienced provider and going to a hospital with an experienced or established provider, I think the evidence would support that you’re better off going to the hospital with a more experienced provider. If you’re not trained to perform the procedure, you’re much more likely to experience the complications of that procedure, and thrombectomy is not a complication-free procedure. All the [past] studies have involved experienced providers at large institutions that do this regularly. If you’re going to quote the benefit of a procedure to an individual patient, you’ve got to know what the risk is for complications. So if you’re talking about providers who aren’t experienced in a procedure, now you have an unknown: I have no idea what the complication rate is going to be, and therefore I have no way of really assessing whether the procedure is going to be beneficial for the patient.
Transcript edited for clarity