NINDS: Stroke Proceedings: Levine

Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

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How to Create and Sustain the Continuum of Acute Stroke Care

Steven R. Levine, M.D.
Henry Ford Hospital and Health Sciences Center, Detroit, Michigan

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• Background Overview
• Creating the Continuum of Acute Stroke Care in an Integrated Health System
• Maintaining the Continuum of Acute Stroke Care in an IHS
• Summary
• References

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Background and Overview

There are several models for providing health care in the United States. Systems that succeed in providing high-quality and consistent care for patients with acute stroke will be those that assure physicians' autonomy in managing each individual patient. Extending the quality and consistency of care in single systems to multiple health systems throughout the United States will be greatly facilitated by the existence of a national stroke database, standardization of care, and uniform measurements of outcome.

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Creating the Continuum of Acute Stroke Care in an Integrated Health System

Stroke neurologists and stroke nurses can join forces to team up with key people ("champions") in the emergency department (ED) and form on-call acute stroke teams. These teams would provide coverage 24 hours a day, 7 days a week, 365 days a year to the ED, hospital, and community. An on-call schedule can be developed each month, coordinated by one of the stroke nurses. A physician (stroke neurologist, stroke fellow, or emergency physician) certified in the NIH Stroke Scale (NIHSS) (1) would always be on call along with a nurse.

A dedicated team-paging system for stroke can be programmed for the stroke team pagers. Considerable time must be spent to build an understanding of acute stroke treatment with different services and departments that form key components of the acute stroke system: ED triage nurses, ED staff and residents, radiology and neuroradiology staff, CT technicians, pharmacy administrators and pharmacists, technicians who perform emergency laboratory testing, acute stroke and intensive care unit nurses, nursing administrators, hospital administrators, intensivists, and neurosurgeons.

Regular inservice training and flow-charting of each step in the treatment of acute stroke must be performed, reviewed, and continually revised and improved upon with the focus on efficiency. In addition, major efforts should be made to educate members of the emergency medical services (EMS)and the general community about stroke risk factors and warning signs and about the use of the 911 emergency system. The education program will require a dedicated telephone line and e-mail address. Continuing medical education programs specifically for acute stroke recognition and management must be provided for emergency medical technicians (EMTs). The EMS link in the chain of stroke survival should be emphasized and reinforced with the old adage: "The chain is only as strong as its weakest link."

Within an integrated health system (IHS), potential patients and the members of the IHS should receive newsletters that provide education about stroke, emphasizing the importance of rapid assessment and treatment, and the need to recognize stroke risk factors and warning signs. Stroke must be presented as a 911 emergency, analogous to severe burns and head trauma. Personnel in every urgent care access site within the IHS should be trained to recognize stroke symptoms, triage acute stroke patients, and activate the acute stroke care system. Easily understood one-page screening checklists can be posted in the ED triage area to facilitate patient screening.

The model IHS recognizes that in systems for acute stroke management and treatment no one person can accomplish all that is required. Hence, a system approach is critical to success. The IHS enhances the care for stroke patients by combining the efforts of many individuals with a wide range of skills: neurologists, ED staff, and EMTs in the community.

Our experience at Henry Ford Hospital is that several months are needed to prepare for treating acute stroke patients. The steps required include training personnel to rapidly identify stroke patients within the ED, training stroke physicians to use the NIHSS, publicizing the acute stroke treatment system, setting up a stroke education program for the public, and initiating inservice training, practice trial runs, and regular meetings to discuss the protocol, maintain enthusiasm, and foster teamwork.

As the acute stroke treatment system is developing, personnel in the system should meet regularly to review current and optimal practice and to monitor integration of the stroke system within the larger health care system. For instance, since giving t-PA to eligible stroke patients reduces the length of hospital stay and increases the number of patients discharged to their homes rather than to a rehabilitation unit or nursing home (2), there may be justification to shift resources within the larger health care system to facilitate development of the acute stroke care system.

