2017 Stroke Annual Report - upstate.edu · window for stroke rescue therapy is now wider with the addition of innovative imaging software called ... flow to resume. Studies have shown

2017 STROKE REPORT

750 EAST ADAMS STREET, SYRACUSE, NY I WWW.UPSTATE.EDU/STROKE

Dear Esteemed Colleagues,

Stroke continues to change manypeople’s lives but we are winning thebattle. In 2014, stroke fell to the fifthleading cause of death in the US. In2015, a new era of treating strokebecame the standard of care –mechanical thrombectomy. In 2016 anumber of clinical trials ventured toexpand treatment windows for acutestroke management, and we continueto fight to enlarge treatmentpossibilities.

On behalf of Upstate University Hospital,I am pleased to present to you ourclinical achievement report for 2017. Asthe largest neuroscience team in theregion with hundreds of hospital staff,Upstate University Hospital is still theonly Level 1 Comprehensive StrokeCenter, the highest level of strokecertification available. Since our initialdesignation in 2014, our program hascontinued to expand and improve ourservices to the region. Our Telestrokenetwork currently supports ninecommunity hospitals throughoutNorthern and Central NY. Our team has

been actively engaging the public andraising awareness of Stroke andcardiovascular disease through directeducation, public awareness campaigns,and numerous community events. Atour recent Regional Upstate Stroke andHealth Summit, we provided localhealthcare providers with theopportunity to network and gaincontinuing medical education.

As 2016 began, we joined other Strokecenters nationally by selecting as aprimary quality improvement initiativereducing time to treatment (time tointravenous thrombolysis). Through anumber of concurrent projects whichincluded: partnering with ouremergency medical service (EMS)providers for prehospital notification,collaborating with our emergencydepartment providers to send patientsdirectly to the CT scanner from theambulance, and reorganization of ourinternal processes, we were able tosignificantly reduce our times. Inpartnership with AHA Get With theGuidelines initiative, Upstate StrokeProgram has been awarded the GWTG-

Gold Plus and the Target Stroke ElitePlus performance award for treating100% of eligible patients with tPA within60 minutes, and 87% of eligible patientswithin 45 minutes. Our current mediantreatment time is 33 minutes. We areworking to reduce it further to less than30 minutes.

Our commitment to Central New Yorkremains. Through our collective efforts,we envision a day when stroke rarelyhappens. But if it does, rest assured thatwe are ready to treat it.

We are happy to share with you ouraccomplishments from this past year aswell as highlight some of our currentinitiatives during this current year.

Sincerely,

Julius Gene Latorre, MD, MPHMedical Director,Upstate Comprehensive Stroke Program

A MESSAGE FROMTHE MEDICALDIRECTOR

UPSTATE COMPREHENSIVE STROKE CENTER

2017 STROKE REPORT 1

Amar Swarnkar, Director of Neuroradiology (right)and resident review a patient's CT profusion. Thewindow for stroke rescue therapy is now wider withthe addition of innovative imaging software calledRAPID DICOM that allows treatment for some strokesup to 24 hours. The software program shows changesin brain tissue perfusion and diffusion in digitalimages captured by computerized tomography andmagnetic resonance imaging. This allows doctors totell the precise area of the brain that is affected bythe stroke, and the area still in jeopardy.

TABLE OF CONTENTSUpstate Focuses on Academics and Research . . . . . . . . . . 2

A Note from the Stroke Program Manager . . . . . . . . . . . . . 4

Achievement Awards for Stroke Care . . . . . . . . . . . . . . . . . . . 8

Stroke Quality and Outcome Measures . . . . . . . . . . . . . . . . 10

Working with EMS For Improved Stroke Outcomes . . . . 14

Stroke Care Beyond Hospital Walls . . . . . . . . . . . . . . . . . . . . 15

Commitment to Our Community and Region . . . . . . . . . . 16

Rehabilitation Improving Outcomes . . . . . . . . . . . . . . . . . . 20

Meet Our Stroke Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2 UPSTATE COMPREHENSIVE STROKE CENTER

Upstate University Hospital, as part ofSUNY Upstate Medical University, is theonly academic medical center in theCentral New York Region and is one of theoldest medical schools in New York. Thiscommitment to education is anchored bythe four colleges:

• Medicine

• Nursing

• Health Professions

• Graduate Studies

As an academic medical center we havethe opportunity to offer many of ourpatients participation in clinical trials.These types of research studies can help todetermine whether new drugs ortreatments are safe and effective. Ourresearch focuses on diseases that affectour local community such as stroke,diabetes, and cancer.

Upstate University Hospital has long heldthe distinction of caring for the mostseriously ill and injured patients in NewYork State. We serve a region that coversover one-third of our state.

Upstate is the region’s only: • Level I Comprehensive Stroke Center

• Level I Trauma Center

• Burn Center

• Poison Control Center

• Children’s Hospital

It is our mission to continue to strive toprovide the best care possible and to meetor exceed the needs of our patients andour families.

UPSTATE FOCUSES ON ACADEMICS AND RESEARCH


Upstate has an entire hospital floor dedicated

to the brain.

Upstate is the only Level I Comprehensive Stroke

Center in Central New York. The international

accreditation organization (DNV) confirms

Upstate provides the most advanced and

highest quality stroke care in Central New York.

