Improving Care in
.4 Mciiilwr ol iiic Rociic (iroiip
' this dialogue don't necessarily reflect the opinions of Genentech.
Excellence in Stroke Care:
Improving Care in
dvances in the treatment and preven-
tion of stroke have yielded significant re-
sults in recent years. In 2008, stroke
became the fourth leading caus" "*
death in the United States, down f
the third leading cause of death, a posi-:
tion it held for decades. A number of fac-
tors are at play, including clinical
advancements, increased awareness
and increased adherence to evidenced-
based care. Yet challenges remain in ;
providing timely equitable and effective care.
To discuss best practices in stroke care within comni
spitals. Health Forum
convened a panel of industry experts Nov. 16 in Chicago for a roundtable discus-
sion. Health Forum would like to thank all of the participants for their open and
candid discussion, as well as Genentech for sponsoring this event.
MODERATOR (JOHN COMBES, M.D., AHA's Center
for Healthcare Governance); Today's topic is best
practices in stroke care for community hospitals.
It's been about eight years since the Joint Com-
mission launched its primary stroke care designa-
tion program. What changes have you seen over
that period? How has stroke care evolved and
improved through the use of the designation of
primary stroke centers?
WENDE FEDDER, R.N. (Alexian Brothers Health
System): First and foremost, is the ability to cap-
ture and access data to look at our clinical out-
comes and compare them with our other hospi-
tals, and with other primary stroke centers and
community hospitals. We've really been able to
see clinical outcomes improvement since we
started with the guidelines program in 2005.
TIM SHEPHARD, R.N. (Bon Secours Health Sys-
tem): Looking at the clinical data has been help-
ful, but I think it's the recognition and promi-
nence that the stroke center certifications and the
work around neurosciences have promoted.
Many community systems are seeing neuro-
sciences as a viable alternative for them to devel-
op as a service Hne that wasn't there before. It's
moved neurosciences into the forefront, surpass-
ing cardiology in some of our hospitals.
MODERATOR: Are you finding that yoxir organiza-
tions are able to demonstrate through the stroke
networks outcomes of care that are equivalent to
even the best academic medical centers in the
SHEPHARD: That's true. If you rely on the data,
community hospitals are achieving great things.
Community hospitals, if they focus and maintain
a focus, can achieve the same results as academic
medical centers. It's a question of whether they go
from stroke on to the next step in developing
their neurosciences program — neurospine, neu-
rosurgical spine, etc.
ANDREW MEADE (St. Luke's Episcopal Hospital):
When we began our telemedicine network, we
started with Beaumont Hospital. Within six
months, they were faster than we at door-to-com-
puterized tomography time. They don't have a lot
of the same bureaucracy that we do and they
don't see the same complexity of cases that we
see. In many areas, they may not be able to han-
dle the complex level of cases. But on the bread-
and-butter stuff, I think they can be faster.
SHEPHARD: That's an excellent point.
MARILYN RYMER, M.D. (St. Luke's Hospital): I
would take another view of the primary stroke
center process. I certainly agree it's been positive
overall. It's made people pay attention to data, to
protocols and to standardization of care. Every
hospital in our city is a primary stroke center It's
become a marketing tool.
I don't think Just being a primary stroke center
guarantees that patients win get the acute care
they need. The continuum of care is well-orga-
nized within the primary stroke center guide-
lines. But we aren't doing as well when it comes
to acute care.
MODERATOR: Would you say, though, that overall,
the level of stroke care in this coimtry in the past
10 years has improved tremendously, even
though we haven't gotten to the reperiusion rates
we'd Kke for them to be?
RYMER: I think "tremendously" might be too big
Every hospital in our
city is a primary
stroke center. It's
Marilyn Rymer, M.D.
www.hhnmag.com / IULY.2 012 / H&HN 51
Now we realize that
we have only one
chance to get it
right. If the closest
hospital is not a
stroke center, we've
lost valuable time.
