In 1994, a CQI group was established to focus on management of stroke patients. Physicians and department representatives met to discuss causes of delays in patient care and opportunities for improvement. They identified rate-limiting steps in the clinical process and found opportunities for reducing costs and length of stay, increasing admissions, and achieving uniform practice standards among physicians. Stroke care is managed by neurology physicians who are stroke specialists. Orders are designed to conform with the clinical pathway.
Process of Care
All potential stroke patients are evaluated immediately. Patients are triaged and admitted to the “resuscitation” room in the ED, which is dedicated to critically ill patients. A packet of all necessary stroke documents is available in the ED. This packet includes the stroke clinical pathway, standing orders, the NIH Stroke Scale, and educational material for the patient and family.
Evaluation using the NIH Stroke Scale is performed in the ED and repeated on every subsequent shift. Heparin is administered according to a weight-based protocol.
Family education begins as soon as the patient arrives. Family support is evaluated immediately, and a discharge plan is determined within the first day. The nursing staff uses a swallowing screening tool to identify patients at risk for aspiration and in need of speech therapy. The speech therapist evaluates patients and works with nurses, respiratory therapists, and the dietitian to implement appropriate patient care. The physical therapists maintain close contact with the attending physicians. Discharge Planning Rounds occur twice a week, at which time each patient’s discharge needs can be evaluated.
A strong relationship with rehabilitation facility has contributed to early patient transfers. Patients on heparin can be transferred to the rehabilitation facility.
An educational program targets the lay public. As part of this program, a stroke risk assessment form was inserted in the newspaper. Upon completion, the form could be mailed to the hospital, where a neurologist specializing in stroke management would review the information. The neurologist’s recommendations would then be mailed back to the person wishing to be assessed.
The acute Stroke Team, which includes attending physicians, is responsible to the care of stroke patients in 15 area hospitals.
Overview of the University Hospital
Rationale and Background of Stroke Clinical Pathway
- Highest quality care.
- Consistent and efficient management.
- Appropriate utilization of resources.
- Identify rate-limiting steps in prolonging patient’s stay.
Reality – Pre-Pathway
- To expensive and too long relative to National average.
- Inconsistency of care delivery and poor knowledge about underlying costs.
- Level of expertise for acute stroke care among the highest in the world.
Rate-limiting steps identified in critical pathway process
- Disposition of patients – delay in consultation to rehab (Drake) setting, delay in getting patients transferred to Drake, no consultation of transfer on weekends, delay of stroke patients with minor medical problems, delay in social work to identify payor source and family supports to facilitate discharge to nursing home or home.
- Certain tests not done on weekends. Delay in echo reports.
- Delay in decision to begin warfarin if indicated.
- Actions to address these issues:
- Process of Drake referral and transfer greatly facilitated. Early standard orders to consult PMR and Drake within the first 2 days of admission. Increased medical presence of Drake has facilitated earlier transfer to Drake (e.g. switching from heparin to warfarin treatment).
- Tests can be obtained on weekends.
- Standard order of tests, as indicated within first day.
Appropriate utilization of resources
- The issue of stroke units – what is needed is often not an intensive-care unit setting but a monitored-bed setting with more intensive care for the first 1-2 days.
- We are addressing the use and overuse of echo as well as other diagnostic tests.
- Review charges and use of respiratory therapy.
Consistent and efficient management
- A packet for each patient form entry with preprinted and standardized orders on each day.
Highest quality care
- High degree of neurologic input from stroke neurologists and neurosurgeons.
- Accuracy of coding (TIA vs. stroke) – already being done by Drs. Brott and Broderick.
- Develop criteria for doing tests.
- Close monitoring of stroke patients to insure things work well and for neede changes.
- Need for stroke monitoring unit, not intensive-care, for most patients – good care, reasonable cost.
- Strong neurologic overseeing of process including patient care.