History of UpstateWhen the hospital opened in1964, it was the first hospital inCentral New York to combineresearch, in-patient facilities andout-patient treatment. Thebuilding cost $20,000,000 andtook four years to complete.

In the 1970s Upstate made asignificant commitment to theneurosciences by establishingthe first dedicated neuro-intensive care unit. In 2006,furthering our commitment toneurosciences, Upstate becamethe first designated stroke centerin Central New York.

ResearchOur neurosurgical team offerspatients the most advanced skills

and technology available today.Our scientists aim to bring themeven more breakthroughstomorrow.

Brain tumors are just one of theresearch areas being explored byUpstate’s NeurosurgeryDepartment.

Research is at the core ofacademic medicine and improveshealth through new insights andtreatments.

As the largest and longestestablished neurosurgery center— and as part of the region’s onlymedical university — Upstate’sfaculty also bring the mostadvanced skills and technologyto patient care.


Our mission as the region’s only Level IComprehensive Stroke Center is toprovide the highest level of care possibleto stroke patients in the Central NewYork Region. The staff of The StrokeProgram consist of multidisciplinaryexperts to ensure that we consistentlymeet and exceed national qualitybenchmarks in stroke care.

In 2016, Upstate’s Comprehensive StrokeCenter saw:• 1489 actual and presumptive stroke

patients• 550 acute ischemic strokes• 200 hemorrhagic strokes• 100 TIAs• And accepted 525 transfers from other

hospitals in our regionThis means we have vast experience incaring for stroke patients and theirfamilies. Our physicians and nurses areprepared and equipped to handle themost complicated of patients. We have150 nurses who receive specialty stroke

training to care for patients in one of ourthree levels of care. Our focus here ispatient and family centered, andapproaches stroke treatment holistically..

We hold strong in our commitment toour region, our counties and ourcommunities. We will continue to worktirelessly to educate our communitiesabout stroke risk factors, prevention andrecognition.

Upstate’s LEVEL 1Comprehensive Stroke CenterUpstate was certified in 2015 as aComprehensive Stroke Center by theDNV, marking them as the region’s onlylevel I Stroke Center.

This certification demonstrates Upstate’scontinued commitment to strokeexcellence and shows the provenresources, infrastructure and skillfulprocesses in place. All of these

contribute to the very best in stroke care,including:

• Multidisciplinary approach thatincludes neurologists, neurosurgeons,interventional radiologists, andrehabilitation therapists

• Three levels of specialized care:Specialized Neuroscience floor,Neuroscience step-down, andNeuroscience Intensive Care Unit allconveniently located on our 9th floor

• Use of clot-busting tPA for ischemicstroke treatment

• Catheter based therapy for those whodon't respond to clot bustermedication that extends the windowof treatment

• State of the art neurovascular andendovascular procedures for repair ofaneurysms and other causes ofhemorrhagic strokes (brain bleeds)

• Telemedicine capabilities to treatstroke patients in rural hospitals

A NOTE FROM THESTROKE PROGRAM

MANAGER Jennifer Schleier RN, BSN, CCRN, SCRN


Number of Stroke Encounters at Upstate

2016 Upstate Stroke Volumes by Diagnosis

16%

7%12%

65%

AIS - Acute Ischemic Stroke

ICH - Intracerebral Hemorrhage

SAH - Subarachnoid Hemorrhage

TIA -Transient Ischemic Attack

The Highest Standards Upstate is the only

Level I Comprehensive Stroke Center in Central

New York. This means Upstate has met and

exceeded the highest standards for stroke care.

Our Team is Here for You Upstate has the

largest and longest established neurosciences

program in CNY. We've recently expanded our

neurology and neurosurgery team.


Rajeev Saini, MD, did not hesitate whenhis 81-year-old father suffered a stroke.He asked the rescue crew to take theman to Upstate University Hospital.

“I trained at Upstate. I knew they had agood stroke program,” he explains.

Saini’s father, Jagdish M. Saini, had a clotin his brain. He received a clot-bustingmedication in the emergencydepartment. Soon after, neurosurgeonGrahame Gould, MD, inserted acollapsible stent into an artery in Saini’sgroin. He threaded it to the blockedblood vessel in his brain and capturedthe clot within the cage-like stent. ThenGould removed it from Saini’s body.

The stroke Saini suffered could haveparalyzed him forever, says his son, whospecializes in family medicine. The Sainis

share a home in Baldwinsville. When Dr.Saini came home at lunchtime May 18,he found his father with a facial droop,unable to talk, unable to move his rightarm or leg.

After Gould completed the clot retrieval,the elder Saini recovered for three nightsin the hospital. He required norehabilitation and no physical,occupational or speech therapy. Thestroke left him with a slight shake in hishand and a mild difference in his gait.

Dr. Saini was impressed with the care hisfather received, and in the improvementhe saw after Gould removed the clot. “I’mjust amazed,” he says. “Everybody isamazed.”

PATIENT STORY


Stroke survivor Jagdish M. Saini, center,

with his granddaughter, Rhea, and son,

Rajeev Saini, MD, who did his internal

medicine residency at Upstate.

