As the drama plays out on television, the Internet and in print media, what seems to be forgotten are the troops in the background—the dedicated doctors, nurses and other professionals who daily deliver the best care they can to meet the needs of their individual communities—a job that’s hard to do at any time, but that becomes even more difficult when under constant scrutiny by politicians and activists with partisan agendas.

Despite the barrage of negative stories about the state of America’s health care system, there’s good news to be reported, particularly in the North Bay, home to several outstanding hospitals and medical centers. Over the past couple of years, significant strides have been made to boost the level and quality of care in our area, using everything from new technology to carefully choreographed teamwork, according to top medical officials.

Good strokes for stroke care

The National Stroke Association (www.stroke.org) estimates that a stroke (“brain attack”) strikes someone in the United States every 45 seconds, making it the third leading cause of death in the country. And while strokes can be suffered at any age, the prime age group at risk is 60 and above. Since Marin, Napa and Sonoma counties are retirement havens with a “graying” population, stroke care has been a focus for all North Bay hospitals, but it’s on the front burner at three in particular: Kaiser Permanente Hospitals in Santa Rosa and San Rafael, and Healdsburg District Hospital in Healdsburg.

In 2008, Kaiser San Rafael became the first hospital in the North Bay to be certified as a Primary Stroke Center by the Joint Commission, an independent, not-for-profit organization that accredits and certifies hospitals and health care organizations in the United States (www.jointcommission.org). In December 2009, Kaiser Santa Rosa became the first hospital to be certified in Sonoma County, while Healdsburg District Hospital, which opened its Kozel Stroke Institute in January 2009, is currently working toward certification.

Dr. Monica C. Minguillon, chief of staff at Kaiser Santa Rosa, says the effort to upgrade stroke care in recent years “confirms our commitment to excellent care” in an era that’s seen new and improved methods of treating stroke victims.

“Several years ago, if you had a stroke, it was just too bad. We’d do what we could with limited options,” she explains. With the advent of new treatments, such as medications to break up blood clots, many more lives can be saved and potential stroke-caused physical disabilities can be limited or eliminated. “That spurred us to bring our services up to the highest standard of stroke care” throughout the Kaiser Permanente system, she says.

Dr. Jerry Schlegel is the chief of neurology and the medical director for the Primary Stroke Center at Kaiser San Rafael, which got its start as a coordinated stroke care program in 1996. “We’ve provided a leadership role in stroke care for Kaiser Permanente in Northern California, which has expanded coincident with major [stroke] care improvements,” he explains. “From the beginning, we took an integrated, multidisciplinary approach to patient care and built a culture with roots that are more programmatic, with more expertise. We did this long before we applied for certification by the Joint Commission.”

Both Kaiser Primary Stroke Centers address stroke care with a two-pronged effort—acute care for those stricken and prevention education for both the community in general and those individuals identified as high risk due to health issues such as hypertension and high cholesterol.

When a person is suffering a stroke, the first three hours—beginning with initial symptoms such as numbness, slurred speech and impaired vision—are the most critical, according to Minguillon. “The problem is that sometimes patients will experience the symptoms for an hour or two before seeking help,” she says, which then leaves the medical team precious little time to fully swing into action and begin actual treatment. That’s why a coordinated team approach is so important.

When the hospitals are first alerted by field medical personnel (first responders/emergency medical technicians) that a stroke patient is on the way, it’s all hands on board.

“The stroke team is notified, and everyone is involved immediately,” Schlegel says. When the patient arrives at the Emergency Department, specially trained personnel of the stroke team are on hand to provide immediate evaluation and treatment.

“Clot busters don’t work for everyone,” Minguillon points out. “It’s critical we have all the information we need to decide if it’s appropriate they be used or not.”

To do this, Kaiser relies on its new electronic medical record (EMR) system, “KP HealthConnect,” which provides critical medical history on each and every patient with the push of a button. “KP HealthConnect means we don’t have to count on our memory,” Minguillon says. “Whether the patient is there at 3 a.m. or 2 p.m., everyone has all the same information and the same approach to care.”

Building the culture for acute stroke care “literally requires the work of hundreds of people,” says Schlegel, who credits his team (with a special nod to Marie Kleinrock, RN and CNS, who championed a nurse education program at Kaiser San Rafael) for their outstanding ability to work simultaneously to deliver the best care for stroke patients.

