Creating Stroke Systems of Care

Elyas Bakhtiari, for HealthLeaders Magazine , June 9, 2010
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Sharp HealthCare has used the American Heart Association's Get with the Guidelines certification assistance program for several hospitals in its system, all of which provide different levels of stroke care, says Mary Elington, director of orthopedic and neurological services at Sharp Healthcare. For instance, although it has been using the Get with the Guidelines program for nearly five years, Sharp Memorial Hospital was only certified as a primary stroke center in 2009. Implementing the guidelines early helped improve the overall quality of the program, Elington says.

"We use that as our vehicle for quality improvement and performance improvement. We track all Joint Commission measures and quality care process measures," she says. "We use that for our process improvement and to track how well we're doing."

One of the biggest challenges has been ongoing staff education requirements. The certification guidelines push hospitals to develop dedicated stroke care teams that have unique training.

If you don't have that kind of a unit where the care is concentrated to those patient populations, and they're mixed into the general med-surg population, she says, you have challenges making sure all nursing personnel are up to speed to get measures done and meet patient needs.

As more hospitals successfully receive primary stroke center certification, the next logical step looks to be certification for comprehensive stroke centers. Most certifying bodies don't distinguish between the two, but in order to expand the systems of care model in the future, comprehensive stroke centers may have to meet additional guidelines to demonstrate their ability to accept transfer patients and perform interventions on severe cases.

Success Key No. 5: Track and share outcomes
One of the key components of a stroke system of care identified by the American Stroke Association was continuous quality improvement initiatives. This is important not only within an individual stroke center, but between spokes and hubs within a network.

St. Luke's quality improvement efforts center on tracking and sharing outcomes. The governance committee meets quarterly with spoke hospitals to share outcomes data. Together, they look for variances in the data and try to collaboratively improve patient transfers and clinical processes.

But the real challenge for stroke care is moving from quality performance measures to true outcome measures. "We can always track outcome measures during hospitalization. What we're really looking for is outcomes at 30 or 90 days post stroke. That's a little trickier to track," says Sacco.

St. Luke's engages physicians at rehab facilities as well to ensure coordination of care extends beyond the acute care phase. Some spoke hospitals have their own in-house rehab services, and coordinating between the various settings makes tracking outcomes longitudinally a little easier.

The National Institutes of Health stroke scale and Rankin scale are two options that more stroke centers are using to get a sense of health outcomes. Both track motor skills, speech recognition, and other stroke recovery indicators and can be used over time to quantify not just if a patient lived or died after a stroke, but how well he or she is returning to normal.

More detailed outcome measures not only help with readmissions, but they can also help sell the value of all these stroke systems of care to other disciplines. Setting up a system requires significant investments of time and resources from multiple departments. If a hospital can show that 70% of people with a 0 Rankin score before intervention have returned to normal, it may be easier to get buy-in from ED physicians and other providers.

Elyas Bakhtiari is a freelance editor for HealthLeaders Media.
Components of Care

The American Stroke Association recommends that stroke systems of care include six components:

  • Primordial and primary prevention
  • Notification and response of emergency medical services for stroke
  • Acute treatment for stroke
  • Subacute stroke care and secondary prevention for stroke
  • Rehabilitation of stroke patients
  • Continuous quality improvement initiatives

SOURCE: American Stroke Association;

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