Hesham Masoud, MD, who has expertise

in endovascular surgical neuroradiology,

holds a stent used to remove a clot from

the brain.

Upstate was the first hospital in the region

to employ stents for the treatment of

ischemic stroke. The technology continues

to evolve and improve to allow physicians

the ability to restore blood flow and

retrieve clots, with few complications.

To retrieve the blood clot, a neurosurgeon

threads a catheter through the patient’s

blood vessels to the blocked artery in the

brain. A mesh stent, deployed through the

catheter, grabs the clot, which is then

removed from the artery, enabling blood

flow to resume. Studies have shown that

patients treated with this device had

higher rates of neurological function and

reduced death from stroke three months

after the procedure, compared to patients

treated with alternate treatment.


Upstate University Hospital’s care forstroke achieved high marks from theAmerican Heart Association (AHA),which offered the recognition inconjunction with the American StrokeAssociation and the American Collegeof Cardiology.

Upstate is honored with the Get WithThe Guidelines®-Stroke Gold PlusAchievement Award with Target:Stroke Honor Roll Elite Plus. The awardrecognizes the hospital’s commitmentto providing the most appropriatestroke treatment according tonationally recognized, research-basedguidelines based on the latestscientific evidence. Upstate receivedthe same honor last year.

Hospitals must achieve 85 percent orhigher adherence to all Get With TheGuidelines-Stroke achievementindicators for two or more consecutive12-month periods and achieve 75percent or higher compliance withfive of eight Get With The Guidelines-Stroke Quality measures to receive the

Gold Plus Quality Achievement Award.

“This recognition of our stroke care isfurther evidence of the outstandingquality of care patients receive atUpstate,” said Steven M. Scott, MPH,FACHE, interim chief executive officerof Upstate University Hospital. “Thedesignation from the American HeartAssociation also recognizes thededication and commitment of ourphysicians, nurses, technicians andothers who ensure patient careexceeds the national standards.”

To qualify for the Target: Stroke HonorRoll Elite Plus, hospitals must meetquality measures developed to reducethe time between the patient’s arrivalat the hospital and treatment with theclot-buster tissue plasminogenactivator, or tPA, the only drugapproved by the U.S. Food and DrugAdministration to treat ischemicstroke. If given intravenously in thefirst three hours after the start ofstroke symptoms, tPA has been shownto significantly reduce the effects of

stroke and lessen the chance ofpermanent disability. UpstateUniversity Hospital earned the awardby meeting specific qualityachievement measures for thediagnosis and treatment of strokepatients at a set level for a designatedperiod.

These quality measures are designedto help hospital teams follow the mostup-to-date, evidence-basedguidelines with the goal of speedingrecovery and reducing death anddisability for stroke patients.

Upstate’s stroke care is often honored,having received the Gold PlusAchievement Award with Target:Stroke Honor Roll Elite Plus in 2016 aswell. Upstate became the onlyspecially designated ComprehensiveStroke Center in the region, in 2015,when it met a rigorous review of itsstroke treatment protocols by DNV(De Norske Veritus) Healthcare, ahospital accreditation organization.

UPSTATE EARNSTOP ACHIEVEMENT AWARDS FOR STROKE CARE


Upstate Stroke Treatments 2015 vs 2016

Total Number of Cases Treated with IV tPA, Mechanical Endovascular Reperfusion (MER), both tPA and MER ortPA at outside hospital transferred to Upstate.

Drip and ship: patients who receive tPA at an outside hospital who are then transferred to Upstate.

2016 Length of Stay: In-Patient Days


The Upstate Comprehensive StrokeCenter (CSC) has consistently exceedednational averages in stroke qualitymeasures over the past three years. Our experience, program growth and implementation of key processimprovement initiatives has resulted in faster imaging, diagnosis andtreatment of stroke than ever before.We have established a wider map ofpatient referrals, refined relationshipswith our EMS providers and supportedconsistent stroke education for ournursing units and our regionalcommunities.

These results speak to Upstate CSC’sability to honestly look at currentprocesses and implementimprovements that impact the

quality of the stroke care weprovide. This in turn improves

outcomes; however, qualitystandards and data only driveone aspect of stroke care.What matters most are theoutcomes of our stroke

patients.The piece that truly drives usin our daily work is when our strokepatients leave Upstate and tell othersthat it was our care, compassion andexpertise that allowed them to face astroke and come out the other side.

To achieve this level of excellence, anorganization must continually evaluateitsr performance. As neurosciencetrained nurses who work dailyreviewing our stroke cases andpreparing data, we analyze andconstructively question our findings,communicate with team membersacross all departments, identify areasfor improvement and reevaluate theoutcomes. As an academic medicalcenter there is an expectation ofexcellence. Thankfully we have strongsupport of quality projects both fromour hospital culture and administration.

Michelle F Vallelunga, MS, RN CNRN,SCRN , Data Coordinator

Patricia Veinot, RN, BSN Data Coordinator

STROKE QUALITY AND OUTCOME MEASURES


Percentage of Patientswith Arrival to StrokeTreatment in < 45 Minutes

Percentage of Patients withArrival to Start of Stroke RescueTherapy in < 90 Minutes

2016 Stroke Core Quality Measures (%)

Upstate National

Upstate National Performance Measure Goal


2015/2016/2017 Patients Transferred to Upstate 2015 2016 2017

A headache that wouldn’tstop.