Equally important is Kaiser’s commitment to community and patient education. Both hospitals have outreach programs to teach people to be alert to the warning signs of strokes, encouraging them to seek care immediately, and they also have an extensive follow-up program with Kaiser Permanente members if they exhibit risk factors.

“Even if you come here just to get glasses, we screen you by taking your blood pressure,” says Minguillon. “Primary prevention of stroke begins at a young age and has a lot to do with diet, exercise, cholesterol levels and hypertension.” When warning flags are raised, members are notified.

“I like to tell my patients that even if you don’t want us to, we will find you,” Minguillon laughs.

At Healdsburg District Hospital (HDH), stroke care is also a primary focus. In January 2009, the hospital opened the Kozel Stroke Institute, named for long-time Healdsburg residents Ed and Betty Kozel, who helped fund the center.

“We feel it’s an important service for our community and our region,” says Evan J. Rayner, North Sonoma County Healthcare District/Healdsburg District Hospital CEO. “Of the 58 counties in California, Sonoma County ranks highest in stroke mortality, largely due to the older age of the population and distance from health care institutions.”

As part of its program, HDH uses a remote presence robot, “which lets us access more specialists and adds depth to our Intensive Care Unit (ICU), emergency department and other departments’ coverage—something HDH pioneered in rural hospitals in California and the North Bay since 2007,” Rayner says. He describes it as a “five-foot-tall, 200-pound robot that looks like a mobile ATM machine.” Besides two-way audio/video communication with patients, it has picture archiving capabilities, EMR interface capabilities, provides real-time video and transmits echocardiograms and ultrasounds, among other things, which enables specialists worldwide to consult and weigh-in on individual cases.

Dr. David Tong, a neurologist with California Pacific Medical Center in San Francisco, and his team provide real-time patient consulting to HDH through the robot, via laptop and desktop connections.

Since the Kozel Institute opened, the hospital has treated upward of 50 stroke patients using the American Heart Association and American Stroke Association criteria. In October of last year, it earned its first award and moved one step closer to becoming certified “Getting with the Guidelines” by the American Stroke Association, a goal it hopes to attain over the next several months.

Robots rule

While Healdsburg District Hospital has its favorite robot, Queen of the Valley Hospital in Napa is using a da Vinci Surgical System robot, developed by Intuitive Surgical, Inc., to perform a variety of minimally invasive surgical procedures, including heart procedures, making it unique among North Bay hospitals.

The robot, which will soon have a name thanks to a community “name our robot” contest, is the second at Queen of the Valley, which bought its first surgical robot in 2002. The new and improved robot not only performs hysterectomies and prostatectomies, as in the past, but because it’s smaller, it’s perfect for cardiac, abdominal and thoracic procedures as well, according to Jaime Peñaherrera, director of marketing for the medical center.

“For cardiac procedures, the robot is a viable option because its ‘tiny hands’ access the heart between the ribs, which can eliminate complicated open-chest surgical procedures. It’s just much easier to navigate within the heart,” she says. “The robot’s ‘hands’ can be rotated 360 degrees, and there’s no danger of hand tremor. The 3D vision lets the surgeon gain greater visibility of the organs and tissue.”

The surgical robot also has many other benefits, not only for the patient, but for the hospital. “Incisions are very small—very often, only a Band-aid is needed to cover them—making procedures much less invasive,” Peñaherrera explains. “As a result, there’s less need for blood transfusions, which limits the patient’s exposure to potential blood diseases. Infections are fewer because the incision is small, which keeps the patient off drugs [such as antibiotics]. In some cases, patients who would have been in the hospital for a few weeks are only here for a couple of days, which is a savings not only for the patient, but for the hospital and the insurance provider. And then there’s the quality of life: Most patients are getting back to work in a few days or so after having a procedure. They’re up and running very, very soon.”

Peñaherrera believes robots will continue to expand their presence in hospitals. “Patients and doctors demand it,” he says. “As instruments get smaller and applications continue to be developed, we’ll see robots more and more.”

Community focus

At Novato Community Hospital (NCH), understanding the community and its unique needs is key to patient care. According to Ann Hosfeld, chief administrative officer, the hospital is particularly strong in outpatient services and sports medicine, while at the same time is making a name for itself with emergency and urgent care.

“We have a lot of very active individuals in Marin County at a variety of ages,” Hosfeld says. “Our focus is to get people back to their optimal active state as quickly as possible, which has been a very good niche for us.”

