Stroke’s Quantum Jump: The Interprofessional Team

| 11 February 2013

There is a moment in the management of a disease when a quantum jump lays bare the futility or wrong mindedness of past therapies. These rare, hard-won moments occur when our understanding of disease mechanisms becomes correct (or at least not totally incorrect). A quantum leap in Medicine, like the movement of electron to a higher orbital, requires input of energy (or so I vaguely recall from Physics 101).

Electron Changing Orbital: energy input from a photon provides the energy to move an electron undergo a jump to a higher orbital

Allusions to electrons aside, when a quantum jump occurs it rapidly changes practice and patient perception. Fear gives way to hope and rationale, effective therapy replaces quackery.

There have been several quantum jumps in Medicine in recent decades. Acute myocardial infarction (also referred to as a STEMI, or heart attack) has experienced two quantum leaps. These advances reflected the correct recognition that heart attack was not caused by progressive narrowing of an artery to occlusion; rather it was sudden plaque rupture and clot formation that blocked blood flow and caused heart cells to die. This correct understanding led to translational research, which proved that clot-busting drugs, like streptokinase and tissue plasminogen activator (tPA), were used to open arteries and abort the heart attack. Subsequently, it was discovered the artery could be mechanically opened by primary angioplasty. These interventions changed the in-hospital mortality rate from 33% to ~5% . Other quantum leaps include Tumor Necrosis Factor (TNF) inhibitors for Rheumatoid Arthritis (i.e. Etanercept or Enbrel®). These disease-modifying drugs prevent joint destruction in arthritis patients and restore function. The TNF inhibitors have eliminated gold clinics and copper bracelets. Gleevec (Imatinib), a tyrosine kinase inhibitor, replaced toxic and ineffective chemotherapy for chronic myelogenous leukemia. Now, instead of death from blast crisis within a few years, most CML patients survive roughly as long as age-matched subjects in the normal population. The reality that quantum leaps are rare is often obfuscated by hyped claims of innovation and breakthrough applied to me-too drugs and devices. The $60,000 drug which allows patients with pulmonary hypertension to walk an extra 30m during a 6-minute walk, the artificial hip that fails in < 5 years, the 8^th angiotensin converting enzyme inhibitor, laser ablation of varicose veins….these are not quantum jumps.

So on to Stroke’s quantum jump, beginning with as case. A previously healthy 20-year-old man suddenly loses the ability to move his arm and leg. He quickly lapses into a coma during the ambulance ride to the hospital. A team of interventional radiologists, stroke neurologists, pharmacicts and nurses go into action. This is a stroke - a brain attack - and they have approximately less than three hours (ideally 60 minutes) to restore blood flow to this young man’s brain. An angiogram and perfusion CT scan confirm the blockage of a middle cerebral artery and reassure them that there is no bleeding. He receives an intrarterial infusion of tPA and the artery opens.

A week later the young man is golfing. Historically this does not happen. A decade before, this young man would have awakened hemiplegic and at best experienced a diminished quality of life. This true story happened a decade ago at the University of Alberta and reflected the passion of several champions who did not accept the status quo of stroke care, interventional radiologist, Dr. Derek Emery and stroke neurologist Dr. Ashfaq Shuaib. At the time I was Chief of Cardiology and this case caught my attention because something miraculous and unexpected had happened. It was evident that a quantum jump in stroke care had occurred. This reflected a complex mixture of science, teamwork and change in process of care, which began outside the hospital.

The springboard for the quantum jump in stroke was the recognition of the role of thrombus in blocking arteries in most strokes. The brain dies in minutes when blood flow is stopped. Restoration of blood flow by intravenous infusion of tPA saves brain cells and lives, but the window for achieving success is brief - usually less than three hours from symptom onset. See the tPA at work in stroke in this video (right). This new paradigm of stroke care is being implemented at a high level at Queen’s University and Kingston General Hospital (KGH). Indeed, KGH’s regional stroke program, which cares for the ~700,000 residents of southeastern Ontario, recently was awarded the Distinction in Stroke Services Award from Accreditation Canada. Seen below is the Stroke Team at KGH. The transformative consequences of the leap for patients is so dramatic that a single case can often tell the story. This quantum jump at KGH required courage: to overcome the gravitational pull of fear of the tPA-induced brain hemorrhage. It required dedication: the team is mobilized in the wee hours of the morning. It required optimism: to overcome the historical inertia in the field that held that stroke could not be cured. The energy for Quantum Jumps in stroke does not belong to physicians. Rather, it derives from the synergy of the interprofessional team. The KGH story has a great champion and a great team. The champion in our story is Dr. Al Jin, a stroke neurologist who envisioned a new and aggressive approach to stroke. However, his vision could not have been realized without an interprofessional team of nurses, pharmacists, paramedics, neurologists, experts in physical medicine and rehabilitation, and radiologists. Leaders like Cally Martin, Regional Director of the Stroke Network and front line staff made this jump a reality. The quantum jump required changes in the process of care that extended across our region and involved partner hospitals. The success also requires public education so that the average person can recognize the warning signs of stroke and call 911 to get urgent attention. The jump also required buy-in from paramedic and regional protocols that ensure stroke patients are taken to specialized centres. It takes a lot of energy to make a Quantum Leap.

What did the KGH team to merit becoming only the 3^rd program in Canada to achieve this recognition? In 2011-12, KGH handled 541 transient ischemic attacks or strokes.

Stroke Fig 6

The Stroke Program’s Acute Stroke Protocol was activated over 250 times, and intravenous tPA was administered 54 times, with a median door-needle time (a measure of the rapidity of giving the tPA once the patient arrives at KGH) of 47 minutes. Since “Time is Brain” and the target is < 60 minutes, this performance ranks KGH as Ontario’s fastest center for thrombolysis in acute stroke. Once admitted, most KGH patients enter the specialized Acute Stroke Unit (right). The specialized care in this unit has helped decrease stroke mortality rates from about 22% to16%. Moreover, the readmission rate for stroke/TIA patients is among the lowest in Ontario at KGH, due to the coordinated efforts of the inpatient acute stroke team, community supports through a new Home First program, and the outpatient Stroke Prevention Clinic. The 90-day readmission rate of 1.6% to 2.0% reflects a 4-fold drop in 5 years. Finally, the Stroke Prevention Clinic sees ~ 540 referrals/year.

The New Stroke Guidelines will soon be published in JAMA and are already available on line. These guidelines will stress the importance of treatment with tPA within 60 minutes. Thanks to the team at KGH we are meeting these guidelines. This interprofessional team has made the quantum leap and propelled Queen’s and KGH to a higher orbit by enhancing the care of stroke patients.