Mary Green, 49, is a licensed practicalnurse who has worked for 30 years atRiver Hospital in Alexandria Bay. Shewas supposed to work there Oct. 25,but at 5:15 a.m. she remained soundasleep, snoring. Her husband, MarshallGreen, tried to wake her up, twice.

When he realized she wasunresponsive, he called for their son,Dustin, to help while they waited forthe ambulance. They thought shemight have overdosed on hermedication.

The day before, Green had a headachethat wouldn’t stop. She remembersgoing to bed early. That’s all sheremembers. “I don’t remember

anything for about 38 days. I kind oflost a month of my life.”

Her husband kept notes for her. AtRiver Hospital, the doctors consultedwith Upstate neurologist Elwaleed ElNour, MD, via Telestroke. Hisassessment allowed for a quickdecision that Green needed prompttransport by helicopter for expert carein Syracuse.

At Upstate, Green immediatelyunderwent an angiogram, showingthe blood flow — and the blockages— in the vessels of her brain. She hadwhat is called a bilateral occipitalstroke, affecting the lower back part ofher brain. This region controls vision,coordination and balance, amongother essential functions.

Green spent 38 days in Upstate’sspecialized neuroscience intensivecare unit for patients with neurologicalproblems. Medications helped herrecover from her stroke. After she wasstabilized, she was transferred toUpstate’s physical medicine andrehabilitation unit.

She went home Dec. 13. Shecontinues to see neurologist CarmenMartinez, MD, who is trying todetermine why Green had a stroke —although the reasons remainunknown for some stroke patients.

Green is not back to work yet. Shecan’t drive, but she can walk, and she’shopeful her vision will continue toimprove. She considers herself “a veryfortunate, lucky lady.”


Mary Green and her husband, Marshall.

EXTENDING EXPERTISESTROKE NEUROLOGISTS CARE FOR PATIENTS IN REMOTE AREAS

PATIENT STORY

The stroke chain of survival starts withEMS and first responders. It is for thisreason that we actively engage our EMSagencies in helping us to achieve ourstroke quality goals. We rely on input fromour region’s EMS providers to assist us increating internal processes that willimprove the efficiency of our care oncethe patient reaches the hospital.

One quality measure that we areparticularly focused on is pre-notificationof an incoming stroke patient to our EDby EMS. This is a measure that is evaluatedboth nationally and state wide. We arecontinuously looking at means in whichwe can improve our percentages of pre-notification as well as improving thequality of the notification call itself.

The highest quality calls containingvaluable information, including thepatient’s “last seen normal” and thefindings of their stroke assessment tools(Cincinnati Pre-hospital Stroke Scale-CPSS), will allow for the physicianreceiving the call to activate the stroketeam prior to the patient arriving in theemergency department. This pre-arrivalactivation allows for the patient to movethrough the system much faster byalerting pertinent departments that thereis an in-bound stroke patient. Thisdecreases the time it takes to obtaincritical imaging and ultimately the time ittakes to begin stroke treatments.

Since faster treatment times translate tobetter patient outcomes, the EMS pre-notification measure has been the mainfocus of the EMS Stroke QualityCommittee.

The EMS Stroke Quality Committee hasrepresentation from many of the providerswithin our region and it has recentlyexpanded to include regional EMSleadership. Through the activeparticipation of these EMS agencies, thegroup was able to identify barriers tostroke pre-notification and createstrategies to improve the measure.

One barrier that was identified was aknowledge gap related to therequirement of stroke pre-notificationalong with the chain of events thatoccurred on the hospital side once EMSpre-notification was received. Educationalmaterials were developed and approvedby the EMS agency representatives to goout to providers across the region.

This education highlighted pre-notification requirement along with thenecessary content of the call in order toactivate the stroke team prior to thepatient’s arrival in the emergencydepartment. The success of this workgroup is evident by the data presented inthe pre-notification and stroke teamactivation graphs.

How does EMS partnership andinvolvement affect our Patients?Our EMS educational materials alsoincluded information on identification ofstrokes in the field in order to prompt ahospital pre-notification. EMS uses a basicstroke scale in their assessment that islikely to catch about 85% of strokes. Oureducation included additional pieces tothe assessment to increase the likelihoodof identifying a stroke to greater than 85%AND to identify those strokes that aremore severe in nature. This information isextremely valuable for our emergency andstroke physicians to know before thepatient arrives. Every minute counts whenit comes to stroke treatment so havingknowledge of the incoming patient alongwith the potential stroke severity impactsour outcomes and improves the patient’slikelihood of functional recovery.

The work of the EMS quality group hasallowed us to achieve the fastesttreatment times that our hospital has everseen and to implement stroke processesthat are truly cutting edge. As thelandscape of stroke continues to quicklyevolve, this foundation work will be ofeven greater value.