NCH’s biggest inpatient demand is for joint replacements, particularly rehabilitations for hips and knees. Because some of the state’s biggest names in sports medicine practice in Marin, the hospital draws patients from all over the Bay Area and has even provided medical services for professional athletes playing for local teams.

Fitness training is also part of its outreach. “We have a certified physical therapist who teaches Pilates, and we also have fitness training for skiing,” Hosfeld says. “Your standard gyms don’t have people trained to take each person’s unique physical conditions into consideration—and we do need to be mindful of our bodies.” The hospital has special equipment that simulates activity and is able to analyze all sorts of sports movements, from golf swings to pitching and throwing, which lets patients “be more efficient and avoid injury.”

Heart-felt care

Since its founding 60 years ago, Santa Rosa Memorial Hospital, a part of the St. Joseph Health System, has established itself as one of the top providers of cardiac care, not only in the North Bay, but in the nation. It was the first hospital in the country to perform open heart surgery in the 1960s and, in the first quarter of 2009, was ranked first in the country (out of 949 hospitals) for its rapid heart attack response (“door-to-balloon” time) by the American College of Cardiology Foundation’s National Cardiovascular Data Registry.

Door-to-balloon time refers to the critical interval between a heart attack patient’s arrival at the hospital and the restoration of blood flow to the heart in the hospital’s Cardiac Catheterization Lab. Memorial’s average time has been reduced to 63 minutes, while the national average is 90 minutes or less. The coordinated effort of all the hospital teams to perform simultaneously is so amazing that the St. Joseph Health System sent a film crew to Memorial to produce a “best practices” employee orientation video to demonstrate how other hospitals in its system can speed up heart attack intervention through similar teamwork between paramedics, emergency medicine, cath lab specialists and other disciplines.

Memorial’s Heart and Vascular Institute opened its doors in November 2008, bringing together nurses, physicians, technicians and other related personnel “to provide the next generation in cardiovascular care,” says Dr. Gary Greensweig, chief medical officer for the St. Joseph Health System-Sonoma County.

“As the world changed, we needed to change to continue providing the community with the level of cardiac care we’ve traditionally provided,” Greensweig says. “Being number one [in cardiac care] isn’t just recognition for trying hard—it means we hit our performance metrics every time with every patient.”

Greensweig notes that cardiac care is evolving. “There’s less focus on coronary bypass and more emphasis on stents, cardiac revision surgery and valve repair. New technology helps us be less invasive,” he explains, noting that such treatment is a trend that’s gaining significant ground in all medical procedures, not just heart care.

“As technology improves, the level of invasion declines, which really reduces the need for open [surgical] procedures,” he says. As a result, the time a patient spends in a hospital following surgery is rapidly declining.

“In the past, someone treated for an abdominal aortic aneurism would have spent eight to 12 days in the hospital. Today, with less invasive surgery, they’re here for 24 to 36 hours. Same thing with gall bladder surgery. Patients used to stay for five days; now they’re going home after 24 hours.”

Less invasive procedures also improve life expectancies, Greensweig adds. “They’re less risky and create fewer complications. Plus they let us take on more patients that we might not have been willing to do surgery on in the past because they were too sick.”

Among other cardiovascular innovations offered at Memorial is “beating heart surgery.” According to Greensweig, instead of stopping the heart during a bypass procedure, for example, surgeons at Memorial are able to stabilize it and operate while it’s still beating. “It’s done with smaller incisions, which makes for an easier recovery,” he says. “Plus we can harvest leg veins [used for coronary artery bypass grafts] with endoscopic techniques, which result in smaller scars and not nearly as much pain for the patient.”

A weighty subject

It’s well documented that obesity, one of the primary causes of heart disease, has become among the top health issues in America, home to the most obese people on earth. According to the Center for Disease Control and Prevention, 33 percent of adults in the United States are obese—an increase of 60 percent in the last 20 years. Obesity-related deaths have climbed to more than 300,000 a year, second only to tobacco-related deaths.

Since 2003, Sutter Medical Center of Santa Rosa has partnered with Northern California Medical Associates (NCMA) and its affiliated Healthy Steps Weight Loss Center (www.healthystepsinfo.com) to prepare North Bay patients for bariatric surgery (also known as gastric bypass or weight loss surgery)—a growing trend in the battle against morbid obesity. Santa Rosa Memorial Hospital forged a similar partnership in 2008.

