Our Team-based Approach to Neuroscience Care

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1 A Publication for Physicians of Holy Cross Hospital Summer 2013 Our Team-based Approach to Neuroscience Care Surgical Expertise page 3 Comprehensive Epilepsy Care page 6 State-of-the-Art Interventional Neuroradiology page 8 Nationally Designated Primary Stroke Center page 10 Clinical Support and Services page 13

2 A Message from Blair Eig, MD Chief Medical Officer, Holy Cross Health Talk to the members of Holy Cross Hospital s neuroscience program and they ll tell you that the foundation of the hospital s successful neuroscience services is teamwork. At Holy Cross Hospital, neuroscience specialists work together to plan the best possible treatment for your patients. The program also boasts dedicated support by specially trained nurses, nurse practitioners and physician assistants who care exclusively for neuroscience patients. Our team of experts in a range of neuroscience-related specialties have come together to offer the best treatment options using the latest technology to provide brain and spine care. Patients at Holy Cross Hospital benefit from access to our in-depth, team-based neuroscience services with a variety of hospital resources for consultation and collaboration, ensuring the best therapy options for each patient. Our experienced neurosurgeons offer specialized treatment options for an array of complex disorders of the brain. And the team of experts in the Neuro Critical Care Unit provides around-the-clock patient assessment and monitoring, connecting with experts from across the country as needed through the technology of virtual care. Read more about Holy Cross Hospital s neurosurgery services on page 3. Holy Cross Hospital also is home to a state-of-the-art spine care program that offers treatment options for back and neck problems. The program features the latest technologies that allow our experienced physicians to identify and diagnose problems. The spine care team also is actively involved in training surgeons from around the world in the latest minimally invasive back and neck surgery techniques at Holy Cross Hospital s GATE Institute. And the spine program also supports the hospital s geriatric program, helping to care for patients with age-related spine problems. Holy Cross Hospital s Epilepsy Center, which is unique for a community hospital, offers a comprehensive diagnostic and treatment service that is among the nation s most sophisticated for patients with seizure disorders. The center combines the expertise of epileptologists, a dedicated Epilepsy Monitoring Unit and surgical treatment options to provide the best possible outcomes for patients. Learn more about the hospital s epilepsy services on page 6. Holy Cross Hospital also has aneurysm specialists who are on hand to provide progressive treatments for patients suffering from a brain aneurysm. The hospital is one of just a few medical centers in the Washington, D.C., area that offers the most sophisticated minimally invasive therapies. Our advanced interventional neuroradiology program features sophisticated diagnostic neuroradiology tools and advanced treatment techniques in interventional radiology, which allows patients to avoid higher-risk, open surgeries. See page 8 for more information on interventional neuroradiology at Holy Cross Hospital. In addition, Holy Cross Hospital provides evaluation and treatment of patients suffering from degenerative central nervous system illnesses, such as Parkinson s disease and Alzheimer s disease. Lastly, Holy Cross Hospital is designated a Primary Stroke Center by The Joint Commission and by the Maryland Institute for Emergency Medical Services Systems. The hospital s stroke program also recently received the American Stroke Association s Get With The Guidelines Stroke Gold Performance Achievement Award, meaning the goal of 85 percent or higher adherence to a number of core standard levels of care was met for 24 consecutive months. Read more about Holy Cross Hospital s stroke services on page 10. Some of the brightest minds in neuroscience care are right here at Holy Cross Hospital. We offer expert brain care, specialized treatment for a range of complex disorders of the brain, state-of-the-art spine care, a comprehensive Epilepsy Center, precise diagnostics, experienced surgeons in minimally invasive procedures, a nationally designated primary stroke center and so much more. Please read more about what we offer in this special edition of Physician News devoted exclusively to Holy Cross Hospital s neuroscience program. Page 2

3 Surgical Expertise for the Brain and Spine Few community hospitals are fortunate enough to provide the array of neurosurgery procedures that Holy Cross Hospital offers the community. Even more notable is the expertise and reputation of the hospital s neurosurgeons. Zachary Levine, MD, medical director of Neurosurgery, is a prominent member of the neurosurgery community and is especially well known for his surgical innovations for patients with movement disorders. His colleagues are equally impressive. Amin Amini, MD, joined Holy Cross Hospital five years ago and has worked tirelessly to build the hospital s neuroscience program. His specialties are treatment of complex brain tumors and pituitary tumors, routinely using minimally invasive techniques. Philip Schneider, MD, is a respected orthopedic surgeon who works closely with neurosurgeons to offer The brain and spine surgeons at Holy Cross Hospital provide specialized treatment for a range of complex neurological disorders. Pictured left to right: Philip Schneider, MD, medical director, Spine Center; Jeff Jacobson, MD, Neurosurgery; Amin Amini, MD, Neurosurgery; Zachary Levine, MD, medical director, Neurosurgery; Frederic Schwartz, MD, Neurosurgery. optimal solutions to patients with spinal disorders. Fredric Schwartz, MD, has some 30 years of experience in neurosurgery at Holy Cross Hospital. Holy Cross Hospital offers the full gamut of neuroscience procedures, from endovascular treatment to functional neurology procedures to surgical treatment of brain tumors, spinal tumors and degenerative spinal disease, Dr. Levine says. We have a very high level of service on par with any academic medical center. Dr. Amini wholeheartedly agrees. We have all the capabilities here that larger hospitals do, he notes. Referring physicians should feel comfortable bringing their patients here for state-ofthe-art care in their own community. What s different about Holy Cross Hospital is the level of collegiality among team members. Subspecialists, physician assistants (PAs), nurse practitioners (NPs) and nurses work as a team to offer personalized, integrated care. We are capable of handling anything that comes our way. From the top of the skull to the top of the pelvis, we have experience in every area of neurosurgery. Zachary Levine, MD Medical Director, Neurosurgery Everyone at Holy Cross Hospital is approachable and team-oriented, Dr. Levine says. We re used to working together. There s a continuity of care here that provides the best outcomes for our patients. Holy Cross Hospital offers patients a full array of neurosurgery procedures to treat any neurologic condition. Continued on page 4 Page 3