WORKING WITH EMSFOR IMPROVED STROKE OUTCOMES

2016 EMS Stroke Pre-notification

Stroke Team Activated Prior to Arrival


Upstate National


Upstate Comprehensive Stroke Centerworks with over 150 EMS agencies andfire companies throughout our region.We also accept stroke transfer requestsfrom 45 hospitals in our region. AsUpstate’s Outreach Coordinator for theStroke Program, I have the opportunityto enhance relationships with ourreferring hospitals and EMS providers.Our program provides stroke educationthrough the use of lectures, discussions,case reviews and real time feedback toour region’s first responders as well asnon-stroke designated communityhospitals. These educational sessionsinclude the most up-to-date, evidencebased stroke protocols, clinical trials andchanges in stroke treatment. My goal isto ensure that a patient who suffers astroke anywhere in this region will haveaccess to the same expert care as if theywere being treated at Upstate.

High quality regional stroke careremains a main focus of the Stroke

Program at Upstate. The recentlydeveloped EMS Stroke QualityCommittee focuses on bridging the gapbetween first responders and our strokecenter. This group has been recognizedas an innovative approach to improvinghealthcare collaboration by linking firstresponders to stroke center qualitymeasures. This further enhances inter-professional communication and allowsfor process improvement initiativeswhich are developed and implementedby a true team approach.

It takes a team to care for strokepatients and I am happy to be a part ofthat team. I have a passion for strokethat has been engrained in me frompersonal experiences. I have had familymembers that have suffered thedevastating effects of stroke. It is fromthese personal experiences that feedmy passion for community strokeeducation. Through community strokeeducation, lectures, discussion and

health fairs we are able to teach strokerisk factors and recognition of strokesigns and symptoms to thecommunities around us.

I look forward to continuing thismission over the next year.

Josh Onyan, RN,BSN, SCRNStroke ProgramOutreachCoordinator

STROKE CARE BEYOND HOSPITAL WALLS


2016/2017Telestroke Consults

A message from Dr. HeshamMasoud, Telestroke NetworkMedical Director The Upstate Telestroke Network hasallowed the region’s hospitals the ability tobetter serve their community's strokeneeds by providing the most advancedstroke care in a timely fashion throughvideoconferencing. We are able tominimize delays to therapy with instantspecialist consultations provided remotely.As our network has grown, we haveimpacted stroke care by assisting EDproviders in initiating local acute stroketherapy and identifying patients thatwould benefit from transfer for moreadvanced stroke services.

Since its inception in 2015, the networkhas yielded an IV tPA delivery rate of 39%and transfers in 65% of the consultationscompleted, representing a previouslyunmet and growing need for strokespecialty care. Looking to the future we

strive to strengthen our currentpartnerships and expand the network toinclude all underserved areas in Central NY.Our team provides ongoing education andquality improvement of our currentdelivery of Telestroke care. Our mission isto continue to lead the region with themost advanced services available focusedsolely on achieving the best outcomes forall stroke patients in Central NY.

Through partnerships with Ft DrumRegional Health Planning Organizationand EMS agencies, Upstate is ensuring themost reliable stroke care, anywhere. TheUpstate Telestroke Network has begun tomake a great impact on the largegeographical area that we serve. TheStroke Program has partnered withnumerous hospitals with the commongoal of providing expert stroke care,despite geographical limitation.

Hesham Masoud, MD, Assistant Professorof Neurology, Neurosurgery and Radiology

COMMITMENT TO OURCOMMUNITY AND REGION

2016 2017


A hand that went numb.

Amanda Peer, 33, lay in her hospital bedSunday, March 12, the day after herstroke. She watched doctors walk by herroom. Then she saw him. “Mom! That’sthe guy who was in the car.”

That guy was neurologist Gene Latorre,MD, medical director of Upstate’sComprehensive Stroke Center.

The car he was in was his own. Thanksto telestroke technology, Latorre was inthe back seat on his laptop computer,

with his wife at the wheel,conferring by video with Peer’s

doctors at Samaritan Medical Center inWatertown.

Shortly before, Peer had been talking onthe phone with her mother, Debra Ezell,who lives next door. She placed fishsticks in the oven, and her right handwent numb. She collapsed onto a fold-out bed in the adjacent room. Ezellcame running when she got noresponse over the phone.

“My words weren’t coming to me,” Peerrecalls. “I couldn’t think of the words Iwas trying to say.”

She was in and out of awareness. Sheremembers seeing Latorre on a monitordoing an assessment. Peer thought shelifted both feet when he asked,although only the left one moved. Oneminute she heard people talking abouttransferring her to Syracuse. The next,she was in Syracuse, and familymembers were pouring into her room.

Peer received a dose of clot-bustingmedication called tPA before she arrivedat Upstate. A scan revealed six clots inher brain. Upstate’sneurointerventionalist and strokeneurologist Hesham Masoud, MD, useda specialized clot retrieval device toremove the largest ones. The small oneswere treated with medication.

Within 12 hours, Peer says she had herspeech back. Four days later, she waswell enough to go home. She creditsGod with helping the doctors help herrecover.

Debra Ezell and her

daughter, Amanda Peer.

The Upstate Telestrokenetwork includes elevenoutlying hospitals:

Canton-Potsdam Hospital

Carthage Area Hospital

Claxton-Hepburn Medical Center

Clifton-Fine Hospital

Cortland Regional Medical Center

Gouverneur Hospital

Lewis County General Hospital

River Hospital

Rome Memorial Hospital

Samaritan Medical Center

Upstate University Hospital,Community Campus

PATIENT STORY


“I hollered Nancy’s name twice. I knew Ihad something going on. That was thelast I could speak.