“When I was training in the mid 1990s, bariatric surgery wasn’t looked at as a mainstream surgical operation,” recalls Dr. Robert Woodbury of NCMA who, with Dr. Allen Cortez, runs the Healthy Steps program for both hospitals. “People would say, ‘Oh, you do the fat surgery.’” But as time has passed, bariatric surgery has proven its worth as a legitimate therapy for metabolic diseases, diabetes, high blood pressure and heart disease.

“Doctors and the general public view it differently. The weird dynamic is, some folks think surgery is cheating and all someone needs is willpower [to lose weight],” Woodbury says. “But you wouldn’t tell someone who needs open heart surgery because they smoked 20 years ago, ‘Gee, you just shouldn’t have smoked.’ Well, the same can be said for people who are obese. You shouldn’t withhold treatment. They’re not cheating. Morbid obesity is a fatal disease.”

Nonsurgical treatment of morbid obesity has a less than 10 percent chance of success, according to a study conducted by the National Institutes of Health. But while the surgery is gaining popularity, the ultimate key to a favorable outcome lies with coaching and presurgical preparation, as well as long-term follow-up of lifestyle changes including psychosocial, exercise, nutrition and support, which is where the Healthy Steps program comes in.

When patients are recommended for bariatric surgery by Sutter or Memorial physicians, they join Healthy Steps for psychological support, education and emotional preparation—a process that can take as little as two months or “much, much longer,” according to Woodbury.

In addition to the ongoing psychological or psychiatric care, counseling covers a wide variety of topics relevant to preparing for bariatric surgery and the new lifestyle. Patients get notebooks and take quizzes as they learn about nutrition, exercise, lifestyle and the commitment they’ll need to reach their ultimate weight loss goals after the surgery is performed.

“We look for the whole lifestyle change first, and then we add the surgery,” Woodbury says. Because of the extensive advance preparation, “most of the morbidly obese patients go through major surgery and only stay in the hospital two or three days. The night of the surgery, they’re up walking and deep breathing for most of the night, which is important in preventing lung collapse, blood clots and pneumonia.”

While the Healthy Steps program is currently focused on bariatric surgery, Woodbury has his own thoughts about its value in other surgeries. “In my view, this type of counseling is important for anyone who undergoes any type of major operation,” he says. “Highly successful outcomes are a result of attitude, lifestyle, nutrition, exercise and commitment.”

Beam me up, Doc!

While it’s unlikely anyone actually says that when they’re told they must undergo radiation therapy for cancer, the new Trilogy Stereotactic System from Varian Medical Systems at the Marin Cancer Institute at Marin General Hospital in Greenbrae (a Sutter Health affiliate) is drastically reducing the “dread factor” among patients.

“Varian Trilogy is a device that lets us deliver a very specialized form of external beam radiation therapy,” explains Dr. Lloyd Miyawaki, radiation oncologist and medical director of the Marin Cancer Institute. “With it, we’re able to pinpoint high doses of radiation directly to a cancer in just one or a small number of sessions.”

Traditionally, radiation therapy has run a six- to eight-week course with daily treatments Monday through Friday, Miyawaki says.

The stereotactic radiosurgery procedure was initially used to treat brain tumors. “With surgery, we have to open the skull, operate on the brain and remove the tumor. With this machine, we can now eradicate the tumor with knifeless surgery on an outpatient basis,” says Miyawaki. “We’ve now expanded its use to other parts of the body. We can use it for small lung cancers—rather than removing a whole section or lobe of the lung, we can have the patient come in and get stereotactic body radiation therapy (SBRT) in one to five sessions and the tumor is gone.” Miyawaki says the hospital is also looking to expand the SBRT application for use in treating tumors in more anatomical sites.

And there’s another benefit. Miyawaki says the SBRT procedure also “offers hope to a lot of patients without other options—those too old or frail for curative surgery, for example. Now they can literally walk into the department, have a painless procedure and walk out a couple of hours later with almost no side effects from the treatment.”

Taking care

Due to space constraints, NorthBay biz was unfortunately not able to talk with every hospital in the North Bay. But if these vignettes are any indication, it’s safe to say the quality of health care—and the dedication of its providers—far exceeds the bad rap the medical community has earned as our national health care reform debate has raged.