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Service Delivery Innovation Profile

Protocols, 24-Hour Neurologist Access, and Ongoing Training Lead to More Patients Receiving Timely Stroke Diagnosis and Treatment


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Snapshot

Summary

Mary Washington Hospital implemented a comprehensive initiative to enhance stroke care using the American Heart Association and American Stroke Association's Get with the Guidelines program. Key features include early activation of a "code neuro" protocol to facilitate faster evaluation and diagnosis of patients experiencing stroke symptoms, quick administration of tissue plasminogen activator when indicated, 24-hour access to a neurologist, enhanced discharge planning, improved documentation and data collection, continuous staff training, and community outreach to educate the public about stroke. The program led to more timely diagnosis and treatment of stroke, with a higher percentage of patients receiving computed tomography scans within 25 minutes and tissue plasminogen activator within 60 minutes of hospital arrival. Overall, 8.5 percent of eligible stroke patients at the hospital received tissue plasminogen activator in 2009, more than triple the national average of 2.4 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of how quickly suspected stroke patients receive CT scans, along with post-implementation data on the percentage of eligible patients receiving tissue plasminogen activator and the percentage receiving it within 60 minutes of hospital arrival, both in comparison with national averages.
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Developing Organizations

Mary Washington Healthcare
Fredericksburg, VAend do

Date First Implemented

2007

Problem Addressed

Stroke is a common, costly, deadly, and debilitating condition. Administration of tissue plasminogen activator (tPA) within 3 hours of stroke symptom onset significantly improves outcomes, but relatively few eligible patients receive the drug due to delays in patient transport and diagnosis. Providers also routinely fail to provide other recommended care to stroke patients.

  • A common, costly condition, with devastating consequences: Stroke is the third leading cause of death in the United States and also results in significant morbidity, disability, and costs.1
  • Delays in tPA administration: Administration of tPA to patients experiencing an ischemic stroke within 3 hours of symptom onset significantly improves patient outcomes.2 Yet relatively few patients receive tPA due to factors such as patient delays in seeking medical attention, delays at the hospital in diagnosing the patient to confirm the presence of ischemic stroke and in getting patient/family consent to administer tPA, and physician concerns that tPA will cause potentially fatal braining bleeding (a risk that increases the longer treatment is delayed). A recent national study found that only 2.4 percent of all eligible ischemic stroke patients receive tPA.3
  • Failure to provide other recommended care: National data indicate that hospital staff routinely fail to provide other recommended care to stroke patients, including smoking cessation counseling, which is given to only 34 percent of stroke patients, and screening for dysphagia (a condition that causes difficulty swallowing), which is performed on roughly half of patients.4

What They Did

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Description of the Innovative Activity