“My left side went limp. My right side hadcontractions in the leg. My right arm wasthe only thing I could move at the time. Icouldn’t talk. My jaw was clamped shut.

“I could hear everything going on aroundme, but I couldn’t speak. It was thescariest thing I’ve ever been through.”

“Mr. Deshaw’s wife saved his life,” Upstateinterventional neurologist HeshamMasoud, MD, says plainly. “If he was notfound in a timely fashion, he would nothave survived.”

On their drive to the couple’s house,Thousand Islands Emergency RescueService paramedics Pamela Jones andEimile Parker made the importantdecision to alert LifeNet of New York —and a helicopter based at WatertownInternational Airport in nearby Dexter wasreadied for flight, just in case. Patients inrural areas such as Clayton with certainmedical emergencies including strokes ordiabetic complications have bettersurvival odds the faster they receivedefinitive medical care.

The paramedics knew Deshaw urgentlyneeded to get to Central New York’s firstand only comprehensive stroke center,some 90 miles away at Upstate UniversityHospital in Syracuse, and the quickest waywas by air. They made sure LifeNet was onthe way and radioed the fire departmentto set up a landing zone for the helicopter.

The Thousand Islands ambulance droveDeshaw about a half mile to the ClaytonVolunteer Fire Department parking lot,where the helicopter landed. Flight nurseRod Kester and flight paramedic JeffSimons climbed out. Once Deshaw was

secured to their stretcher, they openedthe door beneath the tail of thehelicopter and wheeled him in. Deshaw remembers the feel of the heat rising up from the asphalt.

Once LifeNet pilot Scott Talon pointedthe helicopter toward Syracuse, theLifeNet crew radioed the emergencyphysician on duty at Upstate, BrettCherrington, MD. He activated thehospital’s stroke team.

Masoud’s pager notified him, and hegathered in the emergency departmentwith the other physicians and nurseswho are part of the acute stroke team.They were ready for Deshaw even beforehis helicopter landed on the helipad.

Members of the team wheeled himstraight to the computerizedtomography suite in the emergencydepartment for a CT scan, with theinterventional neurologist, Masoud, at his side.

Deshaw had symptoms that suggestedhe had had a seizure or a stroke. “Anyonewith these symptoms gets an immediatevessel imaging study. That way, we canidentify the blocked artery and plan forimmediate therapy,” Masoud explains.

Nurse Jennifer Schleier is the strokecoordinator. She says the CT scan helps

rule out whether a vessel has burstwithin the brain. Patients withhemorrhagic strokes, in which a vessel bursts, are treated differently than those with ischemic strokes, inwhich a clot blocks a vessel.

Treatment was a team effort.

Deshaw received an injection of the clot-busting medication, tPA, or tissueplasminogen activator, at 6:18 p.m.through the intravenous line paramedicsinserted at his home. Then he returned tothe scanner for a CT angiogram, anotherset of images that relies on a contrastmaterial, so details of the arteries andveins are visible.

There, deep in the basilar artery ofDeshaw’s brain, was the clot.

“Time is crucial anytime someone suffers a stroke. In many cases, other healthyarteries can temporarily keep the brainalive while we try to reopen the vessel.But for patients with clots lodged at thebase of the brain, those other arteriesaren’t there to help,” Masoud says. “Forthose strokes, time is exceedinglyimportant.”

Strokes in the basilar artery are rare, andthe outcomes are usually poor. The brainarea that can be damaged in this type ofstroke controls essential functions such as

Nancy Humphrey of Claytonrecognized the signs of a strokein her husband, Larry Deshaw,78, and summoned help.

PATIENT STORY


consciousness, breathing and heart rate,balance and coordination and vision. “Inmy experience, without a rapid treatment,a majority of these patients die, usuallywithin a couple days of having the stroke,”Masoud says.

Deshaw experienced what theinterventional neurologist considers “a miraculous recovery.”

The emergency physician inserted abreathing tube. Then Deshaw waswheeled to the interventional radiologysuite two floors above the emergencydepartment.

Masoud inserted a small catheter into theartery of Deshaw’s right leg. Guided by anX-ray and contrast dye, the doctordelicately advanced a wirelike stent alongthe inside of the artery and into the brain.The stent wrapped around the clot,trapping it as if in a cage. Masoud gentlybacked the device out, removing the clotand restoring blood flow with a singlepass of the device.

Deshaw’s wife arranged for her brotherfrom Watertown to drive her to thehospital. By the time they arrived, hewas already in surgery.

Surgery was complete at 7:43 p.m., andaround sunset Deshaw was settled intothe neurosurgical intensive care unit.The ninth-floor hospital unit is staffedby nurses and technicians withspecialized training in the care ofpatients with stroke and otherneurological emergencies.

“I didn’t really wake up until the nextmorning,” Deshaw says, “but when I wokeup, everything was working.”

A steady stream of impressed doctorsstopped by to see the patient who notonly survived basilar artery thrombosisbut was up and walking the next day.

After a stroke, many patients go throughwhat can be a lengthy rehabilitationprogram. Deshaw was healthy enough tobe discharged to his home three days later.

