New Approaches for Neuro Care Service Lines

This article appears in the November 2012 issue of HealthLeaders magazine.

Before neurologist Andrei Alexandrov, MD, joined the 1,146-bed University of Alabama at Birmingham Hospital more than five years ago, the hospital had an uncertain vision for a comprehensive stroke program, which was more piecemeal than programmatic; the hospital addressed only certain aspects of stroke care. Then Alexandrov and his colleagues drew up a planning document approved by the C-suite that proposed dramatic changes in neurology care that would cascade through the system. This vision encompassed new multidisciplinary teams, revamped hiring practices, new clinical approaches, and innovative research.

Since then, the hospital has developed a proven comprehensive care program, and gave it a name that befits its purpose: The Comprehensive Stroke Research Center has a team of neurologists and nurse specialists who cover a wide swath of specialties, including a neurological urgent care center, and a memory disorders clinic for a variety of neurological conditions such as Alzheimer's, Parkinson's, and other diseases that affect the brain.

As one of dozens of hospitals dubbed a center of excellence by various organizations, the University of Alabama at Birmingham Hospital has tripled the number of patients enrolled in its neurological programs the past five years and is now at approximately 1,000 stroke patients per year. In addition, 60% of ischemic acute admissions are treated in less than two hours from symptom onset. Treatment should be carried out within three hours of onset, according to American Hospital Association guidelines.

What Alabama has done demonstrates the approach to neurological care geared to excellence that is changing the landscape for neurological patients, especially those in need of stroke care. "To organize such a program you need an institutional commitment for change. That's No. 1," Alexandrov explains. "Years ago, the traditional practice of stroke care meant you reacted to a problem and did the bare minimum. Diagnose. You give the patient some aspirin. But the idea of a comprehensive stroke center or a neuroscience center of excellence is that the buck stops here, for care. If a patient needs the most sophisticated procedure or complex care, that's where the patient should go."

Hospitals are finding a path to excellence in different ways. Successful programs are specializing in stroke care, offering advanced procedures, building a case for a primary care stroke center, and taking on strategic opportunities by coordinating programs with other hospitals that have limited programs.

Lacking resources, some hospitals rely on connections with more advanced hospitals that obtained the primary stroke center certification for expanded stroke care delivery for patients. Stroke care is a complicated series of procedures and different specialties, especially focused on what has become a healthcare mantra in dealing with strokes: "Time lost is brain lost."

Most strokes are ischemic, caused by lack of blood flow in the brain usually due to a blockage or blood clot. The window for treatment to reverse the damage from an ischemic stroke is measured in hours. One minute of brain ischemia can kill 2 million nerve cells and 14 billion synapses, thus reducing the odds of a good outcome as time elapses before intravenous thrombolysis, according to the American Heart Association and the American Stroke Association.

Echoing many healthcare leaders, Angie West, RN, MSN, CNRN, CCRN, director of neuroscience/stroke for MemorialCare Neuroscience Institute, part of the MemorialCare Health System, in Long Beach, Calif., says, "Time is brain. The longer patients wait, the more brain cells die, and [patients] have less-functional outcomes. Time is of the essence."

The hospital achieved the AHA's Get with the Guidelines Stroke Gold Plus Performance Award, which showed that it achieved 85% or higher adherence to guidelines for two or more consecutive 12-month intervals and compliance with quality measures.

Timeliness is reflected in the overall target of bringing a patient to be treated within 90 minutes of an attack. Without such attention, a patient can face complications related to other damaging and costly issues, such as readmissions within 30 days. A campaign created by the AHA and American Stroke Association—Target: Stroke—is designed to help hospital teams achieve door-to-needle treatment delivery times of 60 minutes or less for ischemic stroke patients who receive thrombolytic therapy. This prompt care is accomplished by providing evidence-based strategies, clinical decision support, measurement tools, and other resources.

Some hospitals working to achieve those "speed" goals are also wasting no time in developing comprehensive, coordinated stroke programs. Some aren't stopping at building stroke centers and are rounding out a vision for more comprehensive neurological centers, which many hospital leaders say eventually will be accredited by groups such as the Joint Commission.

