By Sandee Curry
Friday, February 26, 2021
The Pomeroy Emergency Services Department at Crouse Health is bringing a higher level of emergency care to patients in Central New York. The facility—completely redesigned and expanded in 2017—features an innovative layout designed to treat patients faster and more safely, especially for stroke, when time is brain, and for cardiac events, when every second counts.
As a dually accredited Comprehensive Stroke Center, Crouse Health provides patients access to the latest technological advances for stroke and interventional neurosurgery along with highly skilled and compassionate providers and an integral partnership with community Emergency Medicine Services (EMS) providers. Each member of this collaborative effort plays a unique and crucial role in the care of patients needing urgent intervention. Additionally, Crouse Health is one of only five hospitals in New York state to use a recently developed artificial intelligence software that can assist in diagnosing stroke, which saves precious minutes for patients.
With stroke being the fifth leading cause of death and a major cause of disability in the United States, the key to better outcomes is reducing the length of time between the onset of symptoms and accurate diagnosis and treatment.
“Our communication with local and regional EMS providers, primary care physicians and specialists is what separates Crouse from other institutions,” says Seth Kronenberg, MD, Chief Operating Officer and Chief Medical Officer at Crouse Health. “We have incredibly talented physicians and advanced practice providers in the emergency department [ED] and in interventional cardiology and neurology. The ability of the specialists and emergency services team to deliver fast treatment times, improved communications and excellent patient care, while having access to the latest technology, results in optimal patient outcomes.”
This collaboration is built on mutual respect and quick action between the ED and EMS partners. Emergency Services receives advance notification from EMS and can then engage the interventional stroke or cardiac teams — even before the patient arrives at Crouse.
David Mason, MD, FACEP, Medical Director and Chief of Emergency Services for Pomeroy Emergency Services, oversees all of Emergency Services’ clinical operations. A strong advocate for Crouse’s partnership with EMS, Dr. Mason and his colleagues constantly re-evaluate their system and processes to improve patient care and make it easy for EMS providers to bring their patients to Crouse.
“We bring our separate areas of expertise to help care for patients,” Dr. Mason says. “The ED is a team, but the bigger team for a stroke or a cardiac patient is the neuroscience team, the cardiac team, the EMS team who brought them in, and the post-acute care team, all working together to provide the most advanced, multidisciplinary care possible.”
“Dr. Mason talks to me as if I were his medical student. He genuinely wants everyone to have the same learning opportunities and for everyone to have the knowledge they need to handle their part of the process, and ultimately that is the best thing for patient outcomes.”
— Sarah Jerjen, paramedic with Fayetteville Fire & EMS, Greater Baldwinsville Ambulance Corps and American Medical Response
Sharing Knowledge Saves Lives
The Crouse team relies on a coordinated effort between emergency, neurology, neurosurgery, interventional radiology services, CT imaging and the nursing staff, to identify stroke patients.
David Padalino, MD, FAANS, Medical Director for Crouse Medical Practice – Neurosurgery, a board-certified neurointerventionalist, has led Crouse in attaining its comprehensive stroke certification , which was granted in 2018 and reflects the highest level of regional experience for the treatment of serious stroke events.
Within seconds to minutes, Dr. Padalino and his team are notified of a potential stroke patient. Information from EMS and the ED is shared with his team, and if the determination is made that neurosurgery is needed, they receive a call. When EMS arrives, they are met at the door and the patient is immediately brought in for a CT scan.
“We pride ourselves on approaching every individual case as if it’s the first one of its kind with the enthusiasm of making sure everything that needs to be done gets done,” Dr. Padalino says. “If there’s potential for a delay, we try to find ways to avoid that delay in the future, anything from information processing to human factors and system issues.”
Joseph Battaglia, MD, FACC, is a cardiologist who leads Crouse’s cardiology team to achieve fastest door-to-intervention times and best patient outcomes.
“The national standard for door-to-cardiac intervention is 90 minutes,” Dr. Battaglia says. “Our goal and our standard is consistently under 60 minutes.”