SHEPHARD: But stroke has dropped to the fourth
leading cause of death from the third leading
cause of death in the United States.
DAVID GHILARDUCCI, M,D. (American Medical
Response): I'll take it from a public health per-
spective. It's raised the bar for a community stan-
dard of care. Hospital administrators realize that
we need to have neiu'ologists on call. I think it's
caused everybody to be more forward leaning.
EMS is more forward leaning with stroke. Before,
we'd say, "This is probably a stroke; we'll take the
patient to the closest hospital."
Now we realize that we have only one chance
to get it right. If the closest hospital is not a stroke
center, we've lost valuable time. But I think the
other issue, from an emergency physician per-
spective, is that there's more accountability on
how we evaluate patients. There's just a lot more
awareness now than there used to be.
FEDDER: The stroke center certification process
in the past 10 years laid a nice foundation for the
development of a system of care. Whether we are
stroke ready, primary stroke, or comprehensive, I
can't imagine that we'd be where we are today
without it. We've definitely seen an improvement
CHERYL BÜSHNELL, M.D. (Wake Forest Baptist
Medical Center): As Maruyn touched on earlier,
there is marketing exposure associated with cer-
tification. It's brought a healthy competition
among providers that's sort of promoted stroke
care. And in changing the goals, with door-to-nee-
dle times now being 60 minutes or less, it has
upped the bar in terms of which hospitals can tru-
ly accomphsh the kinds of process improvements
necessary for getting the appropriate therapy as
quickly as possible.
SHEPHARD: We're seeing a great deal of collabo-
ration between larger and smaller hospitals to
help standardize the level of care. Resources that
may not have been available to smaller hospitals
now are available through the systemization that
stroke center networks have created.
On the other hand, more EMS networks are
creating protocols that will bypass noncertified
stroke centers. Some hospitals will lose some of
their neurovascular volume as a result. You can
project that this is better for the patient, but we
also know that we need to maintain financially
viable institutions in rural areas that may not be
stroke centers. So one of the efforts that was tak-
ing place by the American Heart Association and
the American Stroke Association was to develop
a third tier of care, stroke-ready hospitals. But
that changes the baseline standard of care, going
one level below that to include other hospitals.
There's a lot of debate about that taking place
BUSH NELL: Another argument for not b)rpassing
some of our hospitals in our network is the avail-
ability of telestroke systems. It's a little bit of a dif-
ferent definition in terms of stroke-ready, because
then they've got access to our stroke team. And
they're highly trained in process. They stabilize
patients and prepare them for transport for fur-
MODERATOR: I want to talk about that a little
more, since the future looks like we're moving
toward systems of care. Through telestroke serv-
ices and through the support of the network, can
you actually raise the level of care at smaller facil-
RYMER: The systems of care process is a very
viable option. We have a 25-bed critical access
hospital that successfully treats stroke patients
with appropriate medical therapy all the time
with our help. I don't think aU of these hospitals
need to be stroke-certified, they just need their
protocols in place, and then a relationship with a
ceriified center to care for patients after they
leave the smaller facility
MEADE: That's the same tactic we take with our
telemedicine network. We meet with organiza-
tions and ask them their goals. We ask about their
level of neurology coverage. And then we work
with them to establish programs that meet their
goals and abilities.
MODERATOR: So, are you all working with hospi-
tals that are outside of your primary network?