4 Surgical Expertise for the Brain and Spine Continued from page 3 Neurologic Disease Patients who suffer from such disorders as Parkinson s disease, essential tremor and dystonia used to have to make do with medical management. Dr. Levine is among the first to offer a surgical approach that dramatically improves the lives of these patients. Deep brain stimulation (DBS) is a neurosurgical procedure in which the neurosurgeon places electrodes on the portion of the brain responsible for the disorder. Then, when the neurosurgeon provides stimulation to that area, you can see the tremor stop right then and there, Dr. Levine says. After the tremors have ceased, the electrode is left in place and then, a week later, the neurosurgeon implants a battery pack that contains a computer chip programmed to halt impending tremors on a permanent basis. It s basically like a brain pacemaker, he explains. Dr. Levine has been involved with the development and innovation of DBS and collaborates with the National Institutes of Health. He has performed over 500 DBS procedures in the past 13 years. This is a low-risk, high-yield procedure, he says. Although it does not stop or slow disease progression, it decreases symptoms of the disease and the patient s need for medication, and reduces the medication s side effects. Patients see their neurosurgeon daily. It s very patient focused and much more personalized than at many academic centers. Amin Amini, MD Neurosurgery Epilepsy is another neurologic disease that can benefit from a surgical approach. For patients who do not respond to medical treatment, neurosurgery may be an option. For patients with disabling seizures that arise from a single focal point within the brain, surgical resection can be a cure, Dr. Amini says. We remove the area that is causing the seizure and the seizures stop. Another surgical option is to implant a vagal nerve stimulator that sends electrical pulses to the brain to reduce seizure activity. Aneurysm and AVM Repair Neurosurgeons work closely with an interventional neuroradiologist to repair aneurysms and arteriovenous malformations (AVMs). Many aneurysms and AVMs benefit from an endovascular approach. Additionally, refined microsurgical techniques enable neurosurgeons to remove or clip small, accessible lesions with very low risk to the patient. Neuro-Oncology A collaborative approach characterizes Holy Cross Hospital s approach to neurooncology. Neurosurgeons work closely with medical and radiation oncologists to devise and implement optimal treatment for each patient. The team treats patients with malignant conditions including gliomas, meningiomas, pituitary tumors, and metastatic tumors to the brain or spine. The hospital s Novalis radiosurgery system enables the team to offer highly targeted minimally invasive surgery when indicated. Other patients benefit from embolization of tumors. Dr. Amini specializes in complex brain tumors that require a painstaking approach to removing the entire tumor. Close personal attention can make the critical difference to outcomes, he notes. Patients see their neurosurgeon daily. It s very patient focused and much more personalized than at many academic centers. What makes us different is the teamwork, Dr. Levine adds. We have regular neuro-oncology conferences, where we talk about cases and confer about the best treatment approaches. Spine Surgery Neurosurgeons and orthopedic surgeons with the hospital s Spine Center collaborate to bring patients optimal results with maximum safety. The Spine Center also has well-trained spine-care ortho PAs who manage the center s patients. Minimally invasive surgery is the common approach now, says spine surgeon Philip Schneider, MD, medical director of the Spine Center. We have helped develop techniques and train other surgeons how to do these procedures. Procedures include surgery to repair degenerative spine disease and fractures and to reconstruct and stabilize the spine. Dr. Schwartz also is involved with the repair of cervical disk and lumbar disc herniation, as well as tumors of the spine. We look at our data a lot. There are many ways to measure quality. Compared to national and state benchmarks, we are doing better with fewer readmissions and fewer infections, Dr. Schneider adds. Neurosurgery Emergencies Holy Cross Hospital has the expertise to manage any neurosurgical emergency. Specially trained PAs are in house 24/7 to tend to critical patients in the Emergency Center and throughout the hospital. Neurosurgeons are on call 24/7 for an emergent trip to the OR. We are capable of handling anything that comes our way, Dr. Levine concludes. From the top of the skull to the top of the pelvis, we have experience in every area of neurosurgery. To find out more about Holy Cross Hospital s neurosurgical services, contact Julie Nenichka-Reed, RN, BSN, neuroscience program coordinator, at neuroscience@holycrosshealth.org. Page 4

