Stroke Program
Program Overview
Hoag’s comprehensive Stroke Program is led by fulltime neurohospitalists
who specialize in advanced stroke management and intervention, and continue
to develop best practice care pathways for optimal outcomes. As a founding
member of the designated Comprehensive Stroke Neurology Receiving Centers
in Orange County, Hoag helped pioneer many of the specialized processes
and methods to reverse stroke when possible, and to optimize care for
stroke patients. The ultimate outcome metric is the patient’s ability
to return to a self-sufficient life, an outcome we measure in every patient
with a 90-day survey.
Our stroke rescue process starts immediately on arrival with assessment
of the patient by our experts, and triage for the most advanced treatment
appropriate to the patient’s condition. As part of the stroke team,
Hoag’s Emergency Department physicians and staff initiate the stroke protocol.
In place since January 2008 but continuously updated, the so-called “Code
20” process is like a NASCAR pit crew. Upon a stroke patient’s
arrival at the ED, neurological assessment, lab testing, and neuro imaging
are done within 20 minutes. Evidence-based use of clot-busting drug treatments,
as well as endovascular mechanical intervention – “thrombectomy”
– optimizes the chances for stroke reversal. Our team has the longest
experience with endovascular stroke rescue in Orange County.
Patients are then cared for in the hospital’s Neurosurgical Intensive
Care Unit and/or the 41- bed Advanced Brain and Spine Unit. All stages
of care are staffed with nurses experienced in the diagnosis, treatment,
and complications of stroke patients. Hemorrhagic strokes, including aneurysmal
rupture, have a distinct care pathway, led by our neurosurgeons, neuro-interventional
radiologists and neurohospitalists together with our intensive care physicians.
Preventative aneurysm treatment using image-guided micro-interventional
techniques is a component of the Stroke Program’s portfolio, and
is also used in acute aneurysm rupture.
Hoag’s Newport Beach campus is a certified Comprehensive Stroke Center
and Hoag Irvine is a certified Primary Stroke Center by DNVGL. Hoag has
been awarded the Stroke Gold PLUS Performance Achievement Award by the
American Stroke Association for nine years in a row. In 2018, Hoag achieved
the Target Stroke Honor Roll Elite Award by the American Heart Association
/ American Stroke Association.
Hoag has dramatically increased the rate at which IV tPA is administered
to all acute ischemic stroke patients – up from 2% a decade ago
to 14% currently. This rate triples the national average of 5%. Of the
patients arriving in the Emergency Department meeting the criteria for
the drug, 100% of patients received treatment. At 90 days, 54% of Hoag’s
stroke patients return to a self-sufficient lifestyle.
Hoag’s Stroke Program is led by David Brown, M.D., a neurologist
with a specialty in stroke and cerebrovascular disease and a neurohospitalist.
Dr. Brown leads the dedicated, multi-disciplinary acute stroke team that
provides immediate care to stroke patients, and meets regularly for process
improvement.
The Stroke Program Manager is Deb Mastrolia, R.N. Deb is certified with
the American Board of Neuroscience Nursing for both Neuroscience nursing
(CNRN) and Stroke nursing (SCRN) along with the American Association of
Critical Care nursing (CCRN) specialty. She has worked with Dr. Brown
to develop and certify the multidisciplinary stroke team. She also consults
as a program reviewer for Stroke certifying agencies. Our Physical Rehabilitation
service, including the Fudge Acute Rehabilitation Unit is also key to
our superior outcomes.
The Stroke Nurse Navigator is Victoria Tomczak, R.N., S.C.R.N. She works
collaboratively with the multidisciplinary team to oversee the patients,
care and manage quality. She meets with the patients and families to assess
individual needs for treatment, prevention and education.
Functional Outcomes
All stroke survivors are called at 30 days and 90 days post discharge by
the stroke nurse navigator. A telephone interview is performed to assess
functional status of the survivor. Valuable teaching is reinforced regarding
neurology follow-up appointments, medication teaching, risk factor modification,
stroke symptom identification and the need to call 911 for any recurring
signs of stroke.