FEDDER: Our system has set up a collaboration
with a nonsystem hospital in rural Illinois that
has one of the highest stroke mortahty rates in
the state. We were able to get them to use some of
the tools, like "Get With the Guidelines," and oth-
er things, to develop emergency department pro-
tocols so that they can treat the patient appropri-
ately. If they have cases that are beyond their
scope of practice, they transfer to us. You can see
5 2 HSMH / lUiy.2012 / www.hhnmag.com
that their outcomes have improved in the emer-
gency department. You don't have to be a certified
primary stroke center to provide good stroke
SHEPHARD: One of the impetuses behind stroke
certification is to standardize processes. Even
when we're partnering with smaller hospitals out-
side of our system, we've taken the approach that
any hospital can be a certified stroke center We
have a 98-bed hospital that is a certified stroke
center using teleneurology because that's our
standard of care within the system. I've seen
some sites slide between certifications. You need
that on-site validation to ptish the envelope. If you
don't have a coordinator, if you don't have the
data, if you don't have certification looming over
yotur head, processes slide. And that happens in
The most expensive components of a primary
stroke center are data abstraction, collection and
reporting, a 24/7 coordinator and ED training and
Director, Medical Affairs
American Medical Response
San Jose, Calif.
Alexian Brothers Health
Elk Grove Village, III.o
Elk Grove Village, III.
John Combes, M.D.
Senior vice president, AHA, and
president and COO AHA's
Center for Healthcare
Timothy J. Shephaiflk
Vice president neuroscience
Bon Secours Virginia Health
Marilyn Rymer, M.D.
Saint Luke's Brain and Stroke
Saint Luke's Hospijj
Kansas City, Mo. Í
¡Neuroscience Service Line
it Luke's Episcopal
Director V\'ake forest
Baptist Stroke Center
Vliake Forest Baptist
www.hhnmag.com / JULY.2012 / HSHH 5 3
I Executive Dialogue
processes. And those are the components that
you have to have in place to deliver standardized
care around acute stroke care. So if you can do
those, you might as well go for certification. If you
have to do the most expensive components, a
hospital, by being a third tier, is not going to save
any money, and they're going to lower the bar
The whole goal of stroke certification is to raise
the bar. So I think taking that step down, while it
provides that on-site validation, still lowers the
bar in the extended care savings to a third-tier
FEDDER: I agree with that, but it's going to be dif-
ficult for some hospitals to become primary
stroke centers. Critical access hospitals, for exam-
ple, may not have the stroke volume or the tech-
nology to become certified. But they could part-
ner with a system and meet some of those stan-
dards. However, it would have to be through
development of some type of coUaboration.
RYMER; The most important thing is that every
hospital be stroke-ready, whatever that means for
that hospital. So if there's no CT scaimer and the
family physician is the guy who's manning the
ED and he's home, then that hospital needs a
transfer plan. The ones that can do drip and ship
need those protocols well-systematized and
inline with the hub hospital. And then you work
your way up from there.
But patients generally are going to go to the
closest hospital. Even with these transport proto-
cols that we're trióng to get together in our states,
they often land at the closest hospital. My firm
belief is that every hospital needs to be stroke-
MODERATOR: Tim raised the issue of the cost of
these programs and the investment that hospitals
have to make. Have you seen a documented
reduction in cost of care?
SHEPHARD: Yes, absolutely We have implement-
ed what we call clinical transformation in the Bon
Secours system where we track our highest vol-
ume margin diagnosis-related groups. Stroke is
one of those. We have the volume metrics around
cost per case, complications, etc. All of these
things have come down as soon as we put the
stroke center in place.
MODERATOR: That's good, but I guess we'U have
to change our language to value. You're getting
the costs down, but are you getting great out-
comes, which is really adding value to the whole
SHEPHARD: For reperfusion, the availabuity of a
therapeutic option for severe stroke patients who
come into the hospital has increased, and the
complication rate for these patients has
decreased because the physicians have more
time to make better decisions. As a result, compli-
cation rates are down. It's just giving physicians
time to make more informed decisions about the
course of treatment.
RYMER: If you become a stroke center, you actu-
ally become a neuroscience center by default.
triage, treatment and transport protocols. Stroke-ready certification or telestroke programs are other options that
should be considered.
family members and the community at-large.
Find the best fit. Not all organizations can or should become primary stroke centers. Organizations with limited
resources or inadequate volumes should partner with a primary or comprehensive stroke center to develop
Develop a business plan. Organizations should create a business plan outlining the benefits of stroke certifica-
tion to the patient, the hospital and the community. The business plan should include a financial and clinical ROl.