5 Meet Our Team Amin Amini, MD Neurosurgery Dr. Amini has practiced neurosurgery for five years at Holy Cross Hospital and served as medical director of neurosurgery from 2008 to He is currently the chair of the neurosurgery subsection of the department of Surgery. Dr. Amini graduated from the Medical College of Virginia and completed his neurosurgery residency at the University of Utah School of Medicine, where he was chief resident. He joined Holy Cross Hospital because of his longstanding ties to the region and his belief in the hospital s mission to provide state-of-the art care to the community. His special interests include neuro-oncology, spinal conditions and general neurosurgery. He accepts referrals for patients with any brain or spine-related condition that may require neurosurgery. Zachary Levine, MD Medical Director, Neurosurgery Dr. Levine joined Holy Cross Hospital in 2012 as medical director of neurosurgery. He has 13 years of experience as a neurosurgeon and has extensive training and experience with brain tumors and spinal surgery. He graduated from New York University School of Medicine, and completed an internship in general surgery followed by a residency in neurological surgery at George Washington University Medical Center, where he served as chief resident. Dr. Levine co-developed the Levine-Sekhar Grading system, which is used to determine the ability to resect complex tumors. His special interest is deep brain stimulation surgery for Parkinson s disease and other movement disorders, and he has published, spoken and taught widely on the subject. He accepts referrals for all kinds of neurosurgical patients, especially those with movement disorders. Philip Schneider, MD Medical Director, Spine Center Dr. Schneider has practiced orthopedic surgery for nearly 25 years. He completed medical school at Howard University College of Medicine, followed by a combined residency at Howard University Hospital, Children s National Medical Center, VA Medical Center, Providence Hospital and D.C. General Hospital. He then completed fellowship training at the Hospital for Joint Diseases in New York City. He joined Holy Cross Hospital because of its reputation for excellence and its patient-centered approach. Dr. Schneider has a special interest in minimally invasive spine surgery and teaches other surgeons how to perform the newest techniques. He accepts patients with any type of spinal condition and operates only when more conservative treatment methods fail to provide relief. Fredric Schwartz, MD Neurosurgery Dr. Schwartz has practiced neurosurgery at Holy Cross Hospital since 1979, and has high praise for its strong neuroscience program. He graduated from George Washington University School of Medicine, where he also completed his neurosurgery residency. His areas of interest are brain tumors, and cervical disc and lumbar disk herniation. He accepts referrals of all neurosurgery patients. Expert brain care also is offered by the following neurosurgeons: Sidhartha Chandela, MD Jeff Jacobson, MD James Leiphart, MD Malini Narayanan, MD Michael Rosner, MD Donald Wright, MD Page 5

6 Comprehensive Epilepsy Center Offers Specialized Diagnosis and Treatment Epilepsy is a condition that is feared by patients and hard to manage for physicians. Seizures can be difficult to predict or control, and side effects of medications can be as bad as the disorder, if they work at all. Holy Cross Hospital is fortunate to have the services of an epileptologist, Gregory Mathews, MD, who joined the hospital in Dr. Mathews is a neurologist with fellowship training in the management of epilepsy and other seizure disorders. Epilepsy is a very common diagnosis, Dr. Mathews says, and these patients can be very complex to manage. Holy Cross Hospital is the only hospital in Montgomery County to offer a specialized epilepsy program. Studies show that patients who are cared for by an epileptologist fare better than those under less specialized care, Dr. Mathews notes. We work very closely with neurologists and neurosurgeons to provide the best services for each patient. Quality of life is a common goal of everyone involved in this program. Gregory Mathews, MD Medical Director, EEG Monitoring Seizures The first step is to accurately diagnose the condition and focal point of seizures. To that end, Holy Cross Hospital has an Epilepsy Monitoring Unit that consists of four sets of monitoring systems that can be moved to the neuro unit or the Neuro Critical Care Unit (NCCU) as needed. This is a flexible system with portable machines that can go into any patient care room, Dr. Mathews says. Specially trained nurses and technicians support all monitoring units. The equipment consists of continuous EEG, a video recording system and an alarm to notify nurses when the patient is having a seizure. The intent is to record brain activity continuously for a period of 48 to 72 hours in order to identify the focal point of seizures. The data is monitored remotely by a telemetry technician, who notifies nurses when seizures are occurring. All nurses in the neuro and neuro critical care units are trained to care for patients having seizures. Monitoring may be indicated for patients with frequent episodes that are not well controlled by medications, Dr. Mathews says. Three categories of patients undergo monitoring: patients admitted specifically for monitoring patients who are hospitalized for other reasons but who have a seizure during hospitalization patients with seizure disorders who begin to seize acutely during their hospitalization Dr. Mathews reviews the data to make a diagnosis. I can actually view what the seizure looks like on video and telemetry, so I can get a visual and electrical correlation, he explains. Medical Management If we are able to capture the pattern of seizure activity, Dr. Mathews says, it allows us to develop an individualized care plan for each patient. Using this information along with the results of imaging studies, he can devise the best treatment approach. After identifying the condition, Dr. Mathews narrows down the treatment options. Sometimes patients have both epileptic and non-epileptic seizures, he notes. A significant percentage of patients turn out to have psychogenic seizures, with no EEG changes. This is a very important diagnosis to make, he says. As for seizure medications, There are always innovations, with many more medications in the pipeline, Dr. Mathews notes. Unfortunately, none of these medicines have proven to be superior to the older medications. Other options include access to clinical trials or a ketogenic diet. Holy Cross Hospital Epilepsy Monitoring Unit Designated Level 3 Epilepsy Center The National Association of Epilepsy Centers (NAEC) recently designated the Holy Cross Hospital Epilepsy Monitoring Unit as a Level 3 Epilepsy Center. Level 3 epilepsy centers have the professional expertise and facilities to provide high-level medical evaluation and treatment for patients with complex epilepsy. NAEC developed levels of care for epilepsy for use in evaluating the appropriateness and quality of epilepsy care. NAEC designation as a specialized epilepsy center means that Holy Cross Hospital not only provides routine care to individuals with seizures or epilepsy, but also specializes in providing comprehensive diagnostic and treatment services to individuals with uncontrolled seizures. The Epilepsy Monitoring Unit at Holy Cross Hospital is equipped with state-of-the-art technology to help seizure experts monitor and evaluate patients effectively. Holy Cross Hospital s Epilepsy Center combines the expertise of epileptologists, a dedicated Epilepsy Monitoring Unit and surgical treatment options to provide the best possible outcomes and sometimes a cure for patients. Page 6

