August 15, 2018 News » Cover Story

Dispute erupts over which hospital offers higher levels of care for stroke patients 

Equal treatment?

click to enlarge UCHealth Memorial Central obtained top stroke certification in January 2018. - COURTESY UCHEALTH MEMORIAL CENTRAL
  • Courtesy UCHealth Memorial Central
  • UCHealth Memorial Central obtained top stroke certification in January 2018.

If you or a loved one experiences a stroke, you want trained people with the right equipment to help before it's too late. But what if the hospital you're rushed to doesn't have what you need? "Time is brain" in the world of neurology, meaning every minute a stroke goes untreated, you're losing 1.9 million neurons and falling farther down the tunnel of no return for brain function.

That's why it's important that ambulance crews, and the community, understand which hospitals offer the most help for patients who have a clogged artery or a hemorrhage in their brains.

It's an issue that's been hotly debated — under the radar — in Colorado Springs after an independent local emergency medical oversight group, which directs ambulance drivers where to take patients with certain critical conditions, refused to label city-owned UCHealth Memorial Hospital Central as the preferred destination for stroke care despite it being accredited at the highest level: as a "comprehensive stroke center" (CSC) by DNV GL Healthcare corporation, an international accreditation agency, in January.

UCHealth Memorial's chief competitor, Penrose Hospital, part of Penrose-St. Francis Health Services which is part of Centura Health, is labeled a "primary stroke center" (PSC) by The Joint Commission national nonprofit accreditation agency. While it hasn't yet attained the top credential, Penrose-St. Francis spokesperson Chris Valentine claims the facility has the same capability as UCHealth Memorial for stroke care.

Valentine isn't the only one contending that there isn't much difference between the designations, nor is that debate limited to Colorado Springs. Due to the rapidly evolving world of medicine, medical professionals across the nation have changed their stance regarding which type of facility is preferred in what circumstances. But some involved say there's clear evidence that stroke patients rushed to Penrose instead of Memorial might not get as high a level of care. And some experts agree, saying CSCs offer more advanced care and a better chance for recovery than PSCs.

Take Sameer Ansari, associate professor of radiology, neurology and neurological surgery at Northwestern University's Feinberg School of Medicine. He tells the Indy via email: "The Society of Neurointerventional Surgery and most neurointerventionalists such as myself advocate for changing the EMS triage process and bypassing Primary Stroke Centers."

It's far from merely an academic debate.

UCHealth Memorial CEO Joel Yuhas says that Penrose transferred 33 stroke patients to Memorial Central over an 18-month period in 2017 and 2018, with many suffering "poor outcomes," according to hospital documents, letters, presentations and emails obtained by the Independent from an anonymous, high-level source not connected to either hospital. Four died due to delays in treatment, the documents say. Yuhas declined an interview with the Indy.

Penrose disputes those numbers as does the city government, which oversees emergency ambulance service in the city. More on the discrepancy later.

Regardless, Yuhas has been on a campaign to change the EMS destination guidelines for stroke for more than a year, and intensified his efforts after the city's EMS medical director, Dr. Stein Bronsky, who's paid by Penrose, issued a Jan. 12 memo to EMS crews saying both hospitals "offer the same level of [stroke] treatment," despite UCHealth Memorial's higher accreditation.

Complicating the debate was the disbanding of the Emergency Care Committee last year, which has since been restructured into the Medical Director Committee with equal representation between the two hospital systems. Even the new committee, however, decided in May to keep the current directive in place, which puts both hospitals on equal footing as a destination for stroke treatment.

Since then, Penrose has transferred at least two stroke patients to UCHealth Memorial Central, records show.

Two competing systems

UCHealth Memorial and Penrose have long competed for market share in Colorado Springs. City-owned Memorial is run by UCHealth under a 40-year contract that began in October 2012 and includes UCHealth Memorial Central at 1400 E. Boulder St.

Penrose-St. Francis Health Services, which includes Penrose Main at 2202 N. Nevada Ave., is under the umbrella of Centura Health.

As of April 2017, the most recent information available, UCHealth has pumped more than $130 million into Memorial in new technology, expanded facilities and additional services, and that doesn't include the $110 million current expansion of Memorial Hospital North. That investment has included growth in admissions, outpatient visits, a nearly fourfold increase in the number of physicians employed at UCHealth Memorial and the designation of UCHealth Memorial Central as a Level 1 Trauma Center, the only one outside the Denver metro area, and as a Comprehensive Stroke Center.