Focus on transitions in care. It's critical to develope effective post-discharge follow-up to ensure patients
receive appropriate care.This can help avoid unnecessary complications and readmissions.
Get the word out. The community is often unaware of stroke symptoms and prevention. The best way to treat
a stroke is to not have one at all. Public service campaigns should target those at risk of stroke, as well as their
H&HN / lULY.2012/wiviv./i/inmas.com
Stroke is sort of the leader in a way, and then you
get brain tumors, seizures and aU of those things
that may even lead to neurosurgical procedures,
which most hospitals find to be very profitable.
FEDDER: Well, in sheer volume, neuroscience is
about 30 to 40 percent of our inpatient volume.
That gets the attention of our senior leadership. If
you don't treat stroke, your ED traffic is going to
be rdl. That's what fills your hospital.
GHILARDUCCI: There's a phenomenon that I call
soft triage. There are protocols that direct EMS
staff where to take which patient, but patients
aren't always easy to categorize. So EMS makes a
judgment call, which can be subjective. They may
take the patient to the hospital they perceive to
be the most responsive. They're intrinsically
motivated to know that their patients are getting
good care. So, generally, if they are concerned
about a patient, they wül say, "Let's just go a little
farther to this other hospital." Most EMS systems
aren't able to manage that. That sort of soft triage
happens all the time, though. From a business
perspective, it's important to consider
MODERATOR: But don't you think some of that
soft triage, even from the patient's perspective,
comes from looking at people who seem to have
mastered care? The care is coordinated and it's
efficient. It's sort of a side benefit of what you do.
GHilARDUCCI: If an organization holds certifica-
tion in some area of specialty, EMS knows that
they're competent in that area. There's an
assumption that you're competent in all areas,
and that's not necessarily true. A comprehensive
stroke center may not necessarily be located at a
trauma center, but often those two things go
RYMER: EMS is part of the care team. To that end,
we give the EMS crew a report on how well the
patient did within 72 hours. It's wildly popular.
MEADE: And an appreciative letter from the
physician — that always helps.
MODERATOR: This coordinated care approach
sort of reminds me of Regina Herzüngefs focus
factories in care. Is this now spilling over to other
lines of your business within the organization?
MEADE: It's going to. Our chief quality officer has
looked at our stroke program and said this is
something we need to mirror elsewhere. They see
we are tracking data and doing performance
improvement like nobody else is doing in the
hospital. And as medical home models become
popular and payment becomes linked to quahty,
you can't ignore the success that stroke is having.
The guys running our CT have taken notice.
They see what we're doing for stroke patients and
how well it works. The/ve questioned why all of
this isn't being done for ever5rthing else. The time
to CT is not as good as it would be if we had a sys-
tem of care. It sort of stands out as a sore thumb.
GHILARDUCCi: I'd like to touch on one topic that
was brought up earlier about data. I think one of
the biggest frustrations — and this would be my
message to hospitals — is not to let HIPAA stand
in the way of sharing information because it's for
quality ptirposes. HIPAA certainly allows it, but it
has become such a roadblock in terms of finding
out patient outcomes for the pre-hospital folks
and they often get discouraged. If there's one
thing that wül drive EMS away, it's not knowing
what's happened to their patients.
MËADE: Yes, but you'd be surprised. At a previous
job, I shared information with EMS and then the
legal team found out about it. We spent the next
three months sorting through what we'd share
with them. It was really insulting to our EMS part-
GHILARDUCCI: It becomes an obstacle.
MEADE: It became a three-month obstacle, and
we really had to work to not insult our EMS part-
ners. The numbers are amazing. We found that 99
percent of the time EMS is correct in their diagno-
sis. That's great information to share with them.
BUSHNELL: We focus on the acute stroke setting.