7 Many patients respond well to medications and lead a seizure-free, normal life. Still, we look for minimal side effects; we re always tweaking and optimizing medications. We hope for the best possible outcome no seizures and no side effects. Holy Cross Hospital is the only hospital in Montgomery County to offer a specialized epilepsy program. Surgical Options Patients who have not responded to medical management may be candidates for epilepsy surgery. This is particularly true for patients whose seizure activity arises from a single place in the brain. Surgical treatment is the only cure for epilepsy. We select patients who have the highest chance of success with the lowest risk for recurrence, Dr. Mathews says. Surgical options include removing the part of the brain where the seizures initiate, such as temporal lobectomy, thereby eliminating the seizures and curing the patient of the condition. Gregory Mathews, MD Medical Director, EEG Dr. Mathews joined Holy Cross Hospital three years ago to supplement the hospital s epilepsy services. A boardcertified epileptologist, he completed medical school at Washington University School of Medicine in St. Louis, followed by a neurology residency and epilepsy fellowship, both at Johns Hopkins Hospital in Baltimore. His area of expertise is epilepsy, and he performs electroencephalograms (EEGs), video-eeg monitoring, presurgical evaluation for epilepsy surgery, and manages complicated epilepsy patients. Dr. Mathews is committed to improving the quality of life for patients with epilepsy and welcomes referrals of any patient with seizures or suspected seizures. Split brain surgery is another option; neurosurgeons divide the corpus callosum, which stops seizures from spreading to both sides of the brain. In another option, neurosurgeons implant a vagal nerve stimulator that sends electrical pulses to the brain to reduce seizure activity. Collaboration Holy Cross Hospital s collaborative approach to epilepsy care creates a program that is greater than the sum of its parts. We work very closely with neurologists and neurosurgeons to provide the best services for each patient. Quality of life is a common goal of everyone involved in this program, Dr. Mathews says. We aim to make a dramatic difference in patients lives. We want to make their lives better. We re able to reach that goal with just about every patient. For more information on Holy Cross Hospital s Epilepsy Center, visit Page 7

8 State-of-the-Art Interventional Neuroradiology To offer a truly comprehensive array of treatment options to neuroscience patients, a hospital must have an interventional neuroradiologist on staff. Holy Cross Hospital is fortunate to have the expert services of James Jaffe, MD, who joined the medical staff in The field of interventional neuroradiology also called neurointerventional surgery has been growing rapidly in recent years. Training includes completion of a residency in radiology, neurosurgery or radiology, plus a neurointerventional fellowship that can last up to three years. What I ve found at Holy Cross Hospital is that everybody is behind the neuroscience program, Dr. Jaffe says. It s a real team effort that includes neurologists and neurosurgeons. There also is a physician assistant (PA) dedicated to interventional neuroradiology. We offer all the neurointerventional procedures that any large hospital offers, Dr. Jaffe continues. The difference is that this is a tight-knit team of subspecialists who work together very closely. Many neurointerventional procedures take the place of a craniotomy. The much less invasive transcatheter approach yields the same results with faster recovery. Biplane angiography is a cornerstone of the program. This technology provides a three-dimensional view of brain vessels so Dr. Jaffe can precisely pinpoint the abnormality that needs treatment. We have patients who come in here who can barely walk and, after the procedure, they leave pain-free. James Jaffe, MD Medical Director, Interventional Neuroradiology Page 8

