The standard of care

It was the early morning of March 2, 2004.

Ray Donahue, now 65, a retired resident of Fallon, had stepped out of his house to smoke his first cigarette of the day.

All of a sudden he felt as if someone was twisting a hot poker into his head.

His whole body felt terribly hot.

He dragged himself to get inside the house and hollered to his wife Pam, who was still in bed.

"I'm having a stroke, I'm having a stroke.

Call 911.

I'm paralyzed, I'm paralyzed," he said to Pam, all very coherently, as he kicked his arms and legs.

Donahue was taken by ambulance to the Banner Churchill Community Hospital in Fallon.A young emergency room doctor immediately got in touch with Washoe Medical Center's Comprehensive Stroke Center.

Paul Katz,MD,medical director of the Comprehensive Stroke Center, provided guidance to the community hospital's doctor as an intravenous tPA a potent anti-stroke drug was administered.

"He was very weak on the left side," Katz says,"and that's why we decided to give the tPA."

In less than an hour, Donahue was put on a helicopter to Washoe Medical Center's Stroke Center in Reno.

After three days in the hospital's intensive care, he underwent physical therapy for 23 days.

Since his return home, Donahue says, he has been in "pretty good condition, though not 100 percent." But he adds,"I have never used a walker, never used a cane."

Donahue is one of the hundreds of patients treated by Washoe's Stroke Center which, since it was set up five years ago, has brought under its fold 27 rural hospitals.

They account for a third of its stroke admissions.

And the center receives an average of 20 stroke patients a day, Katz says.And over time it has successfully established a single standard of care for hospitals of all size.

Now all of them have access to the same stroke protocols.

There is one central number where rural physicians reach the on-call neurologist there are four available 24 hours a day, seven days a week who can advise the rural hospital's ER on proper drug usage before the patient heads to the Stroke Center.

Washoe Medical Center's efforts toward setting up the rural stroke care system culminated in its receiving the primary stroke care center designation from the Joint Commission on Accreditation of Healthcare Organizations one of only 192 nationwide to earn it and the first in the state.

Stroke is the third-leading cause of death in the nation and the fourth in the state.

About $40 billion is spent annually on stroke treatment as it's the leading cause of adult disability and placement in nursing homes.

Studies show that knowing how to use the tPA drug better has allowed 50 percent of the stroke patients across the nation to return home and lead independent lives.

"Our data shows 68 percent home and independent.

Otherwise they would be in the nursing home," Katz says.

The center not only standardized protocols for doctors and emergency medical units, but also developed a core curriculum for the nurses both for its own as well as for the rural hospitals.

Also, the center carried out a hospitalwide education what to do in case of a stroke for dietary experts, physical therapists, transport workers, and even front-desk personnel.

Katz highlights the support of the emergency medical services in the outlying counties because they knew the strengths and weaknesses of their communities.

"They gave us ideas of how to do it better, quicker and faster," Katz says.

The Washoe Medical Center's administration has also given treatment of stroke patients a priority, he adds.

Stroke patients get access to the center's neurologists, neuroradiologists, neurosurgeons, rehabilitation staff and critical-care nurses.

The coordinated system of care includes follow-up even after they go home, Katz points out.

"The fact that we have an organized system for the patients means that they get everything they need quickly and so, we can increase volume and reduce length of stay because we're efficient at delivering the appropriate test and treatment at the right time," Katz adds.

The center has been a valuable resource, say emergency room doctors and nurses at outlying hospitals.

"It's given us some criterion for patients that need to go there immediately and for those patients that fall under a sort of gray area.

There's somebody we can call and say 'Here's what's going on and what do you think?'" says Russ Mann, a senior staff nurse at Truckee's Tahoe Forest Hospital's ER Department.

But the challenges remain,Mann says, and that lies in educating the patients and their families.

"Because of news articles and television medical shows, they are aware that there are dramatic treatments for stroke and of course they all want that for their loved ones.What they don't know is that the criterion of using some of those medications is very narrow and so there is a small population that can actually benefit from that," he says.

Katz, however, says rural hospitals and support groups are doing well to educate citizens about the warning signs of a stroke and the availability of the therapy.

The Joint Commission's accreditation, he says, will help bring awareness of the center to the people in northern Nevada.

And more education and awareness will bring in a higher volume of patients.

Still, he says, some physicians both in northern Nevada and nationwide resist use of the tPA therapy.

Some worry about a risk of hemorrhage and are unwilling to take on the liability.

Hospitals, meanwhile, initially wondered if they'd make money with the stroke protocol.

One hospital, Katz says, didn't want to participate but the community forced it to be a part of the system.Another hospital in the region still won't participate.

That reluctance baffles Pam Donahue as she helps her husband recover.

"It has made a world of difference in the treatment and recovery of Ray," she says."I don't know what excuse can anyone use of resisting the treatment."