"We are now able to provide 24/7/365 access to advanced care and specialties including: advanced imaging, endovascular interventions, neurosurgeons, and a dedicated neuro ICU. These capabilities are unique in southern Colorado and are key differentiators for a comprehensive stroke center," UCHealth spokesperson Dan Weaver says in an email.

Penrose-St. Francis Health Services, which also has grown in the last decade, was named one of America's 50 Best Hospitals™ for 10 years in a row (2008-2017) by Healthgrades®, and holds an array of accreditations, including Penrose Hospital's certification as an Advanced Primary Stroke Center by The Joint Commission.

"Centura Health and Penrose-St. Francis are committed to providing reliable care for stroke victims and those at risk," Valentine says. "Penrose-St. Francis has all the necessary components for comprehensive certification, which we are ready to pursue. Our quick response to stroke, advanced technology, specialized staff and acute stroke rehabilitation means we can offer the best all-around care for our patients and their families."

But UCHealth Memorial Central's accreditation as a CSC means it meets all of the lower level PCS requirements, as well as more advanced requirements. Memorial also has a mobile stroke unit, which Penrose lacks.

Accreditations play a role in helping EMS teams determine where ambulances take certain patients, though conventional wisdom has vacillated over the years. For example, the city notes to the Indy that the American Heart Association recently rescinded a previous guidance to bypass primary centers. In some cases, it's appropriate to use PSCs.

Some EMS systems, though, give directives to take stroke patients to a comprehensive center if it's within 15 to 20 minutes, according to an article in the Sept. 5, 2017, issue of EMSworld.com written by Drs. Kenneth Scheppke, EMS medical director in Palm Beach County, Florida, and Paul Pepe, an emergency medicine professor at the University of Texas Southwestern Medical Center, Dallas.

Noting a study that showed median transfer time was more than two hours, they wrote, "Potential delays in definitive care owing to secondary transport times from PSC to CSC highlight the critical importance of EMS taking the patient to the highest level of care within a reasonable distance whenever possible in the first instance."

Tabitha Vieweg, associate director of The Joint Commission's Department of Standards and Survey Methods, tells the Indy in an email that many protocols state that EMS should bypass PSCs if the trip to a CSC adds less than 30 minutes to the transport trip. That's because medics in the field can't be sure if a patient is having an ischemic (obstruction of a blood vessel) or hemorrhagic stroke, "so they put protocols like this in place knowing that a hemorrhagic stroke patient is better off going to a CSC."

Northwestern University's Ansari favors CSCs because they offer the range of treatment beyond what's normally performed at a primary center. "As with all stroke treatment, time is brain and it is imperative to bring the patient to the right hospital immediately, the sooner the better," he says. "These emergent patients with severe stroke symptoms need to be directly transported to Comprehensive Stroke Centers rather than Primary Stroke Centers."

Pushing for answers

In April 2017, Yuhas lobbied the Emergency Care Committee, a group of doctors who oversaw emergency medical issues and protocols, to assure UCHealth Memorial Central's growing capabilities were being fully utilized. The group took a final action in mid-2017 to change the destination guidelines to bypass UCHealth Memorial North and St. Francis Medical Center for stroke patients with more severe strokes, as indicated by arm and leg motor impairment and facial palsy, and take them to Memorial Central or Penrose. These are the guidelines in effect today.

click to enlarge UCHealth Memorial Central has a stroke treatment unit as well as the latest imaging technology for stroke patients. - COURTESY UCHEALTH MEMORIAL CENTRAL
  • Courtesy UCHealth Memorial Central
  • UCHealth Memorial Central has a stroke treatment unit as well as the latest imaging technology for stroke patients.

The group also told Yuhas "to come back if/when [UCHealth Memorial Central's] accreditation status changes," according to Yuhas' statements in documents. But after that accreditation did change, on Jan. 12, Bronsky, the EMS medical director, issued a directive to EMS personnel, saying there had been "NO change to our community's [stroke] destination guidelines." While acknowledging the newly bestowed CSC accreditation, Bronsky said, "This designation does not, however, change Memorial's treatment capabilities... Just as a reminder, Memorial Central and Penrose Main offer the same level of [stroke] treatment."