9 Aneurysms For patients with an aneurysm, Dr. Jaffe threads a catheter from the femoral artery through the neck and into the brain to the site of the aneurysm. For a ruptured aneurysm, he places a coil that seals off the vessel to stem bleeding. For an unruptured aneurysm, a stent is placed over the opening to divert blood flow away from the site, allowing the aneurysm to naturally thrombose. A common complication for patients with aneurysms is vasospasm, which carries a significant risk of stroke or death. To combat this often-devastating complication, Dr. Jaffe threads a balloon James Jaffe, MD Medical Director, Interventional Neuroradiology Dr. Jaffe completed training as an interventional neuroradiologist 10 years ago. A graduate of Temple University School of Medicine in Philadelphia, he completed an internal medicine internship at Albert Einstein Hospital and a residency in diagnostic radiology at Temple University Hospital, followed by subspecialty training in angiography/interventional radiology at Temple and a fellowship in neuroradiology at the University of Pennsylvania Health System, all in Philadelphia. into the site to vasodilate the vessel, thereby restoring blood flow. Clots For patients who suffer an ischemic stroke, there are several treatment options. Intra-arterial tpa is a brain saver for some patients. The intraarterial approach can be more effective than intravenous tpa and has a longer treatment window. Other techniques provide ways to remove a clot after the tpa window has closed. The Penumbra device enables Dr. Jaffe to separate the clot from the arterial wall and aspirate out the debris. Alternatively, the Solitaire revascularization device allows him to retrieve a clot using a stent, which allows him to reopen the artery and then remove the clot. To prevent a stroke, a stent can be placed in a blocked carotid artery to open the vessel. Similarly, for patients with recurrent intracranial strokes, the stenosis can be treated with a stent. AVMs For patients with arteriovenous malformations or dural arterial venous fistulae, a liquid plastic is placed into the site and forms a cast to block off the abnormality. Tumors For patients with certain brain tumors, a microcatheter can be used to inject a liquid plastic to embolize the tumor, cutting off blood supply and effectively killing the tumor. Spinal Compression Interventional neuroradiology also offers an invaluable treatment option for patients with vertebral compression fractures. To perform the procedure, called kyphoplasty, two needles are placed into the vertebral body and a balloon is inflated to restore the vertebra to its correct height. The balloon is then removed and cement is inserted to hold the vertebra in place. We offer all the neurointerventional procedures that any large hospital offers. The difference is that this is a tight-knit team of subspecialists who work together very closely. James Jaffe, MD Medical Director, Interventional Neuroradiology This can relieve pain dramatically, Dr. Jaffe notes. We have patients who come in here who can barely walk and, after the procedure, they leave pain-free. These interventional procedures have made a dramatic difference in the treatment of many brain disorders that used to require invasive surgery. Working with the neurosurgeons, we can do just about anything, Dr. Jaffe concludes. Dr. Jaffe joined Holy Cross Hospital in 2012, drawn by the hospital s commitment to its neuroscience program. He works closely with the hospital s neurologists and neurosurgeons to employ interventional neuroradiology procedures to treat a variety of conditions. For more information about Holy Cross Hospital s interventional neuroradiology services, contact Julie Nenichka-Reed, RN, BSN, neuroscience program coordinator, at neurosciences@holycrosshealth.org. Page 9

10 Nationally Designated Primary Stroke Center Delivers Award-Winning Stroke Care Holy Cross Hospital is home to one of the area s most acclaimed stroke programs. This bold statement is backed up by its designation as a Primary Stroke Center by both The Joint Commission and the Maryland Institute for Emergency Medical Services Systems (MIEMMS). Both certifications attest to the hospital s ability to provide timely care by a team of experts, says Sharon Harriston, RN, MS, ACNP, CCNS, coordinator of the stroke program. Holy Cross Hospital also has been awarded the Gold Plus Award by the American Heart Association/American Stroke Association for the last three years. This honor is accorded to stroke programs that comply more than 85 percent of the time with set criteria that monitors the administration of medications, the provision of therapies and the education of patients. Holy Cross Hospital was listed in the prestigious U.S.News & World Report Best Hospitals issue for this achievement. Working as a team helps us provide all the resources we need and the best care we can deliver. Our stroke team really cares about our patients. - Shahid Rafiq, MD Medical Director, Neurology and Stroke Holy Cross Hospital cares for almost 500 stroke patients each year. The hospital also ranks high on the list of hospitals Holy Cross Hospital Stroke Program Awarded the American Heart Association s Gold Plus Award This spring, the Holy Cross Hospital Stroke Program received the American Heart Association s Gold Plus Award. The Gold Plus Award is an advanced level of recognition that acknowledges Holy Cross Hospital s compliance with the Quality Measures within the Get With The Guidelines Stroke Program. Get With The Guidelines Stroke is an in-hospital program for improving stroke care by promoting consistent adherence to the latest scientific treatment guidelines. The American Heart Association and American Stroke Association recognize hospitals for their success in using Get With The Guidelines to improve quality of care for heart disease and stroke patients. Holy Cross Hospital is listed as a Recognized Hospital for the Gold Plus designation on the American Heart Association s website, Pictured left to right: Shashi Dudi, data abstractor, Performance Improvement, Holy Cross Hospital; Cris Carr, RN, director, Process Improvement, Holy Cross Hospital; Celia Guarino, RN, chief nursing officer, Holy Cross Hospital; Jeffrey Bell, director of Development, Heart Walk-GWR, American Heart/Stroke Association; Judith Rogers, president, Holy Cross Hospital; Andrew Barbash, MD, Neurology, Holy Cross Hospital; Sharon Harriston, RN, MS, ACNP, CCNS, nurse practitioner, Neuroscience, Holy Cross Hospital. Page 10