Hoag continues to have the second highest volume of ischemic stroke patients
in the state of California.
Hoag Stroke Volumes
Hoag Stroke Volumes: Both Campuses,
Principal Discharge Diagnosis
Total Strokes Treated: Primary & Secondary Diagnosis
of Stroke, From the GWTG database
Stroke: Before Clot Removal
Stroke: After Clot Removal
Gold “Get with the Guidelines” Stroke Core Measures
Gold Plus “Get with the Guidelines” Stroke Quality Measures
Treatment Combined HNB & HHI
Overall treatment rate = 15% • At Comprehensive HNB TX rate = 17.2%
• At Primary HHI Tx rate = 7.8%
CY 2018 Thrombolytic Treatments
Increasing Trends of Thrombolytic Treatments for Acute Ischemic Stroke
Number of Acute Ischemic Stroke Thrombectomy Cases
Combined HNB & HHI mRS Results for all Ischemic Strokes
When patients get to Hoag in the time window where acute stroke rescue
is indicated, their outcomes are nationally well above benchmarks: over
70% return to a self-sufficient status when treated with IV Alteplase (IpA).
Modified Rankin Score Data for 90 Days for Ischemic Str oke Treated With
Thrombolytic Therapy
RAPID Image Sample. Note core infarct (purple) vs. salvageable ischemic penumbra.
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CT Perfusion images showing brain tissue at risk of dying due to insufficient
blood flow (Blue green area, left picture, and blue area right picture).
Middle picture shows that the at risk area can be salvaged by urgent clot removal.
Support & Education
A stroke support group meets monthly in the Hoag Conference Center, as
does a brain aneurysm & AVM support group. There is an educational
presentation at each, along with Q&A facilitated by the stroke nurse
navigator. The meetings are attended by survivors and their families and
friends. Community outreach is provided through educational presentations
by Dr. Brown and Deb Mastrolia at both Hoag Hospital Newport Beach and
Hoag Hospital Irvine. They teach the signs and symptoms of a stroke, stroke
prevention and treatments. The Stroke Program also attends employee health
fairs, senior centers and events, and performs blood pressure checks,
while reviewing stroke risks and prevention. Beth McIntyre serves as the
Neuroscience Data Coordinator. Beth’s role has been instrumental
in assisting with data compilation for the Stroke Program.
Interventional Neuroradiology Humanitarian Use Devices (HUDs)
Dr. Michael Brant-Zawadzki, Principal Investigator: Boston Scientific Target
Neuroform™ Microdelivery Stent System and Neuroform EZ Stent System
for Cerebral Aneurysm (H020002)
Dr. Wallace Peck, Principal Investigator: Stryker Corporation Wingspan™
Stent System with Gateway™ PTA Balloon Catheter for Cerebral Anerysm
(H050001)
Dr. Wallace Peck, Principal Investigator: MicroVention Low-profile Visualized
Intraluminal Support (LVIS®) or LVIS Jr. Humanitarian Use Device (“LVIS
HUD”) for Cerebral Aneurysm
Clinical Research
Dr. David Brown, Principal Investigator: Sleep SMART “Sleep for Stroke
Management And Recovery Trial: Phase 3 Multicenter, Prospective Randomized
Open-, Blinded-Endpoint (PROBE) Controlled Trial To Test Whether Treatment
Of Obstructive Sleep Apnea (OSA) With Continuous Positive Airway Pressure
Is Effective For Secondary Prevention And Recovery After Stroke.”
Funded By NINDS.
Publication
Evolution of a US County System for Acute Comprehensive Stroke Care. Radoslav
I. Raychev, Dana Stradling, Nirav Patel, Joey R Gee, David A. Lombardi,
Johnson L. Moon, David M. Brown, Mayank Pathak, Wengui Yu, Samuel J. Stratton,
and Steven C. Cramer. Originally published 6 Apr 2018. https://doi.org/10.1161/
STROKEAHA.118.020620. Stroke. 2018; 49: 1217-1222.