Mary Washington Hospital implemented a comprehensive initiative to enhance stroke care using the American Heart Association and American Stroke Association's Get with the Guidelines program. Key features include early activation of a "code neuro" protocol to facilitate faster evaluation and diagnosis of patients experiencing stroke symptoms, quick administration of tPA when indicated, 24-hour access to a neurologist, enhanced discharge planning, improved documentation and data collection, continuous staff training, and community outreach to educate the public about stroke. More details on each of these features follows:
  • Expedited evaluation via "code neuro" protocol: Once called by a patient or family member, specially trained emergency medical service (EMS) personnel work with hospital staff to avoid delays in determining whether the patient is having a stroke. To that end, EMS staff immediately call the Mary Washington Hospital emergency department (ED) when they observe any signs of a stroke in a patient. This call automatically activates a "code neuro" protocol that mobilizes all necessary staff to prepare for the incoming patient. Once the patient arrives, ED staff immediately conduct critical laboratory tests, such as blood counts and blood chemistries, with results being available within 2 minutes. The code neuro protocol also triggers a call to radiology staff, who make sure that one of the hospital's two computed tomography (CT) scanner devices will be available upon the patient's arrival. An initial CT scan to rule out the presence of a hemorrhagic stroke as part of the determination if a patient is a candidate for tPA is conducted within 25 minutes of arrival, with results available within 45 minutes of arrival. In addition, ED staff screen all suspected stroke patients for dysphagia (which can interfere with treatment) by conducting a short test with applesauce and water.
  • Fast administration of tPA after diagnosis: The process outlined above allows for quicker diagnoses, resulting in a greater percentage of patients being ready to receive tPA within the allotted time frame from stroke symptom onset. To eliminate delays after diagnosis, the ED places a tPA tool box at the patient's beside that includes everything needed to administer the treatment, including the drug itself, a consent form to be signed by the patient or a family member, and dosing guidelines. Using this process, the hospital strives to give the drug to all appropriate patients within 1 hour of arrival at the hospital.
  • 24-hour neurologist access: The hospital employs four neurologists, with at least one being available to cover the ED at all times.
  • Enhanced discharge planning: Before discharge, staff ensure the patient has all appropriate prescriptions (e.g., for blood-thinning and cholesterol-lowering drugs), an appointment with their primary care doctor, a referral to a rehabilitation center, if appropriate, and educational information explaining what to do to reduce the risk of future strokes (e.g., quit smoking, exercise, follow a healthy diet). Staff also encourage patients to follow up with a primary care provider and/or neurologist within 4 to 6 weeks.
  • Improved documentation, data collection to facilitate quality improvement: Hospital staff keep comprehensive records of stroke care provided, including how quickly patients receive tests, how quickly test results come back, how many patients receive tPA, and how quickly eligible patients receive tPA, thus allowing for continuous evaluation and improvement of stroke care.
  • Ongoing training: All ED staff (more than 300 employees) received training on the American Heart Association and American Stroke Association's Get with the Guidelines program, the code neuro process, and the diagnosis and treatment of stroke. Each month, an interdisciplinary team known as the stroke steering committee meets to review hospital policies and discuss new strategies for improving stroke care. EMS staff, who are privately employed, are encouraged to attend these sessions, which include time for staff to present and analyze one recent stroke case.
  • Community outreach: Hospital staff who specialize in stroke care work with area media and speak to local groups in an effort to increase the public's awareness of early signs of stroke and the importance of seeking immediate medical attention (rather than waiting to see if symptoms subside).

Context of the Innovation

Mary Washington Hospital is a 437-bed hospital in Fredericksburg, VA. As a part of Mary Washington Healthcare's Journey to Excellence, senior hospital administrators identified a need within the broader community for a primary stroke center. Hospital officials believed that the development of a comprehensive program to improve stroke care would not only benefit patients, but also enhance the hospital's reputation, making it a hub for stroke care in the region.

Did It Work?

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Results

The program led to more timely diagnosis and treatment of stroke, with a higher percentage of patients receiving CT scans within 25 minutes and tPA administration within 60 minutes of hospital arrival. Overall, 8.5 percent of eligible stroke patients at the hospital received tPA in 2009, more than triple the national average of 2.4 percent.
  • More timely diagnosis through CT scan: In 2009, all suspected stroke patients received a CT scan within 25 minutes of their arrival at the hospital, compared with just 45 percent in 2008.
  • More patients getting tPA, in a more timely fashion: In 2009, 8.5 percent of eligible stroke patients received tPA at the hospital, more than triple the national average of 2.4 percent. Among patients receiving tPA, 50 percent received the drug within 60 minutes of hospital arrival, well above the national average of 30 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of how quickly suspected stroke patients receive CT scans, along with post-implementation data on the percentage of eligible patients receiving tissue plasminogen activator and the percentage receiving it within 60 minutes of hospital arrival, both in comparison with national averages.

How They Did It

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Planning and Development Process

Key elements in the planning and development process include the following:
  • Forming steering committee: In July 2007, the hospital formed a 25-member stroke steering committee that included hospital administrators, physicians, and nurses who met monthly to plan the program's development. The committee designated a registered nurse as the "stroke team coordinator" who oversaw program planning and operation.
  • Developing enhanced data collection system: The committee focused on improving data collection efforts related to stroke care by identifying opportunities across the continuum of stroke care, from prehospital EMS care to a stroke support group. Committee members retrospectively gathered data from past years and implemented a system to track new stroke cases. Data collection was also shared across the team to improve care and target areas for education and streamlined processes, such as the code neuro protocol and standardized stroke order sets.
  • Hiring neurologists: To ensure 24-hour neurologist availability, the hospital employed four in-house attending neurologists.
  • Gathering information from external resources: The steering committee researched evidence-based standards on stroke care and purchased the American Heart Association and American Stroke Association's Get with the Guidelines program, which offers instruction on implementing a quality stroke treatment program. The committee also reviewed and incorporated guidelines from the Academy of Neurology and visited several other hospitals to learn about their stroke treatment protocols.
  • Redesigning processes to speed test results: The committee worked with representatives from other hospital departments, such as radiology and laboratory, to ensure that conducting and reporting results from laboratory tests and CT scans for suspected stroke patients became a top priority. For example, they developed the aforementioned process for ensuring the availability of a CT scanner when suspected stroke patients arrive at the hospital.
  • Dedicating ED rooms to stroke patients: The ED decided to dedicate two trauma rooms in the front of the facility to treat arriving patients suspected of having a stroke.
  • Receiving stroke center designation: In July 2009, following a successful inspection and other administrative reviews, the Joint Commission certified the hospital as an advanced primary stroke center.

