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Certifiable Stroke Care

Elyas Bakhtiari, for HealthLeaders Magazine, September 10, 2009
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With a growing emphasis on stroke center certification, hospitals must demonstrate that they have the teams in place to treat stroke patients quickly and effectively, or risk losing patients to a competitor down the road.

At the onset of stroke symptoms, speed is essential—lost minutes can be the difference between full recovery and brain damage, or even death. So the standard protocol for most emergency medical services has been to rush stroke victims to the nearest hospital.

But stroke care quality hinges heavily on two factors—speed and capability—and some are beginning to wonder if the healthcare system is focusing too much on the former at the expense of the latter. A growing number of states—Florida, Massachusetts, New York, New Jersey, Illinois—have passed legislation aimed at equalizing stroke care priorities; though the specifics vary, the common idea behind the legislation is to get patients to the right hospital—one that has processes in place to treat patients quickly once they arrive—rather than the closest hospital.

The laws generally allow ambulances to take patients to the nearest hospital certified as a primary stroke center—either by the Joint Commission or the state—even if that means bypassing a closer hospital that hasn't been certified. In those states, certification is a necessity if a hospital wants to maintain a leading stroke service line. More state governments are considering similar legislation, and the certification requirements could offer a glimpse into the nationwide future of stroke service lines.

The impetus has in part been the studies that have found the percentage of stroke patients who receive clot-busting, and potentially life-saving, drugs to be in the single digits. The onset of stroke symptoms is like the starting gun of a relay race—getting the patient to a hospital is important, but that is only the first leg. The "door-to-drug" time is also crucial.

The window for administering IV tPA, a clot-busting drug that can substantially increase survival, is between zero and three hours and again between three and four-and-a-half hours; intra-arterial tPA can be administered within six hours of a stroke. Thrombectomy devices only have about an eight-hour window.

The challenge of reaching and treating stroke patients in such a short time frame is one reason that stroke remains the No. 3 killer in the United States and costs the healthcare system more than $45 billion a year. And it is compounded by demographics—not just the growing number of baby boomers who are reaching ages when stroke becomes more common, but shifts in location, as well. Retirees are moving out of cities into suburban or rural settings but expect levels of care similar to what they would get in Boston or Chicago or New York, says Bill Likosky, MD, medical director for stroke at Swedish Medical Center, a nonprofit health system in Seattle.

"The impact on smaller hospitals is to say, 'How do we step up to the plate. We can't transfer them quick enough for them to get quality stroke care. How do we gear up?'"

Service Line Success Key No. 1: Get certified
As certification requirements domino through the states, the obvious response to the growing trend is to get certified—either through a state-level commission (if required) or the Joint Commission's primary stroke center certification program. But those who have gone through the process caution that it isn't an easy endeavor.

Cedars-Sinai Medical Center worked for two years to fully incorporate the Joint Commission certification criteria, even with the American Heart Association's "Get with the Guidelines" certification assistance program. Depending on the existing level of sophistication at a given hospital, stroke center certification may require significant changes, both within the stroke service line and in other hospital departments, says Laurie Paletz, RN-BC, stroke program coordinator at the 952-licensed-bed hospital in Los Angeles.

"It takes buy-in and a multidisciplinary approach like no other program in the hospital," she says. "We work very closely with pretty much every department in the hospital. We had to change a lot of the documentation—standing order sets for physicians, stroke patient education forms, and swallowing screens specific to the Joint Commission."

Just to implement a requirement for 24-hour cardiac monitoring of stroke patients, the hospital had to invest hundreds of thousands of dollars in cardiac monitors and in training for the stroke floor nurses to learn the technology and processes. And it isn't just the resources and time off the floor for the stroke nurses that add up—nurses and staff in other departments also have to be trained to deal with strokes that happen within the hospital.

It doesn't get much easier after the certification, either. Lauren Brandt, clinical program director for neurosciences for Seton Family of Hospitals, a network of 31 facilities providing care in central Texas, has guided Seton's stroke program through two recertifications and has had more difficulty engaging employees as time goes by and the novelty of the certification process has worn off. "The certification reviewer even told us that this recertification is the hardest one because hospitals change leadership and physician champions and have been under fiscal constraints, so it's difficult to maintain same level of enthusiasm," she says.

Yet for all the hassles of certification, it is increasingly difficult to see a future without it. It doubles as a marketing tool, both through the better reputation and with EMS providers (who bring in more patients) and through the community outreach requirement in the certification measures. And, if the rest of the nation ultimately follows the states that have already established guidelines for EMS, not being certified could cost hospitals.

"Stroke is going in the direction of ambulance-directed care and if you are not a Joint Commission-certified stroke program and a patient has a stroke on the steps of your emergency room, that patient is going to go to the nearest certified stroke center," says Paletz.

Key No. 2: Integrate vertically
Can a hospital run an effective stroke service line without being certified? Of course. But certification provides a tested road map for stroke care that gives legislators, insurers, and quality improvement organizations greater confidence in a hospital—not just its results, but its organization—at first glance.

Because time is so crucial, stroke care requires a higher level of vertical integration than most service lines. It's not enough to just have a multidisciplinary team within the hospital—the coordination (and education) has to begin the moment the patient becomes aware of symptoms and end only when the patient is recovering and adjusting to a post-stroke lifestyle.

Ultimately, the patient is a key stakeholder in the program, says Susan Catto, MD, codirector of stroke care at William Beaumont Hospital, a 1,061-bed major academic and referral center with Level I trauma status in Royal Oak, MI. The sooner a patient recognizes the symptoms of a stroke and seeks treatment, the better the chances of survival; that's why community education is an integral piece of most stroke programs, and why it is required for certification.

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