Assembled in the suite where Larry Deshaw was treated are members of the Upstate Comprehensive Stroke Center team who cared for him, including

from left: nurse Chelsea Wilson; radiology technician Gary Denigro; Aiga Rakhesh, MBBS; nurse Jillian Saunders; Elena Schmidt, MD; Hesham Masoud,

MD; nurse practitioner Sari-Ann Yonaty, PhD; Larry Deshaw; Nancy Humphrey; J. Gene Latorre, MD; Gregory Meola, PharmD; nurse Alexis Coomey;

Claribel Wee, MD; and radiology technician Jeff Ledbetter.

Larry Deshaw and his wife, Nancy Humphrey,

gathered for a photo with rescuers at the spot

behind the Clayton Volunteer Fire

Department where the helicopter landed to

pick him up. Among his rescuers were, from

left, Clayton firefighter Curtis Harvey;

paramedic Pamela Jones from Thousand

Islands Emergency Rescue Service; and

paramedic Jeff Simons and nurse Rod Kester,

both from LifeNet.


Upstate Regional Rehabilitation CenterStroke is one of the leadingcauses of long term adultdisability, affectingapproximately 795,000 people each year in the U.S.

The Upstate Regional RehabilitationCenter offers Inpatient and Outpatientcare throughout the region. Upstate’sInpatient services are offered at theDowntown and Community campusesproviding full hospital level of care. TheOutpatient Clinics offer neurologicalrehabilitation at five clinics throughoutCentral New York.

Our OutcomesStudies show that stroke survivors treatedat an acute rehabilitation hospital likeUpstate have a higher level of functionalindependence and are more likely to bedischarged to home that those treated inother care settings. Upstate’s strokepatients have greater improvementduring their stay and a higher level offunctional independence upondischarge, based on regional and

national benchmarks that measurecriteria such as mobility, cognitive abilityand activities of daily living.

Continuum of CareTo help individuals successfully transitionto life at home, at work and in thecommunity, Upstate delivers anunparalleled continuum of care services.

Stroke Specialty ServicesThe care program at Upstate can include:vocational counseling, recreationaltherapeutics, orthotic services, assistivetechnologies and advanced wheelchairseating and mobility options. Upstatealso offers patients in need advancedspeech and language pathology servicesincluding barium swallow studies, vitalstimulation and augmentation devices.

Stroke Survivors Support GroupStroke support groups and educationalprogramming give patients and theirfamilies the opportunity to shareinformation, discuss common concernsand learn from the experiences of others.

Treatment, Technology andResearchUpstate Rehabilitation Center isrecognized as a pioneer in medicalrehabilitation, integrating education,biomedical research and advancedclinical excellence. State of the art andleading technologies include:

• Spasticity and tone management:Botulinum toxin, ITB, NMES, serialcasting, taping and pain management

• Bioness, stim bike, WalkAide

• Body-weight Support Treadmill Training(BWST)

• Constraint induced movement

• Lokomat, Andago, Armeo-Robotictherapies

• Latest computer-based rehabilitationaids

SUPERIOR OUTCOMES AND EXCEPTIONAL

REHABILITATION CARE


Stroke Rehabilitation TeamMembers include:

Physical Medicine andRehabilitation Physicians

Rehabilitation Nurses

Physical Therapists

Speech and Language Pathologists

Case Managers

Psychologists

Therapeutic Recreation Specialists

Vocational Counselors

Occupational Therapists

Percentage of patientswho returned home fromrehabilitation in 2016

Upstate RegionalRehabilitation Center

Other RehabilitationCenters in the Region

22 UPSTATE UNIVERSITY HOSPITAL- COMPREHENSIVE STROKE CENTER

REHABILITATIONIS CRUCIAL FOR STROKE PATIENTS

PATIENT STORY

Many people recovering from strokes inCentral New York receive rehabilitation atUpstate, the only hospital in the regionoffering inpatient rehabilitation. Patientswho meet certain criteria can transferfrom Upstate’s neurological intensive care unit, or from other hospitals for their rehab.

Rehabilitation ideally begins early in thepatient’s recovery.

“Studies show that the earlier you can getpeople to rehabilitation, the better theoutcome,” says Shernaz Hurlong, DO, adoctor of physical medicine andrehabilitation at Upstate. She says most ofthe recovery that will occur after a personhas a stroke takes place within the firstthree months.

William Bouchard’s rehabilitation therapybegan with a stretch band in his bed inthe neurological intensive care unit.Bouchard, 72, of Clay suffered a strokeApril 4. He was working as a biomedicalengineer at the Syracuse VA MedicalCenter. Co-workers found him slumped in a stairwell.

At Upstate he received medication tohelp shrink the size of the clot, andneurosurgeon Grahame Gould, MD, used a clot retrieval device to removewhat remained of the clot. All Bouchardremembers is being told that he couldnot go to karate the next morning.

Bouchard trains regularly at ImpactMartial Arts in Clay. He was determined to return to the dojo – and thatdetermination has helped in his recovery,says physical therapist Kelly Grier, whobuilt karate into Bouchard’s therapy.

“I do my very best to make sure that each patient’s goals and interests arebeing talked about in therapy, so thatrehabilitation is meaningful to them,”Grier explains.