In 2018, Crouse Health earned the American Heart Association (AHA) Mission: Lifeline Gold Receiving Quality Achievement Award for STEMI (heart attack), the first hospital in the region to receive this designation. Crouse’s cardiology group, Crouse Medical Practice — Cardiology, has almost doubled in size in the past few years, adding several physicians and bringing the number of providers to 13.
Dr. Battaglia and his team have always worked closely with Emergency Services. Crouse’s Miron Cardiac Care Center has active adult and pediatric cardiac catheterization labs, and Emergency Services and the cardiology team hold monthly joint meetings to review patient cases.
From the time the ambulance gets to a patient, EMS can transmit an EKG to the ED. The ED and a cardiologist review the status of the patient prior to arrival. “Coordination of care happens well before the patient even arrives in the ED, which can save precious minutes — and save lives,” Dr. Battaglia adds.
ED physicians can call the cardiologists’ cellphones when they have questions, and the cardiologists come to the ED frequently throughout the day to review cases with the teams. There is also a monthly quality control meeting focusing on the hospital’s STEMI patients.
Joseph Battaglia, MD, FACC, a world-class cardiologist who leads Crouse Health’s cardiology team
“There has always been support 100% of the time for every emergency case, and it’s a huge responsibility for us to be able to provide the kind of care we provide to the community. It is a privileged role we have, and I feel fortunate that we are fully supported to take care of our patients and make sure they get the best treatment possible.”
— David Padalino, MD, FAANS, Medical Director for Crouse Medical Practice – Neurosurgery
Partners in Care: A Crucial Role Recognized
Sarah Jerjen, a paramedic with Fayetteville Fire & EMS, Greater Baldwinsville Ambulance Corps and American Medical Response, appreciates how the providers at Crouse recognize the importance of EMS, especially in critical calls for stroke and cardiac issues.
“Every hospital gets a pre-arrival notification, but at Crouse, I feel confident calling ahead, not only for neurology and catheterization lab calls, but just to get the opinion of a doctor,” Jerjen says. “I know that the next time I go there, I can find that same doctor or physician assistant, talk to him or her about it, and they’ll remember what I said and take time to explain the case to me. Crouse sees us as critical partners in the care of our patients. That level of attention and interest does not happen in every ED.”
Crouse also offers classes that are not only open to physicians, PAs and nurses, but EMS providers as well, providing opportunities for EMS to enhance skills and knowledge.
EMS and Emergency Services are fully integrated with the neurosciences team for stroke care.
“Not every person who comes in exhibiting stroke symptoms is having a stroke,” Dr. Padalino says. “The ideal situation is to work together to find the best way to identify the patients who are having true strokes as fast as possible so the most appropriate treatment can be administered.”
“Healthcare workers all share a mission, and that is to do the best we can for patients and to help alleviate suffering. Whether it’s this pandemic or the opioid crisis, whatever it is, we’ll always be here to support each other and our community.”
— David Mason, MD, FACEP, Medical Director and Chief of Emergency Services for Pomeroy Emergency Services
A Feedback Loop
Jerjen is thankful that everyone at Crouse recognizes EMS providers and appreciates and respects their role.
“That does not go unnoticed,” Jerjen says.
Another way providers who work with Crouse constantly learn and improve is through feedback about stroke patient outcomes. Oksana Kaskov, Crouse Neuroscience Institute Stroke Coordinator, makes posters highlighting their success stories to all EMS providers who come into the ED, as well as physicians and nurses, emphasizing the critical role EMS plays in the delivery of life-saving care. The posters include photos of the patient’s imaging, showing pre- and post-intervention for a clot and showing post-reperfusion imaging.
“It creates a good rapport between EMS and the physicians, which ultimately benefits the patients at Crouse,” Jerjen says.
Patients who came to the hospital in an ambulance with severe, potentially life-altering deficits, and who are able to walk out of the hospital after treatment,are certainly rewarding cases of which the entire collaborative team can be proud.
