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January 3, 2006

U-M opens new stroke treatment unit, and launches new statewide stroke study to improve care

U-M Stroke Program leads efforts locally and across Michigan to reduce the effects of the No. 3 cause of death and a leading cause of disability

ANN ARBOR, MI –Two new initiatives from the University of Michigan Stroke Program will give stroke patients the best chance at recovery from potentially deadly “brain attacks,” through innovative care and a research effort that will involve hospitals statewide.

stroke image

The first, a new six-bed Stroke Unit at U-M Hospital, opened last month and is now the destination for nearly all stroke patients who come to U-M for treatment.

Made possible by intense cooperation among physicians, nurses and others from many disciplines, the unit will offer patients advanced care after their initial emergency treatment. Among the most unique features: physical therapy that begins within hours of a stroke, advanced monitoring and specially trained nurses working with teams of doctors to plan and deliver customized treatment to each patient.

The second initiative, just launched, is a new NIH sponsored study involving 24 Michigan hospitals. Called INSTINCT, it is aimed at increasing the use of an emergency stroke treatment called tPA, which is currently only given to a small percentage of patients who could benefit from its clot-busting effect. If given within the first three hours after a blood clot starts blocking blood flow to or within the brain, tPA can help prevent the permanent loss of physical and mental functions that often disable stroke survivors.

INSTINCT will use intensive education and system modification techniques to help doctors and hospitals confront and overcome the barriers to broader tPA use in acute stroke.  Research by a U-M team has shown that under-use of tPA may be due to fears of causing bleeding within the brain and lack of rapid, 24-hour access to diagnostic tools and specialists.

Working with leaders in each participating hospital, the U-M team will assess the impact of the educational intervention on tPA use, system performance, and ultimately, the impact on patient outcome. The study is funded by the National Institutes of Health.

“The state of stroke care in this country, and this state, is not where it should be, and patients are becoming permanently disabled or dying because we don’t have coordinated care and widespread use of tPA and other proven treatments in appropriate patients,” says U-M Stroke Program director Lewis Morgenstern, M.D., a professor of neurology, neurosurgery and emergency medicine at the U-M Medical School and member of the U-M Cardiovascular Center. “Our new stroke unit will address that on a local scale, while INSTINCT will address it on a statewide scale.”

Morgenstern led a study in Texas that improved tPA use dramatically through education of health professionals, the implementation of stroke-treatment protocols in hospitals, and a public awareness campaign. The INSTINCT trial, led by Phillip Scott, M.D., an assistant professor of emergency medicine, with contributions from Morgenstern and several other U-M faculty, aims to build upon that success.

More than 700,000 Americans suffer a stroke each year, and more than 162,000 of them die – including about 5,800 Michigan residents. Many of the rest are left with long-lasting problems with movement, speaking, thinking or other functions.

"I am excited that the stroke unit is in place to support our ongoing efforts in stroke care, and will serve as a model of care in the region," says U-M Hospitals & Health Center Chief Operating Officer Tony Denton. "Our clnical team involved in this effort deserve the credit for developing this initiative, emphasizing their commitment to safe, quality and efficient patient care. The Stroke Unit and Program is an example of what we are continually striving to do for our patients: right care, right place at the right time."

Michelle Aebersold, MSBA, RN, the nurse manager for the Stroke Unit, says her nursing staff is very excited about providing specialized services for stroke patients, and have eagerly entered training to provide advanced monitoring and treatment delivery. “They’re very excited about this opportunity and have enjoyed learning new things,” she remarks. “They have said how great it is they can spend concentrated time with their patients, and work with them to help them improve their ability to care for themselves post-stroke.”

Morgenstern notes that recent national efforts to recognize high-quality stroke care, including the Primary Stroke Center certification offered by the organization that accredits hospitals, are helping.

U-M and a few other Michigan hospitals have achieved that certification, which is given to programs that offer coordinated acute stroke care that includes emergency treatment protocols, specialized diagnostic and medical capabilities, and more.

Also important are research efforts that study the results of advanced stroke treatment, and report them to the medical community to build the evidence for making specific changes in stroke care.

U-M researchers are currently carrying out a major project to do just that. Funded by the Michigan Department of Community Health, they are delving into ten years’ worth of stroke treatment records at the four southeastern Michigan hospitals where emergency physicians have led the use of tPA in treating acute stroke.  This encompasses over 300 treated patients and forms one of the largest series of emergency physician treated patients in the world.  The research will evaluate treatment times, patient characteristics, treatment safety and outcome.

According to Dr. Scott, “Our MDCH study, while retrospective, will provide us with a real-world picture of how stroke care has been delivered and what the results have been. Only through research will we be able to document the effects of our efforts to improve stroke care and give patients the best chance at recovery,” he says. “INSTINCT will do this prospectively, with a randomized controlled design that will increase the validity of our results.”

Also funded by the MDCH, Scott and his U-M colleagues are preparing a stroke-specific geographical information system for Michigan, to help the state government assess the need for specialized stroke care in various regions of the state.

The project will take into account population density, demographics, geography, transportation time, existing health care facilities and other factors. It will yield a map showing where new or expanded stroke-care capabilities might be needed in order to ensure that all residents have rapid access to care that will increase their chances of receiving tPA within the three-hour window.

For more information on the U-M Stroke Program, visit www.med.umich.edu/stroke

For information on the Texas stroke study results that showed an increase in tPA use, see www.med.umich.edu/opm/newspage/2003/strokestudy.htm

Other features of the U-M Stroke Unit:

Hospital stroke units, common in Europe, have been shown in several studies to save lives while reducing the length of hospital stays.

The new Stroke Unit will serve as a single destination for nearly all stroke patients, centralizing care for patients who previously would have been cared for in various hospital units depending on bed availability. The most critically unstable patients will continue to be treated in the Neuro Intensive Care Unit.

The Stroke Unit will provide care customized to the specific needs of patients needing acute care for ischemic and hemorrhagic stroke, and post-procedure care for operations involving blood vessels in the brain and neck.

A team of doctors, including stroke neurologists and rehabilitation specialists, will see each patient.

Specially trained nurses will provide intensive monitoring and deliver treatments normally provided only in an intensive care unit, including continuous EKG and hemodynamic monitoring, intensive checks of neurologic and cardiovascular functions, and care for patients who have recently received tPA.

Physical and occupational therapy sessions will begin soon after a patient's admission and continue until they go home, with additional training for family members to help augment therapy delivered by staff. This kind of early intervention aims to restore as much of patients' physical function as possible, and has been shown to improve outcomes.

The new unit will also feature closed-circuit television monitoring to allow constant vigilance for falls and complications, specialized discharge planning to make the transition to home and follow-up care go smoothly, and its own nursing station.

Written by Kara Gavin

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