Once a patient recognizes stroke symptoms, emergency medical services are often involved, and they should also be a key stakeholder, Catto says. EMS drivers must be able to recognize symptoms and have a protocol in place for radioing ahead and notifying the hospital. At Beaumont, however, only about half of stroke patients arrive by EMS; the other half come by private transport and are greeted by a security guard at the front of the hospital, so Catto worked with both EMS and the guards to help those employees learn to identify stroke symptoms and react quickly when necessary.
"When we broke down the time intervals, we found that even if it takes seven minutes for the security guard to get the person into a wheelchair and get them in, you could miss the window with IV tPA," she explains. "You have to get everyone onboard, from security to triage to your ER nurses and physicians."
Many hospitals extensively train ED personnel to respond routinely to stroke cases. But because of overcrowding in Beaumont's ED, Catto formed a stroke team of 14 nonphysician providers to answer rapid response stroke calls before contacting a neurologist.
The vertical integration continues through to rehabilitation—another requirement consideration for stroke care. Beaumont has an inpatient rehab unit but also partners with nine sub-acute rehab facilities.
There are a number of ways to handle rehab, but one of the key components is the ability to show outcomes, says Brandt. Rehab facilities need to be willing to track performance measures for prevention of secondary stroke and follow complications and outcomes measures.
Key No. 3: Integrate horizontally
Horizontal integration at the clinician level can be a bit trickier as advances in treatment have opened up turf wars between specialists. Service line leaders are often tasked with figuring out how to divvy up cases between both hospital and private medical groups representing a variety of specialties.
For instance, both vascular surgeons and radiologists can do carotid doppler, an ultrasound test that can find arterial abnormalities or blockages, and both specialties will argue that their results are superior, says Catto. For a year, Beaumont had a private neurosurgeon performing interventional work in addition to the staff radiologists. Even cardiologists were campaigning to get in on the stroke program.
How the service line is organized can make a difference. Catto is a board-certified internist and says her neutrality had helped somewhat in mediating turf disputes because she isn't seen as advocating for a particular specialty group. Buy-in and support from the C-suite also helps, she says, but even that has its limitations.
For many physicians, call coverage is the sticking point. Interventional radiologists who see cases 24/7 can argue that their outcomes on certain procedures are skewed by the difficulty of emergency cases they see, for instance. And private practice neurologists often aren't interested in taking call at all.
"A lot of the community neuros are in-office and that's where they make money. Leaving office to see an acute stroke patient is disruptive. We had 29 neurologists and none wanted to come into the hospital," says Brandt.
Early on in the program, Seton was working with neurologists who were affiliated with but not employed by the University of Texas. Because of the call coverage issue, Seton began employing a number of hospital-based neurologists and moved them to the university to handle emergencies, in addition to paying a small stipend for taking call.