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  • Introduced by: Vemuri S. Murthy, MD, Delegate, for Chicago Medical Society

    Subject: The Illinois Cranial Anticoagulation Reversal (ICARE) Initiative

    Referred to: Reference Committee C

    Whereas, cerebrovascular disease is the third most common cause of mortality in Illinois and is responsible for 5.3% of deaths statewide, or 5,600 per year1;

    Whereas, intraparenchymal hemorrhages are the most common nontraumatic hemorrhagic stroke, and have the highest risk of mortality2; and

    Whereas, the largest reversible risk factor for poor outcomes in intraparenchymal hemorrhages is use of anticoagulants, such as warfarin3; and

    Whereas, the effects of anticoagulants can be mitigated with rapid use of newer reversal agents which have replaced transfusion as a standard of care4; and

    Whereas, many emergency rooms do not know about new anticoagulation reversal medications or do not know how to use them, resulting in worse outcomes for patients prior to transfer to tertiary centers; and

    Whereas, savings in healthcare expenditures and worker productivity are expected with better patient outcomes, while reversal medications are relatively inexpensive5; and

    Whereas, legislation exists in the Illinois General Assembly that emphasizes the responsibilities of stroke centers to care for ischemic and hemorrhagic strokes, including the administration of anticoagulation reversal medications up to date with current guidelines, defines stroke to include ischemic and hemorrhagic types, and provides an educational reference for practitioners; and

    Whereas, on February 27, 2018, the Chicago Medical Society adopted a resolution in support initiatives that reduce barriers to the use of anticoagulation reversal agents that are up to date with contemporary guidelines in emergency settings for hemorrhagic stroke and other life-threatening clinical indications, including the Illinois Cranial Anticoagulation Reversal (ICARE) initiative or subsequent iterations for the benefit of Illinois stroke patients, and to further introduce the resolution to the Illinois State Medical Society; therefore, be it

    RESOLVED, that the Illinois State Medical Society support initiatives that reduce barriers to the use of anticoagulation reversal agents that are up to date with contemporary guidelines in emergency settings for hemorrhagic stroke and other life-threatening clinical indications, including the Illinois Cranial Anticoagulation Reversal (ICARE) initiative or subsequent iterations for the benefit of Illinois stroke patients.


    1. Leading Causes of Death by Age Group, Illinois Residents. Illlinois Department of Public Health, 2016.
    2. Alaraj A, Esfahani DR, Hussein AE, et al. Neurosurgical Emergency Transfers: An Analysis of Deterioration and Mortality. Neurosurgery. 2017.
    3. Esfahani DR, Radnis CA, Hussein AE, Amin-Hanjani S, Charbel FT, Alaraj A. Thresholds for Volume and Expansion in Intraparenchymal Hemorrhage: Predictors of Neurologic Deterioration and Mortality. World neurosurgery. 2017.
    4. Hemphill JC, 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-2060.
    5. Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime Cost of Stroke in the United States. Stroke. 1996.

    Existing ISMS policy related to this issue:



  • The commenting period is now over.
    Comment List
    Darian R. Esfahani, M.D. I favor this resolution

    Dear ISMS Members,

    Apologies for not being able to testify in person on behalf of this resolution; I am on call this weekend and cannot make the meeting. Below you will find my testimony on behalf of our Senate (SB 2235) and House (HB 4109) bills and this ISMS Resolution. We seek the support of the ISMS for our legislative effort to help hemorrhagic stroke patients in Illinois.

    Stroke is an epidemic in Illinois, and is responsible for 5.3% of deaths in the state, 5,600 people per year, and costs us hundreds of millions of dollars annually. Hemorrhagic strokes are a growing epidemic in our state that my neurosurgical colleagues and I face on a daily basis. My colleagues and I recently published a study of Illinois hemorrhagic stroke transfer patients, finding that the largest reversible risk factor for death and disability in these patients is anticoagulants, which have become increasingly more common in our population over the last several years.

    Recently, however, a number of reversal agents – medications that can stop the effect of anticoagulants – have become available. If given in the emergency room promptly, they can stop brain bleeds from growing and keep patients from getting worse. The challenge is that many emergency rooms (and even stroke centers!) in Illinois don’t stock these agents – or don’t know how to use them. If patients don’t receive these medications, by the time they are transferred to neurosurgeons like us, their bleeds are larger and often they are beyond our ability to help them.

    It saddens me that we have many patients – dozens a year – that could have been helped if only emergency rooms had the medications they needed. Sadly, many of these patients died – and many others ended up in expensive, long-term ventilator facilities – often at the state’s expense.

    The Illinois Cranial Anticoagulation Reversal (ICARE) initiative is a statewide drive to make blood thinner reversal medications available in stroke centers throughout the state. The American Stroke Association recommends that certain medications be provided to reverse the effects of patients on blood thinners. Of these, we have identified only four that are needed to reverse almost all blood thinners on the market. While one of the four can cost several thousand dollars, the rest are inexpensive and this is money well spent. Healthier patients are discharged from the hospital faster, are less likely to go to an expensive ventilator facility, and are more likely to return to work.

    The ICARE Initiative is an amendment to the Emergency Medical Services Systems Act that defines stroke to include hemorrhagic as well as ischemic stroke, emphasizes stroke center responsibilities include administration of anticoagulation reversal medications, and designates an educational reference on the Illinois Department of Public Health website. This is effective, straightforward policy. Patients need these medications. Requiring stroke centers to carry them follows American Stroke Association guidelines. This requirement will save money – and lives.

    We are grateful for the leadership of Senator Heather Steans and Representative Robyn Gabel for sponsoring ICARE in two bills currently in the Illinois General Assembly – SB 2235 and HB 4109, and having received support from the University of Illinois, our home institution, the Illinois State Neurosurgical Society, and the Chicago Medical Society.

    We now respectfully ask members of the ISMS, as leaders of medicine in Illinois, to support our drive to help Illinois stroke patients by supporting our initiative and its bills. On behalf of my fellow neurosurgeons and our stroke patients – thank you.

    Darian Esfahani, MD
    Delegate, Resident & Fellows Section

    Neurosurgery, PGY-6
    University of Illinois Hospital & Health Science System

    Senate Bill (SB 2235): http://ilga.gov/legislation/billstatus.asp?DocNum=2235&GAID=14&GA=100&DocTypeID=SB&LegID=107962&SessionID=91
    House Bill (HB 4109): http://www.ilga.gov/legislation/BillStatus.asp?DocNum=4109&GAID=14&DocTypeID=HB&SessionID=91&GA=100

    Apr 18, 2018 at 8:44 p.m.

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