11 Shahid Rafiq, MD Medical Director, Neurology and Stroke Dr. Rafiq recently joined Holy Cross Hospital this summer. He is board certified in neurology, vascular neurology (stroke) and sleep medicine. Dr. Rafiq received his training in neurology from Seton Hall University, Neuroscience Institute in New Jersey. He completed his fellowship in clinical neurophysiology at the University of Texas, Health Science Center. Before coming to United States, Dr. Rafiq first practiced medicine in Pakistan and South Africa. Dr. Rafiq joined Holy Cross Hospital because the hospital is leading the way in neuroscience and he was excited to support the effort to be a center of excellence. In addition to his areas of expertise in stroke and sleep, Dr. Rafiq is also interested in dementia and memory disorders, and migraines and headaches. to administer tpa, the life-saving clotbuster. More than 15 percent of all stroke patients admitted to Holy Cross Hospital receive tpa. There is a level of consistency here in how families are engaged with specialists that is quite unique, says Andrew Barbash, MD, a neurologist who has served as medical director of the stroke program. All the pieces are working in a collaborative mode. If the goal is to positively impact the population, Holy Cross Hospital is doing that. Shahid Rafiq, MD, also a neurologist, recently assumed leadership of the neurology and stroke program at Holy Cross Hospital. I ve been impressed with how everyone works really closely as team, he says. The care is very personalized. Here are some of the reasons why Holy Cross Hospital s Stroke Program stands out: Team of Experts Holy Cross Hospital benefits from the services of neuoradiologists, neurologists, an interventional neuroradiologist, neurosurgeons and a physiatrist who Continued on page 12 Lana Rigby, MD Physical Medicine and Rehabilitation Dr. Rigby has practiced for eight years as a physical medicine and rehabilitation (PM&R) specialist. She graduated from the University of Maryland School of Medicine in Baltimore, and completed a residency in PM&R at the National Rehabilitation Hospital/ Georgetown University Hospital in Washington, D.C. Her areas of interest are neurorehabilitation for patients with strokes and acquired brain injuries, and early mobility in the ICU setting. Dr. Rigby was attracted to Holy Cross Hospital by its teamwork approach toward seamless patient care. She provides consultation on the acute care of inpatients with neurological and musculoskeletal disorders. Page 11

12 Nationally Designated Primary Stroke Center Delivers Award-Winning Stroke Care Continued from page 11 Andrew Barbash, MD Neurology Dr. Barbash has 28 years of experience and first joined the medical staff of Holy Cross Hospital as a Kaiser Permanente physician. He completed medical school at the Feinberg School of Medicine at Northwestern University in Chicago and a residency in neurology at the Mayo Clinic in Minnesota. He joined Holy Cross Hospital because he appreciates the hospital s community focus and congenial working environment. Dr. Barbash s special interests are stroke, neurocritical care and teleradiology. He has been a leader in the application of new technology to the practice of neurology. He is available for consultation on stroke patients. work together to diagnose and treat stroke patients. They are supported by a specially trained team of physician assistants (PAs); nurse practitioners (NPs); physical, occupational and speech therapists; and highly skilled nurses. Fast Response The hospital has a Rapid Response Team in place to quickly identify potential stroke patients. A triage nurse alerts the medical team to a potential stroke, and the patient is brought into the Emergency Center (EC) for rapid evaluation. The EC has its own CT scanner, and an MRI is down the hall. A neuroradiologist interprets the images and confers with the emergency physician and neurologist to diagnose patients quickly. Virtual Consultations Holy Cross Hospital is among the first hospitals anywhere to implement a virtual consultation program. Developed by neurologist Andrew Barbash, MD, a virtual consult works like this: the emergency physician contacts the neurologist on call, who then can meet the patient and family online via smart phone or computer, view the images with the neuroradiologist, and then confirm the diagnosis of stroke. This rapid response allows fast administration of tpa, which can stop the stroke in its tracks. (NCCU) for observation and further treatment. Stroke-trained NPs work with neurologists to manage care. The physiatrist visits the patient and begins to formulate a rehabilitation program. After the critical period is over, the patient is then transferred to a 28-bed neuro unit. Full Array of Treatment Modalities When tpa is indicated, it is administered intravenously within two to three hours of the stroke onset. The interventional neuroradiologist can administer intraarterial tpa well beyond the three-hour window. For ischemic strokes, the interventional neuroradiologist can extract or suction a clot. For bleeds, the interventional neuroradiologist can insert a coil into an aneurysm to seal it off. Neurosurgeons are on hand to treat subarachnoid hemorrhages and other surgical emergencies. Focus on Education and Rehabilitation Holy Cross Hospital has a full-time physiatrist to tend to stroke patients. Beginning with a visit early in the patient s hospital stay, the physiatrist assesses the patient s needs, develops a functional recovery program, and institutes a rehabilitation program with physical, occupational and speech therapists. Early intervention improves functional outcomes, says Lana Rigby, MD, stroke physiatrist. Our intent is to avoid complications, maximize recovery and decrease stroke recurrence. We also educate patients and families about what to expect during rehab and recovery. Holy Cross Hospital is among the first hospitals anywhere to implement a virtual consultation program. Rehabilitation begins in the hospital, and then the hospital s social worker and case manager work with each patient to identify a rehabilitation facility or outpatient rehabilitation program as needed. Stroke patients also may enroll in a support group at Holy Cross Hospital to help them adjust to life after a stroke. We see some remarkable results and patients are very grateful, said Harriston. That makes our day. Dr. Rafiq adds, Working as a team helps us provide all the resources we need and the best care we can deliver. Our stroke team really cares about our patients. Dedicated Stroke Units Stroke patients are admitted to the hospital s Neuro Critical Care Unit For more information on Holy Cross Hospital s stroke program, visit Page 12