Enhanced Communication through Artificial Intelligence
Crouse is one of only five in the state with access to the cloud-based Viz.ai software. This app can be used on a smartphone and provides communication that allows for sharing of CT images with the neuroscience and stroke team. Within moments of a patient receiving a CT scan, the crystal-clear image is available and the team can message each other about the patient’s care through HIPAA-compliant software. Image sharing previously took much longer because it required access to a computer.
“It’s not just the PA and the surgeon communicating,” Dr. Padalino says. “It’s the PA, the neurosurgeon, the neurologist, the neuro interventional team and the emergency services team. We are all on the same page regarding the patient’s plan of treatment.”
With stroke care, imaging is a significant part of finding and removing the clot, so having advanced imaging, perfusion studies and angiograms available for the neurosurgeon at a moment’s notice is invaluable. Algorithms within the software’s programming read the images and flag the team if the patient is someone who would benefit from endovascular therapy and stroke rescue.
“We still have to train, so we don’t rely solely on the AI software,” Dr. Padalino says. “Programmers are using a national database of images from those who use this software to train the computer to recognize when it sees a problem that needs immediate intervention.”
Secure communication has long been problematic among providers. The benefit of having a HIPAA-compliant system in which patient names, ages and medical record numbers can be disclosed, is that everyone involved in the communication can be sure they are referring to the same patient, leaving less room for error. Before, providers had to make phone calls or encrypt their conversations. This platform has provided the ability to communicate securely with the team, allowing everyone to be on the same page while saving valuable time.
A Reflection on 2020
During the COVID-19 pandemic, healthcare workers around the globe were suddenly faced with an unprecedented challenge.
For David Mason, MD, FACEP, Medical Director and Chief of Emergency Services at Crouse Health, 2020 was a challenging year. Reflecting on the past 12 months, he is grateful for how the healthcare providers came together to support each other in caring for the community.
The staff at Crouse implemented safety protocols long before they were mandated, and there was a significant effort to minimize exposure to other patients, staff and EMS personnel who needed to be in contact with those patients.
“We are proud of our relationship with EMS,” says Seth Kronenberg, MD, Chief Operating Officer and Chief Medical Officer at Crouse Health.
Seth Kronenberg, MD, Chief Operating Officer and Chief Medical Officer at Crouse Health
“Ever since March, they have been on the frontlines — out in the field with no negative pressure rooms. The work they have done for our community is incredible, and we couldn’t be more thankful for the service they provide.”
The American College of Emergency Physicians was sending dozens of emails each day from physicians across the United States sharing their experiences. Dr. Mason and Crouse leadership assimilated lessons people were sharing from other parts of the country that had already been hit with the pandemic and tried to prepare as best as they could.
Telemedicine became invaluable for both providers and patients during 2020. Access to telemedicine exponentially increased in a short time, which helped keep people safe. In coming years, it could mean a long-term decrease in unplanned Emergency Department (ED) and urgent care visits, which could shift the landscape of urgent and emergent care.
“Crouse has done a phenomenal job managing the COVID crisis,” says Sarah Jerjen, paramedic with Fayetteville Fire & EMS, Greater Baldwinsville Ambulance Corps and American Medical Response. “They were one of the first hospitals that asked for a pre-arrival notification for anyone exhibiting COVID-19 symptoms, and they opened their doors to COVID patients from other city hospitals.”
The ED is one of the safest places to be during the pandemic, according to Dr. Mason. With stringent infection control practices and visitation policies in place, nothing is more important at Crouse than the safety of patients and staff. Heart attacks and strokes are time sensitive, so it is critically important for patients to not miss windows for lifesaving care.
“Healthcare workers all share a mission, and that is to do the best we can for patients and to help alleviate suffering,” Dr. Mason says. “Whether it’s this pandemic or the opioid crisis, wherever it is, we’ll always be here to support each other and our community.”