"We have seen neurosciences as an up-and-coming service line," says Mona Euler, RN, vice president of neuroscience at the 3,326-bed Indiana University Health, based in Indianapolis. "It's relatively new compared to other service lines, but it is being driven by the need of patients. Millions of Americans are suffering at some point from neurological disease and need treatment. The neuroscience service line is just an excellent area for most hospitals to get into."

Euler says Indiana University Health has developed a "one-stop shop" for neuroscience care for various neurological system disorders. The system's health neuroscience center is combining resources with the Indiana University School of Medicine for multiple neuroscience specialties.

By having a coordinated approach, Indiana University Health has been certified as a primary care stroke center, a recognition of making an exceptional effort to foster better outcomes for stroke care. Demonstrating compliance with the Joint Commission's national standards and performance measurement expectations may help obtain contracts with purchasers and help control costs and improve productivity, the commission states. The Joint Commission's Primary Stroke Center Certification program was developed in collaboration with the American Stroke Association.

"We want to offer the most comprehensive care in neuroscience," Euler says. "It was a vision of our senior leaders. We wanted to unite research, education, and clinical all in one. We felt we were fragmented by being in different locations before."

Success key No.1: Coordination

By implementing a coordination of care program, the 86-staffed-bed Saint Luke's Neuroscience Institute has increased its speed in responding to stroke patients sent to the hospital. As a result, the Kansas City, Mo.–based facility has been able to use a significant medical therapy for stroke patients more often than other hospitals have.

Saint Luke's Neuroscience Institute has specialized in tissue plasminogen activator (tPA), the only FDA-approved therapy for acute ischemic stroke.

Despite being widely available since 1996, the therapy is still significantly underutilized. That can be attributed, in part, to the fact that tPA must be used on patients within three hours of a stroke's onset. In 2009, tPA treatment rates nationwide were only up to 5.2%, about twice the rate from 2005, according to Marilyn Rymer, MD, medical director and director of research at Saint Luke's Neuroscience Institute.

Saint Luke's uses the treatment at a rate twice the national average, says Rymer. Its initiatives have resulted in greater access to treatment, showing an increase of 23% in volume from 2005 to 2010. Overall, the total number of stroke patients treated at Saint Luke's increased 19.6%, from 567 to 678 from 2010 to 2011. The tPA treatment increased from 136 to 177, a 30% increase from 2010 to 2011, she adds.

"The first barrier is getting people to the right facility in time for treatment, with the IV tPA time window of three to four-and-one-half hours for treatment," Rymer says. "The next barrier is that many hospitals do not have acute stroke teams to attend to the patients very quickly. The CT scan is essential before treatment, and some hospitals do not have 24-hour access."

Saint Luke's also implemented key program initiatives to drive excellence in stroke care, including standardized care sets and care paths, and interventional stroke reversal protocols to extend the treatment window. By showing improved outcomes, Saint Luke's has reached agreements with other community hospitals for a regionalized program in which its hospital staff evaluates and offers assistance to others, she says. Other facilities in a 150-mile area, through agreements with Saint Luke's, have 24/7 access to its stroke expertise.

"We decided to organize stroke care in 1993, before any therapies were available," Rymer says. "Early in the game we evolved, and engaged these 60 or 70 emergency service providers in the area, and we have streamlined our process for transporting patients for referral hospitals."

Success key No.2: Dedicated critical care unit

For many hospitals, being named a center of excellence means possibly gaining the services of a neurosurgeon they were courting or developing grant proposals that may bring dollars that otherwise they could not obtain.

The Joint Commission has certified several dozen hospitals across the country as primary stroke centers or centers of excellence for treatment of stroke. As such, these hospitals have specialty-trained staff with innovative equipment and proven strategies to offer better overall care.

Those strategies include focusing their work on an interdisciplinary unit such as the University of Alabama at Birmingham Hospital's 64-bed combined neurology-neurosurgery unit, which includes an ICU for stroke patents.