13 Invaluable Clinical Support and Services It takes more than an expert team of physicians to constitute an outstanding neuroscience program. Holy Cross Hospital knows that, and has acquired all the necessary technologies, configured the optimal facilities and, most importantly, assembled and trained the ancillary staff to deliver expert care in a patient-centered environment. The continuum of care begins with a patient s initial presentation and continues through recovery. Diagnostic Excellence Neuroimaging is critical for determining a precise diagnosis. Holy Cross Hospital has three neuroradiologists on its medical staff. This is unusual for a community hospital, says Anil Narang, DO, neuroradiologist. It shows the hospital s commitment to our neuroscience program. These fellowship-trained neuroradiologists are an essential part of the care team, focusing on the evaluation of abnormalities of the central and peripheral nervous system, spine, head and neck. They work closely with other neuroscience specialists. Continued on page 14 Anil Narang, DO Neuroradiology Dr. Narang has 26 years of experience as a neuroradiologist and is chair of the neuroradiology subsection for the department of Radiology. Dr. Narang joined Holy Cross Hospital due to its commitment to neuroscience. He completed medical school at Des Moines University in Iowa, followed by a residency at Howard University Hospital and a neuroradiology fellowship at George Washington University Hospital. His expertise is the application of technology to diagnose complex neurological problems, with a special interest in spinal disorders. Dr. Narang welcomes referrals of patients who need specialized diagnosis of spinal disorders, especially for minimally invasive treatment of back pain and compression fractures. Sameer Pandit, MD Neuroradiology Dr. Pandit has 17 years of experience as a diagnostic radiologist of which he has worked 10 years as a neuroradiologist. His other areas of interest are breast imaging. He graduated from B.J. Medical College in Pune, India and completed his internship and residency at the Hospital of Saint Raphael in New Haven, Connecticut. Dr. Pandit joined Holy Cross Hospital because of the excellent patient care, experienced and compassionate staff and state-of-the-art equipment. He sees patients from the Holy Cross Hospital Emergency Center and other inpatients and outpatients. Dr. Pandit accepts referrals. Page 13

14 Invaluable Clinical Support and Services Continued from page 13 The hospital has made a strong effort to put together a multidisciplinary team, Dr. Narang continues. We interact on a regular basis so we know how each other thinks. Tools of the trade include CT and MRI scanning, and biplane angiography. The hospital has three CT scanners and an MRI scanner. We use CT in the acute setting to look for strokes and hemorrhages so we can triage patients, Dr. Narang says. MRI is available to provide better contrast resolution, which shows additional details in areas of concern. Biplane angiography provides an even more detailed view of the brain s vasculature. Physician Support After neuroscience specialists evaluate patients and develop treatment plans, they use an interdisciplinary team to help them carry out these plans. Physician assistants (PAs) play a major role in the hospital s neuroscience program. Holy Cross Hospital has five full-time PAs with special training in neuroscience. We re involved in all aspects of patient care, says Aleko Kimbouris, PA-C. PAs provide 24/7 coverage, including consults in the Emergency Center (EC), rounding on neuro patients, managing pre- and post-operative patients, serving as first assist in the Operating Room (OR) and managing neurointerventional patients pre- and post-procedure. They also routinely admit and discharge patients. The hospital has made a strong effort to put together a multidisciplinary team. We interact on a regular basis so we know how each other thinks. Anil Narang, DO, Neuroradiology Nurse practitioners are an equally important resource. Holy Cross Hospital has a nurse practitioner devoted exclusively to neuro patients. Physician assistants (PAs) play a major role in the hospital s neuroscience program. Holy Cross Hospital has five full-time PAs with special training in neuroscience. Pictured left to right: Samantha Tuttamore, PA-C; Alyssa Benning, PA-C; Aleko Kimbouris, PA-C; Sheila Rao, PA-C; and Theresa Bosanek, PA-C. Page 14