Once the patient is admitted and past the hjper-
acute phase, we don't share information. But EMS
should know what happens in the emergency
department and whether or not the patient
MODERATOR: You can share your aggregate out-
comes, and you can talk about the patients who
were brought there. Not by individual name, but
in aggregate, and include the EMS team in any of
your improvement efforts as well. It's important,
too, that in this whole concept of coordinated
Our chief quality
ofñcer has looked at
our stroke program
and said this is
something we need
to mirror elsewhere.
www.hhnmag.com / JULY.2012 / H&HN 55
• Executive Dialogue
The idea of a
is pretty amazing
to me from an acute
to do the checks
Alissa Gorelick, D.O.
care, there's a strong team approach throughout
the continuum, so the HIPAA issue should not get
in the way because you're all taking part in the
care of the patient, and sharing outcomes is cer-
GHILARDUCCi: The Santa Clara County Public
Health Department brings all of the stroke cen-
ters together once every two months to share
data. And with the exception of Kaiser, none of
them are part of a system. Only the organization
knows which set is its data. The idea is that it
provides a forum for people to look at each oth-
er's outcomes. It provides an opportunity for
organizations to share best practices. One of the
things that has come out of these meetings is
that we've streamlined our intrahospital transfer
process. We're basically leveraging our 911 sys-
tem to move patients quickly from one place to
the next, and we agreed on criteria as to which
patients wiU qualify I would recommend to hos-
pitals that they collaborate. I know that your
organizations compete, but there's also an
opportunity to collaborate on a communitjrwide
basis that would serve everybody's interest.
MODERATOR: Well, it sounds as though this was,
for aU of you, a great business decision — that it
was great for patients and improved outcomes
and care, and that almost everybody can play at
some level. So what are the obstacles to getting
this to happen? What are the roadblocks?
RYMER: It has a lot to do with the expertise and
availability. We've had stroke center develop-
ment teams visit us for the last 10 years, and you
can almost tell who's going to make it and who
isn't by whom they bring, and they're often
missing the neurologist. There's been a lot of
resistance in the neurology community because
it's a change in lifestyle, basically. They used to
be outpatient doctors and now, suddenly, they're
ia the ER more than the cardiologists are. We've
got a wonderful young group of trainees who are
embracing this and saying this is something they
want to do. But the older practitioners are not
necessarily embracing it as much. So there's that
kind of resource scarcity And we did have some
pushback from ED for a whue, but that's chang-
ing. The tide has changed because the data are
SHEPHERD: There is a constant shortage of high-
ly skilled neuroscience experiise. Whether it's
skilled neurovascular neurologists, skilled neu-
roscience nurses, neuro-interventional techs,
neuro-interventional physicians, these resources
are difficult to find. If a hospital has those
resources and can share them with other hospi-
tals for training purposes, for standardization,
for data analysis, it's a real benefit. Finding a
skilled neuroscience coordinator or stroke coor-
dinator for a program can be a long search.
We've actually had to grow some of ours, which
requires intensive training, but we just couldn't
find the right match for our system. So the
scarcity of neuroscience expertise is another
reason why you need to share those resources in
hospitals that don't have them.
MEADE: I'm inserting a neurohospitalist into one
of our community hospitals right now from our
academic group because it just can't get a neu-
rologist. The hospital is willing to pay full time
for a neurohospitalist, who will probably see
two or three patients a day. They can't get
patients out without one. We've seen the same
thing in psychiatry; we just can't get somebody
to come in and consult on our patients.
BÜSHNELL: I understand the reason for the shift
toward using neurohospitalists, but there's going
to be a negative consequence, and that is in the
continuity of care. And we have a neurohospital-
ist. He doesn't see clinic patients, though. Lucki-
ly, we have a nurse practitioner who kind of
bridges that continuum between inpatient and
MEADE: From the fiaancial point of view, I think
we wül be setting up a hybrid model where the
neurohospitalist will spend the morning round-
ing on patients and the afternoons seeing
patients ia the clinic. From a financial point of
view, the pro forma is going to look better from
a physician perspective under this model.
