Let's begin with what we all should know about strokes. They can be deadly. They can be difficult to diagnose. Time is of the essence for effective treatment.
What we all should also know is that hospitals haven't traditionally done the best job caring for stroke patients. That's because many of them, especially small ones and those in rural areas, may not see very many of them in the course of a year. And recognizing stroke symptoms can be difficult.
Perhaps this is why the Centers for Medicare & Medicaid Services is putting an emphasis on quality metrics. Beginning Jan. 1, 2013, hospitals must begin reporting on 17 areas and 76 new measures under CMS's Hospital Inpatient Quality Reporting Program. Eight of those measures evaluate the care of stroke patients.
Providing those metrics will not be much of a challenge for big regional health systems such as the Bon Secours Virginia Health System, where Timothy Shephard, PhD, is vice president of the Bon Secours Neuroscience Institute, a primary stroke center.
But others will have difficulty, and that's where Shephard sees opportunity not only to educate about better stroke care, but to improve compliance at smaller hospitals.
As one of the founding chairs of the Virginia Stroke Systems Task Force, he has helped bring together all the stakeholders in the state on acute stroke and rehab services, which helps hospitals, even small ones, develop as primary stroke centers.
"When I talk about organizing this in a hospital system, the most challenging and most rewarding is the orchestration of the ED services," he says. "They see everyone who is critical and if the staff isn't highly trained to notice subtle signs of stroke, they may take a victim who has more painful injury before they take a stroke victim."
That lost time counts in stroke more than anywhere else, simply because the symptoms can be so subtle, and damage from strokes can be minimized with early intervention.
"Once you recognize, the steps are protocol-driven just like trauma and MI (heart attack)," he says. "But that takes skill and training. Training takes time. And that's one thing they don't have a lot of, is time."
In a system full of large and small hospitals, the challenge, ultimately, is to bring all of them up to the speed of diagnosis of the big tertiary center. That's something on which Shephard spends a considerable amount of time and effort.
Systemwide, "the key is to have a neuroscience coordinator and stroke educator—people who are dedicated to providing that service to everyone who gives care in the hospital," says Shephard.
Another one of the chief enablers of that effort is technology, predominantly through telemedicine.
For smaller hospitals that may be independent and cannot afford the investment in a neuroscience coordinator, a stroke educator, and a vice president like Shephard, or for whom stroke may not be the educational priority at that moment, developing certified stroke centers may be an option.
Virginia, thanks to efforts from Bon Secours and others to share their expertise, now has 36 stroke centers. When the task force was started, it had six. Bon Secours has also expanded its teleneurology capabilities to offer smaller hospitals expertise in their emergency departments 24-7. That's where smaller hospitals, not owned by Bon Secours, fit into the equation.
"That's one of the components of our success," says Shephard. "We're developing certified stroke centers in hospitals as small as 75 beds."
Rappahannock General, which has 75 beds and a clinical affiliation agreement with Bon Secours Virginia Health System, now has teleneurology with 24-7 backup and is on track to becoming a certified stroke center by next year.
Leaders shouldn't neglect the business case, which is also important, cautions Shepard.
"It's not the size of the hospital, but a limiting factor to developing stroke care is having the expertise on the campus," he says. "You need an administrator who can do the appropriate business analysis on what it will cost and the benefit to the patient and to train your staff to monitor and prepare for certification by the Joint Commission."
With significantly smaller volumes than heart attack, neurology is challenging for smaller hospitals, he says, because it's difficult to find experienced administrators.
"From a clinical expertise standpoint, teleneurology helps there, but not necessarily from the business case side. What is the ROI for patient and the hospital?"
More important is dealing with care protocols regardless of stroke center designation, he admits.
"The hospitals that are not certified stroke centers and who have not paid attention to these metrics are going to be challenged if they haven't already started training their quality team," he says.
"While most are already submitting core measures, the stroke stuff is new. You may be able to abstract, but you may not have expertise to be able to improve it. That will be challenging for hospitals that don't specialize in neurosciences."
Philip Betbeze is the senior leadership editor at HealthLeaders.