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Maintaining the Continuum of Acute Stroke Care in an IHS

Establishing a system for maintaining, improving, and expanding the continuum of acute stroke care within a health care system will not be simple or inexpensive. Permanent, rapid, and effective linkages are needed to maintain a continuum of stroke care that encompasses:

• Stroke education and awareness campaigns -- Community response to stroke
• Community -- use of 911
• 911 -- rapid response by EMS
• EMS -- rapid transport to hospital
• Hospital -- access to expert stroke care
• Expert stroke care -- access to rapid diagnostic tests (CT, laboratory tests)
• Hospital resources -- treatment and monitoring after treatment

To develop new linkages, it will be critical to:

• Show value
• Demonstrate high quality
• Demonstrate efficient care at low cost

The major goals for the new system of linkages are to:

• Maximize the number of patients receiving effective care
• Minimize the risk involved

Developing local standards of care may be one way to begin establishing an acute stroke care system. It may be useful to start within a hospital system and then grow outward--to the community, to the county, to the state, and eventually to a regional or even national level of care. Within the hospital, the process can begin with conducting more physician education courses about acute stroke. A hospital system can be expanded to the community by providing stroke expertise on call to multiple hospitals that may agree to use the same paging system to notify physicians. Communication between hospitals can be encouraged. For example, the same courses for inservice training can be given to personnel at different hospitals. Ongoing communication will help ensure timely patient evaluations and timely acquisition of clinical data needed to identify optimum patient care in the acute stroke setting. The communication will also identify those key people who will become the champions for rapid acute stroke care.

Keeping the acute stroke care system as simple as possible (e.g., a "one call does all" stroke beeper system) is key. Shifting toward disease management rather than staying focused within departmental/divisional walls will assist in establishing collaborative practice patterns. Linkages to satellite sites within larger health systems will be needed. These linkages could (a) include hands-on skills workshops for continuing medical education credit provided by established stroke centers and professional societies (e.g., American Academy of Neurology); (b) increase multidisciplinary practices that involve internists, intensivists, neurosurgeons, and emergency physicians; and (c) promote "bundling" acute stroke care with other acute neurological/neurosurgical/trauma care plans. Barriers to simplifying and defining standards must be identified and addressed. Because national guidelines do not always change physician practices, local plans with local champions are needed. Practitioners in the community may not want to be told what to do, as has been the case in the past with other top-down approaches. Medical professionals should be offered several alternatives, creating an environment where there are real opportunities for participation.

"Reverse gate-keeping" in a managed care environment, which allows complete access to stroke experts early in the course of an acute stroke, may prove to be an effective model for stroke care.

One way to treat more patients effectively, in both rural and urban areas, may be acute stroke care via telemedicine. Telemedicine for stroke is currently unproven, but holds promise as a technology-intensive rather than people-intensive method of providing rapid, expert acute stroke management and treatment expertise for hospitals and EDs with available head CT scanning but limited access to stroke experts. Telemedicine could provide access to an acute stroke treatment system for more patients, would help train physicians as they are treating the patient, and would be cost-effective. Interest in telemedicine is growing nationwide. It may provide the needed link to rural and urban care facilities lacking rapid access to appropriate specialists (e.g., neurologists and neuroradiologists). Further, telemedicine offers a means to centralize medical specialists in an environment more conducive to teaching and research. Teleradiology and telepathology have already been approved for reimbursement in different systems. Telemedicine for stroke is a new application for existing technology that ultimately could provide a rapid global response system making optimal use of critical resources.

Developing an interactive medical record for each acute stroke patient and every patient at risk for stroke within a health system would facilitate accurate relay of real-time patient information. This information might include standardized, quantitative stroke scale scores and live video of functional assessments, neuroradiological imaging, laboratory studies, protocols, and care maps. Data could be transmitted from the patient's current location to the facility where care will take place (local physicians or regional experts). Primary prevention strategies, secondary prevention measures, acute interventions, and neurorehabilitative protocols could be implemented on a more widespread and standardized basis. Further, use of this technologically based system could easily enhance clinical trials (3), testing hypotheses related to lay and professional education, acute intervention, prevention, and the poststroke period. Thus, rigorously and scientifically acquired data could be accumulated much more rapidly than has been possible previously, hastening the advancement and refinement of care for patients.

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Summary

Most effective behavior change requires alteration of the environment in which the system functions and in which care is provided. Education is often necessary but, by itself, usually insufficient. Effective behavioral and system change usually requires a combination of changes in administration, regulation, financial incentives, and information feedback.

The goal is to provide the highest level of acute care for stroke patients as quickly as possible.

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References

1. Brott TG, Adams HP Jr, Olinger CP, et al. Measurement of acute cerebral infarction: A clinical examination scale. Stroke 1989;20:864-870.

2. Fagan SC, Morgenstern LB, Pettita A, et al (and the NINDS rt-PA Stroke Study Group). rt-PA reduces length of stay and improves disposition following stroke (abstract). Stroke 1997;28:272.

3. Adams RJ, Fisher M, Furlan AJ, et al. Acute stroke treatment trials in the United States. Rethinking strategies for success. Stroke 1995;26:2216-2218.

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Last Edited: June 01, 2000

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892