ALISSA GORELICK, D.O. (Alexian Brothers Medical
Center): From the ER perspective, the worst time
in the ER is 3 a.m., when there's nobody in the
hospital but you. We do have an ICU physician
24 hours a day But in the ER, it's usually just me.
And I run with the codes, and 25 beds are fuU,
and there are 10 patients in the waiting room.
And it's never black and white. The idea of a neu-
rohospitalist is pretty amazing to me from an
acute care standpoint because there's someone
there to do the checks and balances.
5 6 H&HH I ¡UVi.2012 / www.hhnmag.com
Our neurologists are very responsive. They
call back right away and help make decisions.
But another pair of eyes is the best-case sce-
MEADE: We set up our telemedicine program
that way, where the patient comes in at 5 p.m.,
and we'll see the patient through tmtil morning,
when the neurohospitalist or the neurologist
gets there to take over care. So that's where you
can stari developing that hybrid of care. But if
you put one neurohospitalist in a hospital, and
you don't provide any support, you'll bum him
or her out. How many 3 a.m. calls can one per-
son take? That's where you can mix in telemed-
icine. We'll do that in our system hospitals;
telemedicine will provide coverage when the
neurohospitalist is not there.
GORELICK: So are they there 24 hours a day, or
are they just taking calls from home?
MEADE: It could be set up that way
RYMER: We have what we call our code neu-
roteam. These are nurses who are neurocritical
care trained nurses and are National Institutes of
Health stroke scale-certified and have a lot of
experience with acute stroke intervention. They
provide coverage 24/7. They're our first respon-
ders to help the ED not just make the decision,
because the neurologists are always available for
that, but to help the ED nurses take care of the
patient. ED nurses can use an extra set of hands
to do the NIH stroke scale and to really be part-
nered with the ED staff. That has been a real sat-
isfier for the ED and also for the neurologist
who, if they can't get there within three hours,
knows there are at least two sets of eyes looking
at this patient.
SHEPHARD: We've implemented teleneurology
within our EDs, even where we have employed
physicians. So, it's easier to recruit a neurologist,
because you don't have to do ED call. Their qual-
ity of life is better, and their patients' outcomes
are better. It's been a boon to be able to recruit
highly qualified neurologists into our system
because they don't have to do ED call.
MODERATOR: I want to get back to Cheryl's
issue: the discontinuity of care that some of this
may lead to, especially as we move into an era
where we're going to see bimdled payment and
organizations are going to be penalized for read-
missions. How do you build in at least the imme-
diate outpatient care after a patient comes
through your primary stroke center?
BUSHNELL: Our issue was access to the follow-
up appointments; it took literally six months to
get a patient into the resident clinic. In hiring the
nurse practitioner, I developed a template for all
the things that patients should go through for
prevention and follow-up and now our access is
more like four to six weeks for the follow-up.
That's had a tremendous impact on our out-
comes. Our readmission rates have diminished
somewhat because of the input of the nurse
practitioners and we've also developed a transi-
tion coaching program that basically is calling
patients after they go home to go over medica-
tions and appointments.
FEDOER: We don't have residents and we don't
have neurohospitalists, so we do have gaps
between levels of care, even with the team that
we have. We've tried to be a bit creative with the
transition from inpatient hospital to outpatient
physician appointments. We started a program
called the Stroke Nurse Navigation program.
Navigation is not new to health care, but it is rel-
atively new in stroke. We have two nurse naviga-
tors who see patients while they're in the hospi-
tal. They meet them and then follow them by
phone at certain intervals, up to a year after dis-
What we found is that you can hand patients
all this wonderful information and literature and
try to educate them whue they are in the hospi-
tal. But patients and their families retain very lit-
tle of that information, and they may not make
their appointments with their primary care neu-
rologist. So, we've employed this particular
group of nurses in the Nurse Navigation pro-
gram to help make sure patients are getting
those appointments, their therapy appoint-
ments, going to rehab, etc.