15 I m available to tend to stroke patients wherever they are, says Sharon Harriston, RN, MS, ACNP, CCNS, stroke coordinator. This includes the EC, the Neuro Critical Care Unit and the progressive care neuro unit. Nurses who work in the neuro units have specialized training. Nurses serve as our eyes and ears, says Shahid Rafiq, MD, medical director, Neurology and Stroke. Any neuroscience program is only as good as its nurses. Neurosurgeon Amin Amini, MD, has high praises for the hospital s PAs, NPs and nurses. I take a lot of pride in our staff, he says. All our staff members are trained in the care of neuro patients. They provide expert care. Patients and families are much more comfortable seeing the same faces throughout their stay. Last but not least, hospitalists work closely with neurologists and neurosurgeons to manage patients care. Many of our patients have comorbidities, Dr. Rafiq notes. It takes a team to care for these patients. Dedicated Facilities Holy Cross Hospital has dedicated space for the care of neurology and neurosurgery patients. The Neuro Critical Care Unit is a 16-bed unit equipped with advanced monitoring technology to tend to the needs of patients recovering from neurosurgery or complex, critical neurological disorders such as stroke, aneurysms, traumatic brain injuries, spinal cord infections, infections of the brain, seizures and brain tumors. This unit is staffed by critical care nurses and PAs who work closely with neurosurgeons, neurologists, and interventional neuroradiologists to manage patient care. A separate progressive care neuro unit has 28 specially equipped beds and is staffed to meet the needs of stroke and other neuroscience patients as they continue their recovery. NPs play a critical role in patient care. Physical, occupational and speech therapy begins at patients bedsides, provided by a highly skilled team of professionals. Nurse practitioner Sharon Harriston, RN, MS, ACNP, CCNS, and clinical nurse specialist Maranda Jackson, MS, CCRN, CRNP, are essential resources for the doctors and patients of the neurosciences program at Holy Cross Hospital. Advanced Technology Holy Cross Hospital has a Novalis radiosurgery system, which provides image-guided intraoperative navigation to treat brain lesions and disorders. Interventional neuroradiology devices include the Penumbra device that separates the clot from the arterial wall and allows aspiration of the debris. The Solitaire revascularization device allows clot retrieval by using a stent to reopen the artery and thereby enabling clot removal. Specially equipped ORs and an interventional neuroradiology suite are set up for the unique demands these specialized services require. Pain Management A team of anesthesiologists who specialize in pain management work closely with team members to evaluate and manage pain arising from neurologic sources. They treat patients with cervical and lumbar spinal disc disease and displacement, arthopathies, pain arising from cancer of the brain or spine, and pain as a result of spinal injury. The team makes effective use of the latest pain management approaches, including such delivery methods as drug pumps, skin patches, regional nerve blocks, spinal cord stimulator implants, and oral and intravenous pain medications. Physical therapy and psychotherapy provide additional relief for patients suffering from chronic pain. The hospital administration has made every effort to supply us with what we need for a first-class neuroscience program, said Zachary Levine, MD, medical director of Neurosurgery. Page 15

16 1500 Forest Glen Road Silver Spring, MD Presorted First Class U.S. Postage PAID Suburban, MD Permit No. 390 Physician News is a quarterly publication distributed by Holy Cross Hospital to members of the physician community. The goal of this newsletter is to communicate news of interest and disseminate relevant information to local physicians. Kevin J. Sexton, President and Chief Executive Officer, Holy Cross Health Judith Rogers, President, Holy Cross Hospital Blair Eig, MD, Chief Medical Officer, Holy Cross Health Elizabeth Dooley, Director, Marketing Nicole Leandro, Managing Editor To be added to the mailing list, leandn@holycrosshealth.org. Holy Cross Hospital is one of the largest hospitals in Maryland. Founded 50 years ago, today Holy Cross Hospital is a 443- bed, not-for-profit teaching hospital serving Montgomery and Prince George s counties and caring for more than 196,000 patients each year. This hospital is a member of Trinity Health of Novi, Mich., one of the largest health systems in the country. Meet Holy Cross Hospital s Neuroscience Program Coordinator Julie Nenichka-Reed, RN, BSN, neuroscience program coordinator at Holy Cross Hospital, is a graduate of the Georgetown University School of Nursing and is currently pursuing a Master of Science in Nursing and Healthcare Administration. Julie has 15 years of nursing experience of which 12 years are in the field of neuroscience. Her neuroscience experience has been obtained through a variety of hospital settings such as MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Sinai Hospital of Baltimore, several military hospitals, and now here at Holy Cross Hospital. Julie was attracted to the neuroscience program at Holy Cross Hospital because of the unique and exciting opportunity to help develop a program in a field that she loves. As your point of contact for neuroscience services at Holy Cross Hospital, Julie can answer all of your neuroscience-related programmatic questions. Julie can be reached at or neuroscience@holycrosshealth.org.