She can’t recall a patient with goals asambitious as Bouchard’s. He wanted towalk up the Adams Street hill. He wantedto do 500 wall kicks, per leg. He wantedto spar. He wanted to run a mile. So Grierhelped him, and sometimes his therapysessions felt more like work-outs.

After 22 nights at Upstate, Bouchard wasdischarged, returning for physical andoccupational therapy appointments.

“What really stands out is his high selfefficacy to get better,” says Grier. “He’s had a remarkable recovery.”

Number of days a patient waits foradmission to a rehabilitation program

Upstate RegionalRehabilitation Center

Other RehabilitationCenters in the Region

At the end of June, after a stroke on April 4,

William Bouchard, 72, of Clay strapped on

boxing gloves and punched a target, while his

physical therapist Kelly Grier stood ready to

steady him if he wobbled.



Antonio Culebras, MD Anuradha K Duleep,MD

Grahame Gould, MD Julius Gene Latorre,MD

Carmen M Martinez,MD

Hesham Masoud, MD Michael L Vertino, MD Sari-Ann Yonaty, NP,PhD

Elena Schmidt, MD Awss Zidan, MD

Stephanie Loveless, NP Marcia Tommie Harris,NP

STROKE MEDICAL TEAMOur stroke team is comprised of expertsfrom multiple disciplines. It includesneurologists, neurosurgeons,

interventional radiologists, cardiologistsand rehabilitation therapists. Thesespecialists are supported by our three

levels of neuro-nursing care, allconveniently located on our 9th floor, at Upstate University Hospital.

"Upstate's Level 1 ComprehensiveStroke Center designation providesour Neurology residents with anexperience at the cutting edge ofadvanced stroke care. Our residentslead emergency stroke codes in theER and wards, their diligence andefficiency results in faster treatmenttimes, consistently faster than thenational standard. To this end theresidents undergo tailored

simulation training sessions, formaldidactics on cerebrovascular diseaseand neuroanatomic localization, inaddition to bed-side teachinghighlighting the importance ofeffective communication andcompassionate delivery of care.With the strength of our residents,we maintain our status as theregional leader in stroke care." - Dr Hesham Masoud

Resident Training for emergent stroke care


STROKE NURSING TEAMSERVING OUR PATIENTS AND THE COMMUNITY

Our 100 Neuroscience nurses have apassion for stroke care. They completeover 8 hours annually of strokeeducation and being located on thesame floor as the stroke program staffhear more about stroke than theyprobably want to in any given day! Ournurses specialize in all phases of strokecare: acute care and tPA administrationand monitoring, post thrombectomyassessments, family support for patientsdischarged to rehab or home and areoften the first line of defense inteaching about stroke prevention. Weare proud that we have many nurseswho have earned their SCRN credential.SCRN is a national certification in strokecare given by the American Associationof Neuroscience Nurses (AANN). Thispassion and desire to be challenged

has led some to transfer to higher levelsof care from the Neuro-Med Surgicalfloor to our Neuro Intermediate CareUnit or Neuro ICU. They give manyvolunteer hours to stroke communityevents and participate in several workgroups for quality improvementprojects. We hope that no one has toexperience their expertise andcompassion first hand but if you do,you are in good specialized hands!

Outreach projects

Pars for Stroke

Strike out Stroke

Strikes against Stroke

American Heart Association Heart Walk

Stroke Camp

Accolades: Publications,Trials, Research, Posters“Morphological Features of Intracranial

Aneurysms Predicts Risk of Rupture”Author(s):Gentian Toshkezi, MD, AmarSwarnkar, MD, Satish Krishnamurthy, MD,MCh (Syracuse, NY)

Kapinos G, Latorre JG. Seizure burden insubarachnoid hemorrhage: “Time is brain”as well. Neurology 2016;86(3):206-7.

Rosenberg D, Latorre JG. Hearing one’s voicein your speech: An unusual case ofpalinacousis due to acute intracerebralhemorrhage. Neurologist 2016;21(1):13-15.

Prasad A, Sharma S, Schmidt E, Latorre, J.Cerebral amyloid angiopathy presentingas new onset refractory status epilepticus(NORSE) complicated by PRES. AAN 2016Annual meeting. Neurology 2016;86:16Suppl P6.219

Kaur G, Sharma S. Latorre, J. Single centerexperience of endovascular interventionin extra and intracranial vertebrobasilarstenosis at a tertiary care center. AAN2016 Annual meeting. Neurology2016;86:16 Suppl P1.197

Stroke Code simulation lab (April 17, 2016AAN presentation)www.neurology.org/content/86/16_Supplement/P2.375

Schleier J, Onyan J, Vallelunga M, Rainbow S.Direct to CT Impacts Door to NeedleTimes. 2016 North East CerebrovascularConsortium (NECC) Annual Conference,poster presentation.

The Highest StandardsUpstate is the only Level IComprehensive Stroke Centerin Central New York. Thismeans only Upstate has metand exceeded the higheststandards for stroke care.

750 East Adams StreetSyracuse, NY 13210

Documents

2017 Stroke Annual Report - upstate.edu · window for stroke rescue therapy is now wider with the addition of innovative imaging software called ... flow to resume. Studies have shown