MODERATOR: It seems the other advantage is
that you can collect a lot of longitudinal data on
these patients. As far as that's concerned, what
have you seen in the longitudinal data for these
patients who pass through the primary stroke
SHEPHARD: We've implemented "Get With the
Guidelines" for data collection. It has 13 addi-
We've tried to be a
bit creative with the
inpatient hospital to
Wende Fedder, R.N.
www.hhnmag.com j JULY.2012 / H&HN 57
A business plan
too often does not
decision to develop
a stroke program.
Decisions are based
on the desires
of the neurologists
and other factors.
Tim Shephard, R.N.
tional blank fields that you can use, so we've
been capturing data at 30-day clinic visits, and
then up to one year. We just implemented this in
the last few months, and it's also being integrat-
ed into our electronic medical record as we
expand that across the system. Once that's done,
we should be able to capture that, especially as
our employed neurologist group grows larger.
RYMER: We've been tracking our 90-day modi-
fied rankings for about three years on patients
who receive acute therapy, either intravenous
thrombolytics or some sori of intra-arterial ther-
apy It's a real challenge, though. It's a manpow-
er issue to have the number of people you need
just to do these phone calls. This is a huge issue.
MEADE: So, Marilyn, who's doing that for you?
Who's doing the follow-up calls, discharge
RYMER: We divide it up. The nuises attached to
our interventional team do the intra-arterial fol-
low-up calls, and neuronurses do the others. But
we're patching it together. It's not as nicely
organized as we would üke.
MODERATOR: How do you assess your stroke
programs? What is the ultimate measure of suc-
cess from a clinical perspective?
SHEPHARD: We look at recurrent strokes and
secondary prevention. Is the patient taking
antiplatelets and antihypertensives? We have a
Nurse Navigation program for our cancer
patients, but we haven't implemented one for
our stroke patients. But that's key to keeping
patients out of the hospital. And with bundled
payments, we're not going to be reimbursed for
that. So it's good for the patient, it's good for the
hospital. We measure success based on our recur-
rence. We compare the NIH Stroke Scale results
for incoming and outgoing patients. But we don't
have sufficient data on how the patient is faring
long-term, and that would be very helpful.
BUSHNELL: The Adherence evaluation After
Ischémie Stroke Longitudinal (AVAIL) registry,
though, showed the recurrent stroke rate was
about 8 percent. And these patients were actual-
ly pretty good at taking their medications and
following their course of treatment. About 75
percent of patients were still in the same dis-
charge regimen at three months, and 65 percent
were on the same regimen at a year. That's pret-
ty good, and you stül have a recurrent stroke
rate of 8 percent.
MEADE: It is difficult to reach out to every
patient after discharge, with the resources avaü-
able. But it is possible to identify which patients
may be a problem post-discharge. At my previ-
ous place of employment, we reduced réadmis-
sions from 6 to 3 percent by focusing on those
patients. I developed a business plan; we're
devoting about $150,000 a year to reducing
readmissions. If we focus on the 50 patients who
come back repeatedly, we could cut $4 mulion
BUSHNELL: You are right, you can identify those
patients. The more severe the stroke, the more
cognitive impairment, the lesser the resources
and social support; those are high-risk patients.
SHEPHARD: A business plan too often does not
accompany the decision to develop a stroke pro-
gram. Decisions are based on the desires of the
neurologists and other factors. But organizations
often don't quantify the patient benefit, the hos-
pital benefit and the community benefit.
MODERATOR: Let me dig inside a little bit deep-
er, Tim. So you're talking about developing an
overall ROI. We're used to calculating just the
financial ROI. If you just did the financial ROI on
these programs, where would you be?