Meantime, a state panel — the Regional Emergency Trauma Advisory Council — was helping to establish a new local group to replace the Emergency Care Committee that folded. The new group, called the El Paso County Emergency Medical Director Committee (MDC) is composed of four doctors each from Penrose and Memorial, and one from Fort Carson's Evans Community Hospital.

While Fire Department Medical Division Battalion Chief Jayme McConnellogue says the MDC formed in January 2018, emails between Fire Chief Ted Collas, who oversees the city's EMS contract, and Yuhas say the committee wasn't formed until several months later, and it just adopted bylaws on Aug. 2.

Regardless, since there was no committee to appeal to, Yuhas contacted Collas, McConnellogue, the mayor's Chief of Staff Jeff Greene and Mayor John Suthers. Yuhas expressed grave concerns at mounting numbers of stroke patients being transferred from Penrose to UCHealth Memorial Central.

As of Jan. 22, Yuhas told Collas that 15 patients with poor outcomes had been transferred to Memorial Central due to "service unavailable at Penrose," including a person with a "3 day old stroke" and another who didn't have a fairly common imaging procedure for some types of strokes before arriving at Memorial Central. One person died, he said. Yuhas noted in a subsequent email to Collas that Penrose had transferred patients to Denver for stroke care, though such care was "readily available locally."

"I am expressly concerned that patients in our community are currently being injured, sustaining irreparable neurological deficit, or worse due to avoidable delays in treatment," Yuhas wrote. Yuhas also complained that Bronsky was being paid by Penrose, noting, "His actions [in issuing the destination guidelines] have clearly demonstrated the reality of this conflict of interest."

Penrose's Valentine dismisses the allegation, saying, "No decision is made without the consensus of this joint medical direction team."

On Feb. 13, Yuhas met with Collas again, revising the count to 16 patients with permanent injuries, two of whom had died, after transfers. Two weeks later, on Feb. 27, Yuhas met with Greene and city HR director Mike Sullivan, updating the number of transfers to 17 people injured and three deaths.

On March 10, Collas told Yuhas in an email a new task force would be created to review destination guidelines under the direction of Penrose doctor Ed Hurtado. Collas also said the guidelines decision would be based on quality performance, not capability of the hospitals.

"Procedures need to be developed in order to ensure that patients are being transported to the facility which is best capable of definitive treatment of their injury/illness," Collas told Yuhas, adding that a system was being developed to allow hospitals to alert ambulance crews of changes in capabilities, so ambulances could take patients elsewhere.

Yuhas immediately protested the use of performance data instead of capabilities, records show.

Debate over qualifications

On March 27, retired Air Force Gen. Gene Renuart, UCHealth Memorial's board chair, wrote a letter to Suthers noting the "sheer volume" of stroke patients taken to Penrose only to be transferred to Memorial after "significant delays," which have caused "permanent injury" and death of three people.

"Many of these people," he continued, "were deemed by Penrose-St. Francis physicians to require surgical intervention for their stroke — but by the time they arrived at UCHealth Memorial were no longer surgical candidates due to transfer delays. This is a community public health crisis that requires hospitals and Fire/EMS to work together to solve."

Renuart also said UCHealth Memorial Central "should not be underutilized for any political purpose when the evidence continues to mount on delayed access and care for the community based on current stroke destination guidelines."

That same day, Yuhas and two neuro services doctors met with Suthers, walking him through types of stroke, UCHealth Memorial Central's capabilities, accreditation requirements and implications of destination guidelines.

By this time, they said, 26 patients spanning 13 months had been transferred to UCHealth Memorial from Penrose, 80 percent of whom were delayed more than two hours, many longer than that. They noted no independent neuroscience experts would be asked to participate in the Medical Director Committee's review, which they viewed as a shortcoming of the process, and told Suthers their goal was to see patients directed to the most capable hospital in the least amount of time.

As for Yuhas' numbers, Penrose strenuously disputes them, saying Penrose has transferred only two patients to UCHealth Memorial Central since May 2017, and that it's received three from Memorial. The city wouldn't give specific numbers, but said Yuhas' figures include patients who went to Penrose via private vehicle or life flight, not just by ambulance.

Asked about that, UCHealth spokesperson Weaver said via email that UCHealth Memorial Hospital had "carefully documented transfers and concerns over the past two years, and we have provided this information to the Colorado Springs Fire Department for their quality review. While we stand by this information, it was intended for the Fire Department and EMS to help identify areas for improvement, not for public release."