"The patient needs to be coming on time to the hospital; there needs to be public education, so the comprehensive stroke center should be visible to the community," Alexandrov says. "We need to provide therapy as a standard of care, 24/7 and 365 days. That's a commitment as an institution. Physicians are recruited and prepared for that."

Although academic institutions may have access to resources needed for complex clinical and research programs, it is important for large community hospitals to expand their reach to include clinical research in stroke care as well, says Chere Gregory, MD, medical director of neurosciences for the 921-licensed-bed Forsyth Medical Center in Winston-Salem, N.C., a nonprofit regional medical center. Forsyth received the Get with the Guidelines Gold Plus Performance designation.

Coordinated, comprehensive care is important for dealing with a wide array of neurological issues, says Gregory. Smaller hospitals must transfer patients to another location, she adds. Forsyth Medical Center has its own neurological intensive care unit, with 28 beds in the stroke unit to focus on patients with stroke, brain injuries, and other neurological conditions. "We decided to create a center of excellence for stroke care by having a comprehensive interdisciplinary approach to providing that care," Gregory adds.

A key part of the program is having a neurosurgeon and neurointerventional radiologist available around-the-clock "for those acute therapies when needed," Gregory says. Because timing is so critical in stroke care, "even accounting for that 15-minute drive that a patient makes to the hospital is crucial, and we can make a difference having a neurosurgeon and neurointerventional radiologist there, ready," she adds. "It has become important to shave off time any way we can. Few hospital systems have a neuro-critical care unit dedicated to the critically ill. In effect, we are changing the face of neuro-stroke care."

Success key No. 3: Improving awareness

While healthcare organizations acknowledge that speed is essential in stroke care, some patients may not be aware that they are having a stroke simply because they are unfamiliar with the symptoms. A stroke sufferer may misinterpret a headache or trouble moving a leg, not realizing that the situation is potentially serious.

Because of that lack of knowledge among the general public, some hospitals are committed to increasing education programs for patients. There is much work to do. Long Beach (Calif.) Memorial began offering an array of education programs after it realized that less than 20% of stroke patients seek hospital care quickly after identifying possible symptoms, says Angie West, the stroke care program director for the MemorialCare Neuroscience Institute, part of the MemorialCare Health System, which has 1,549 beds. "Less than 10% get here in the right amount of time to make a difference," West says.

Generally, the AHA and the ASA aim to increase the number of eligible acute ischemic stroke patients who receive IV rtPA in 60 minutes or less, but that hasn't been easy to do. In a review of more than 2 million patient records contained in the organizations' Get with the Guidelines Stroke registry, only 19% to 22% of patients had a "door to needle" time of less than 60 minutes within the past two years.

Long Beach Memorial runs community meetings to spread the message about stroke care. West coordinated one recently for a group of aeronautical engineers in Southern California. The hospital reached out to the group because of the lack of understanding about strokes, she says.

"We work in the community and try to encourage people in the community to know what the signs and symptoms of stroke are," she says. "The problem with stroke or the challenge with stroke is that it doesn't hurt; people ignore it, because you don't have crushing chest pain or symptoms such as slurred speech or heaviness in the arm. People wait and don't act on it, so it's really important to push the community to get here in the hospital for care," she says.

Hospitals are taking different steps to improve educational processes for patients. The 840-licensed-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C., implemented a coaching program that focuses on stroke patients. The coach is often a nurse, but could be another healthcare professional or a social worker, for instance, says Cheryl D. Bushnell, MD, associate professor of neurology and director of Wake Forest Baptist's primary stroke center.

The coaching program has been included in a pilot project that also includes educational screening tools to help identify hospitalized patients who may be at higher risk for a second stroke or are having trouble with their medications or appointments, says Bushnell. The idea is to improve transition from hospital to home and avoid potential rehospitalization, she adds.