SHEPHARD: It depends on the makeup of the
stroke program. For example, at Virginia Com-
monwealth University Medical Center in Rich-
mond, 47 percent of stroke patients are African-
American, many of whom are impoverished,
without resources. But they have smaller strokes,
smaller intracerebral hemorrhage, shorter
lengths of stay and lower complications. Seventy
mues away in Charlottesville, we have a smaller
community, mostly white and aftluent. They have
the resources they need, but they have larger
strokes and longer lengths of stay But the reim-
bursements are better because it's private pay.
The financial ROI wül depend on the makeup of
the program, but you can do both a clinical ROI
and a financial ROI for stroke programs.
MODERATOR: What are some measures that they
can use to determine the clinical ROI? How can
organizations look at their overaü business from
/ ¡ULY.2012 / www.hhnmag.com
the clinical side? What are the community meas-
ures that should be considered?
SHEPHARD: From the community standpoint,
you can look at the preference for your hospital
in the community, as well as physician prefer-
ence scores. Organizations also can look at
patient satisfaction scores in both the acute care
and clinic setting. And then they can get into
clinical metrics: length of stay, the pre- and post-
NIH Stroke Scale scores, health care-acquired
infection rates, etc. Every one of those has a
quantification relative to dollars, as well. So you
can calculate what you've done to care for the
patient and quantify it into a clinical metric.
These are standards that can be put into the pro
forma — what it costs to develop a core program
based on your hospital and cost per case. We can
decrease the cost per case, the length of stay, the
complication rate, the number of full-time
employees, and improve ED throughput, among
other things. All these are quantifiable from a
patient outcomes standpoint, as well as from a
MODERATOR: Marilyn, you mentioned earlier, in
terms of some of the immediate outcomes, that
overall, the reperfusion rates of stroke centers
are not that high. How can this be improved?
RYMER: It bears on some of the things we've
already talked about, including ED staffing levels
and the support of ED physicians. I generally find
that ED physicians are very wiUing to do this, but
they're not willing to do it in isolation. We just
don't have the systems of care in the acute setting.
Primary stroke center certification has done won-
ders for prevention of complications and for sec-
ondary prevention. But in the acute care setting,
there are stul some significant barriers.
RYMER: It seems as though some of the systems
that Tim has put in place, including the special-
ists on call, making the consultation immediate-
ly available, is a major solution to some of the
problems we're up against.
GORELICK: It's never black or white. During
business hours, the neurologist comes down
when we provide any medical intervention.
Overnight, they always call back right away and
they do come in if we are going to give it. But
sometimes it's just an issue of being a squeeze to
get this in. These are the decisions that are hard-
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er when we're alone and there's nobody else in
the ER but you. You have to puU the trigger. We
are very scared of those complications.
FEDDER: That's exactly the reason why we didn't
do an internal telestroke system, because our
nevirologist said, "We want to be at the bedside."
BUSHNELL: Commimication is key. We're work-
ing on a project to help communicate the indi-
vidual risk to patients. We're working to provide
the individual risk for providing therapeutic
choice or not. If we can get that worked out, it
will help neurologists and the ED physicians to
communicate the situation to the patient.
MODERATOR: What are some of the things you're
doing in terms of outreach and bringing people
into the system and making them aware of your
GHILARDUCCI: The target audience is not the
stroke patient because, when the stroke happens,
they're not going to be thinking right. They may
not even be able to dial a number The target au-
dience is the person closest to the stroke patient.
So it's a family member, it's the general public.
I've seen banners on buses, I've seen stickers on
the newspaper and magnets for refrigerators.
And I don't know what the answer is because it
seems to be a continual problem.
MEADE: I had an outreach coordinator at my pre-
vious job and I have one now. We've run the
gamut. We talk to church groups. And we've spo-
ken to elementary schools, junior highs and high
schools because those kids are there when
grandma's taking care of them and has a stroke.
The focus shouldn't be on assisted living facilities
and nursing homes. That doesn't work. You have
to take a broad section.
key. We're working
on a project to help
Cheryl Bushneil, M.D.
www.hhnmag.com / IULY.2012 / HSHN 5 9
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