After the Medical Director Committee asked both hospitals to provide patient performance information, or quality data, upon which a decision for the guidelines would be based, Penrose provided it, but UCHealth Memorial did not. In an April 20 letter to McConnellogue, Yuhas opposed using a patient performance methodology.

"UCHealth Memorial is the only CSC in all of Southern Colorado and as such receives transfers of critical patients from other community hospitals within and outside the Colorado Springs area," Yuhas wrote. "Because UCHealth Memorial's data includes higher level of care transfers from other stroke programs, including over 30 cases from Penrose-St. Francis Health Services since January 2017, it is not scientifically appropriate to compare data sets from two dissimilar stroke programs of substantively different accreditations and treatment capabilities."

In other words, Yuhas says Memorial's stroke treatment capabilities shouldn't be judged based on patient outcomes, because they get the patients in the worst condition, including those who have already languished in other hospitals. He also cited state and federal protections for patient information in refusing to share it.

Vieweg, with The Joint Commission, which accredited Penrose, happens to agree with Yuhas, saying that capability is a better measure. Using performance data in comparing a PSC to a CSC "is comparing apples to oranges," she says.

While the MDC initially chose to review the two hospitals based on patient performance, after UCHealth Memorial refused to provide patient information, the committee decided not to review Penrose's patient information and based its decision on the hospitals' capabilities.

click to enlarge UCHealth Memorial Central has a stroke treatment unit as well as the latest imaging technology for stroke patients. - COURTESY UCHEALTH MEMORIAL CENTRAL
  • Courtesy UCHealth Memorial Central
  • UCHealth Memorial Central has a stroke treatment unit as well as the latest imaging technology for stroke patients.

McConnellogue and Collas, responding to the Indy's questions in writing, contend the committee intended to look at both methods — patient performance and capabilities — all along, but documentation obtained by the Indy indicates performance was intended as the sole criteria leading up to the meeting. Hence, UCHealth Memorial's opposition.

When McConnellogue notified the Medical Director Committee that UCHealth Memorial wouldn't submit performance data, member Dave Hakkarinen, a Penrose physician, responded, saying, "should we not assume they have worse outcomes then [sic] other facilities and as a result why should we not direct Stroke Traffic Away from them.... [if] they will not share data we would have to assume the worst and assume they are providing low quality care and direct patients away from them."

But committee member and UCHealth Memorial physician Sean Donahue responded, "To me the only piece that matters in this discussion is the patient. If one organization is stating they have the exact same capabilities as the other, and they do not...even 1% less of the time, then we have big issues, and indeed patient care has suffered. To state that all EMS traffic should be diverted from one institution based on data that has yet to be seen, but whose capabilities have been fully verified by an independent 3rd party is preposterous." He added that his mother lives a mile from Penrose, but if she suffered a stroke, "At this point I view taking her to Penrose as a huge gamble."

In the end, status quo

On May 3, the MDC voted to continue the guideline that puts the two facilities on par for stroke patients. Three UCHealth physicians, two from Penrose and one from Fort Carson were present for that vote, which was unanimous.

Asked about that, UCHealth didn't explain why their doctors voted for the status quo, but spokesperson Weaver says in an email UCHealth supports additional research into destination guidelines and recommends the Fire Department "seek guidance from a national expert to ensure all stroke patients are being transported to the most appropriate hospital, as quickly as possible." UCHealth also has asked the city to remove any conflicts of interest from the EMS program, educate EMS crews on hospital capabilities and require hospitals to notify EMS any time those capabilities change due to temporary lapse in physician coverage or other circumstances.

Since the May 3 vote, Penrose has transferred at least two patients to UCHealth Memorial Central, records obtained by the Indy show.

McConnellogue says the committee reviewed those cases and another one this summer. She also says the committee has yet to develop a formal inquiry process although a draft is in the works, and hospitals will be asked for their input. She also notes the Fire Department is coordinating with hospitals to ensure the EMS notification process is used to put ambulance crews on notice when a hospital isn't capable of providing certain types of care.

Meantime, the city is looking to replace Bronsky as its medical director, and the deadline to apply for the services contract is Aug. 28. A new contract would become effective Jan. 1.

Asked if the RFP stemmed from Yuhas' concerns over Bronsky being paid by Penrose, Collas and McConnellogue side-stepped the question, saying it's in the best interest of citizens if the city funds the majority of the medical director's salary, although the city will ask both hospital systems to pay some portion of the cost.

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