Resources Used and Skills Needed

  • Staffing: As noted, the program required the hiring of three additional neurologists to provide 24-hour access. All other clinicians, including ED physicians, nurses, and other hospital staff, participate in the program by providing care to suspected stroke patients as part of their regular duties.
  • Costs: The hospital purchased the American Heart Association and American Stroke Association's Get with the Guidelines program through the Joint Commission for approximately $3,000. The program did not require significant additional costs, as it mostly entailed using existing resources (e.g., space, staff, diagnostic equipment) more effectively.
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Funding Sources

In 2010, Mary Washington Healthcare won the National Quality award, known as the Spirit of Excellence, from Sodexo and Modern Healthcare. The stroke steering committee chose to use the one-time award of $5,000 to establish a scholarship fund for ongoing stroke education for Mary Washington Healthcare staff. All costs associated with obtaining Primary Stroke Center Certification were funded by Mary Washington Healthcare.end fs

Tools and Other Resources

American Stroke Association and American Heart Association Get with the Guidelines stroke treatment program. Available at: http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStroke/GetWithTheGuidelinesStrokeHomePage
/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp


American Academy of Neurology. Practice advisory: Thrombolytic Therapy for Acute Ischemic Stroke. Available at: http://aan.com/professionals/practice/pdfs/pdf_1995_thru_1998/1996.47.835.pdf

Adoption Considerations

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Getting Started with This Innovation

  • Identify and correct delays: Because every minute matters to a stroke patient's survival, scrutinize each step of the current care process, from the moment the call is placed for an ambulance until the patient has been diagnosed and treated with tPA. The goal is to identify and eliminate unnecessary delays wherever they occur.

Sustaining This Innovation

  • Keep focus on patient: Although improving stroke care can be complex and often involves numerous details, remember that positive changes can directly affect patient outcomes. In continually redesigning care processes, staff at Mary Washington are reminded to keep asking themselves, "What kind of care would I want my mother or father to receive?"
  • Emphasize ongoing case review: Even when steady improvements occur, avoid complacency by critically evaluating every case. If care deviated from recommended guidelines, determine why this happened and take steps to ensure it does not happen again.
  • Stay on top of new developments: Because guidelines on stroke care frequently change, follow current developments and adjust practices accordingly. Mary Washington Hospital's stroke team continually attends and presents at stroke-related conferences, and updates treatment protocols and stroke care as needed.

More Information

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Contact the Innovator

Maha Alattar, MD
Medical Director, Stroke Team
Mary Washington Healthcare
1001 Sam Perry Blvd
Fredericksburg, VA 22401
Phone: (540) 899-1671

Innovator Disclosures

Dr. Alattar has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Hall J. Hospital certified for treating strokes. Fredericksburg.com. August 23, 2009. Available at: http://fredericksburg.com/News/FLS/2009/082009/08232009/488245/index_html

Finkel E. An idea with heart. Modern Healthcare. December 14, 2009. Available at: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20091214/REG/312169997# (registration required)

Footnotes

1 Rosamond W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics—2008 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117(4):e25-146. [PubMed] Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.187998
2 Lansberg M, Bluhmki E, Thijs VN. Efficacy and safety of tissue plasminogen activator 3 to 4.5 hours after acute ischemic stroke. Stroke. 2009;40(7):2438-41. [PubMed]
3 Kleindorfer D, Xu Y, Moomaw CJ, et al. US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke. Stroke. 2009;40(11):3580-4. [PubMed]
4 Adams K, Corrigan JM, editors. Priority areas for national action: transforming health care quality. Institute of Medicine: National Academy Press; 2003.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 21, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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