Hospital officials get a sense of patients' health literacy, "such as their confidence in filling out medical forms without help," she says. In her study, 93.9% of those in a coaching group knew what to do if there were problems or if their conditions worsened, compared to 77.8% who weren't coached, she adds. Overall, 93.8% of the patients who had been in the coaching group saw their primary care providers after discharge, while only 60% in the control group made such a visit.

"We are assessing the best way for patients to learn new information through the coaching program," she says.

Success key No. 4: Targeting the TIAs

A big concern for a hospital system is ensuring that patients don't go back to the hospital as 30-day readmissions. The Forsyth Medical Center has reduced its readmission rates in stroke care by working to "bridge the gap" of those who are discharged, says Gregory. The program is run out of the stroke center's Transient Ischemic Attack Center, a dedicated facility for rapid diagnosis and treatment of patients who experienced a TIA stroke, often known as a "ministroke."

The Stroke Bridge Clinic, another Forsyth Medical Center initiative, is an outpatient facility; it provides 30-minute follow-up appointments, as well as coordinating 20 minutes with a pharmacist and 20 minutes with a stroke navigator for stroke patients within one to two weeks after they are discharged from the hospital.

"Our data shows that a stroke patient has a greater chance of being readmitted to the hospital if they do not visit the Bridge Clinic," says Gregory. Indeed, 8.8% of patients who did not receive Bridge Clinic follow-up were readmitted in 2011, but only 2.6% of those who visited the Bridge Clinic were readmitted. Overall improvement continues. From January through July in 2012, readmission rates were 6% for non-Bridge and just 0.4% for Bridge patients.

A TIA occurs when a blood clot interrupts blood flow to the brain, and can last anywhere from a few minutes to 24 hours, but produces no visible damage and can disappear quickly. However, a TIA can be a precursor of things to come, with studies showing that half of all strokes are preceded by a TIA. Studies have shown that people who suffer strokes within 48 hours after experiencing a TIA often have a more debilitating or potentially deadly stroke.

The TIA Center at the Forsyth Stroke and Neurosciences Institute provides for fast-track diagnosis so treatment can be carried out quickly, reducing the risk of a full-fledged stroke in the future. The unit also treats diabetes, heart, or blood pressure problems, and high cholesterol and other conditions that could increase the risk of stroke.

With new protocols, the hospital also has substantially decreased lengths of stay as well as the 30-day readmissions, Gregory says. Both TIA lengths of stay and readmission rates were much lower in the TIA Center than for patients with TIAs admitted to other parts of the hospital. Average length of stay in the TIA Center from January to July of this year was 1.5 days, but was 2.8 days for all other hospital units, the hospital stated.

At the Stroke Bridge Clinic, a neurology nurse practitioner reviews patients' treatment plans to make sure that recovery is progressing as well as it should, according to the hospital. A stroke navigator also guides patients and their caregivers through the recovery process, answering questions and helping with arrangements such as transportation and appointments.

"About seven to 10 days after someone is discharged from the hospital, they go to Bridge Clinic and a specially trained nurse practitioner and educator and a pharmacist have discussions with patients and caregivers," Gregory says. A multispecialty team, including radiologists, pathologists, ED physicians, as well as counselors, an internal medicine physician, and a neurosurgeon, is involved in program planning.

The best use of the Bridge is to provide clarity of information for patients, who are often confused while in the hospital because of the sheer volume of information they receive, she says.

"Clearly, there's a distinct difference for patients who are in Bridge and for patients who are in the hospital right after a stroke," Gregory says. "In the hospital, they get so much information, and it's really difficult to wrap your head around all of it.

"While we created a bridge between the hospital and outpatient," Gregory adds. "We don't replace the family doctor. We partner with them. We want to ensure that patients have everything they need, because they are still at risk for having another event. There has to be an understanding about the medications they need, about their need to make their appointments."

Challenges to patients are mirrored by challenges to hospitals that are likely to see a rising tide of stroke patients needing care with the aging population. How they organize to meet this influx will be a decision that can save lives and elevate the reputations of their institution.

This article appears in the November 2012 issue of HealthLeaders magazine.