1 North East LHIN Stroke Care Review 2013 Draft Recommendations (as of April 22 nd, 2013) Proposed Change 1: Consolidation of Inpatient Acute and Rehabilitation Stroke Care 1. Pre-Consolidation Allied Health Staffing Enhancements at North East LHIN Designated Stroke Centres (HSN, SAH, TDH, NBRHC) In comparison to best practice guidelines (3 hrs therapy/day, 7 days/week), a gap exists in the acute and rehabilitation inpatient allied health staffing at each designated stroke centre in managing their current stroke patient volumes. This staffing gap, which amounts to 10.0 s at a cost of $850,831 is outlined in Appendix A. This gap must be addressed prior to moving forward with consolidating community hospital volumes to these centres. 2. Regional stroke care consolidation should proceed. To ensure all stroke patients in all geographic locations across the NE LHIN have access to best practice inpatient care, both inpatient acute and rehabilitation stroke care should be consolidated to the NE LHIN s four designated stroke centre hospitals - Health Sciences North (HSN), Sault Area Hospital (SAH), Timmins and District Hospital (TDH) and North Bay Regional Health Centre (NBRHC). This consolidation would require the transfer of approximately 268 acute stroke patients per year from community hospitals to the region s designated stroke centres. Also, this consolidation, in conjunction with a move towards meeting the provincial benchmark of 42.3% of stroke patients (TIA not included) accessing inpatient rehabilitation, could see approximately 74 more patients admitted to inpatient stroke rehabilitation programs at the region s designated stroke centres. A district level breakdown of the anticipated new patient volumes at each of the designated stroke centres in the NE LHIN are outlined in Appendix B. 3. West Parry Sound Health Centre Special circumstances for consolidation of care due to proximity to designated stroke centre outside of NE LHIN. Stroke patients that would normally receive inpatient acute and rehabilitation care at the West Parry Sound Health Centre (44 acute, 10 rehab) should receive care at the closest designated stroke centre to their home community. In general, patients in this catchment would transfer to the designated stroke centre in Huntsville (North Simcoe Muskoka LHIN). Patients that reside in communities in the northern part of this catchment area could potentially transfer to either Sudbury or North Bay (Note: these volumes are not accounted for in the chart in Appendix A)
2 4. Planning for Additional Resources for Consolidation Note: At this time, it is unknown what impact the Quality Based Procedure Funding Model (scheduled for implementation for inpatient stroke care sometime during the 2013/14 fiscal year) will have on hospital operating budgets. It is recommended that formal discussions/negotiations be conducted by the NE LHIN to discuss budgetary implications at community hospitals, designated stroke centres and with EMS partners to determine the financial impact of the following resource issues related to consolidating stroke care. a. Hospital Bed Impact The anticipated increase in inpatient beds required at each designated stroke centre to accommodate the volume of patients being consolidated to each site (assuming 90% occupancy rate to ensure system flow, with 10 day acute LOS for stroke (5 days for TIA) and 30 days for rehabilitation) is as follows: Additional beds required at each site are as follows: STILL DRAFT Acute Stroke Unit Rehabilitation Stroke Unit Site Current # Beds # Additional Beds for District Volume Note: WPSHC volumes not include above. If included, total bed # s would be: Acute beds; Rehab 26.4 beds b. Allied Health Staffing Consolidated Stroke Unit Size (10 day LOS) The inpatient allied health staffing in both acute and rehabilitation settings at each designated stroke centre would need to be enhanced to ensure best practice care is provided following consolidation. This equate to 6.3 s at a cost of $553,212. A breakdown of these costs is outlined in Appendix C. Appendix C outlines the total cost for additional allied health to provide best practice stroke care to both the existing volume and consolidated volume at each designated stroke centre. This equates to a total of $1,405,139. Appendix E outlines the recommended allied health staffing s for both the Acute and Rehab Stroke Units at each designated stroke centres based on consolidated volumes. These s would be dedicated to provide care to just the stroke inpatient population. c. Acute Stroke Unit Nursing Model Current # Beds # Additional Beds for District Volume Consolidated Stroke Unit Size (30 day LOS) HSN TDH NBRHC SAH
3 TBD: Suggest for Acute Care: RN Model 1:4, 1:6/7 for Nights Suggest for Rehab Care: RN/RPN Model: Or just use staffing ratio (e.g. 1:4 RN; 1:8 RPN) d. Physician Model TBD e. Ancillary Services (DI, Lab, Medical Supplies, Housekeeping, etc) TBD -? impact of Quality Based Procedure (QBP) Funding Formula f. EMS Transfer Volumes To be developed NOTE: need to discuss the issue raised of splitting the EMS transfers from Elliot Lake between Sudbury and Sault Ste. Marie to decrease impact on Algoma EMS 5. Revision of Memorandum of Understanding for Medical Redirect and Repatriation of Northeastern Ontario Acute Stroke Patients. The current Memorandum of Understanding (MOU), which primarily outlines the role of EMS and hospitals during hyperacute (tpa) stroke cases, roles/functions should be revised to become a single region-wide policy for stroke care transfers and repatriation including the following: a. Revisions to the current Repatriation Agreement including the following: i.patients that are re-directed to a designated stroke centre for possible thrombolysis will no longer be repatriated back to their home hospitals hour post tpa delivery (or once medically stable for patients not receiving tpa). These patients (if diagnosis of stroke or high risk TIA is confirmed and admission is required) will now be admitted at the designated stroke centre for the completion of their acute care hospital stay. ii.specific language should be added that outlines once a patient has completed their acute care but are deemed ALC, they should be repatriated back to their home community hospital. Repatriation of stroke patients deemed ALC should be completed by the appropriate service based on the patient s condition (e.g. via EMS or Non-Urgent Transfer Service). iii.special note: Patients that are deemed ALC but have been accepted for inpatient rehabilitation should not be repatriated to their home hospital while awaiting admission.
4 b. A new section developed that outlines the Protocol for Inter-Hospital Transfers for stroke patients that initially present to a community hospital emergency department (i.e. not involved in a medical direct for possible thrombolysis). This protocol will allow for: i. Emergent transfer (via EMS) of a stroke patient to a designated stroke centre hospital ii.direct admission to a stroke unit inpatient bed iii.completion of a CT-Scan (minimum) c. The Protocol for Inter-Hospital Transfers described above will need to include a decision tree for patients where the diagnosis of stroke or TIA is not confirmed (i.e. stroke mimic) following transfer to a designated stroke centre. The decision tree will assist in determining the appropriate course of action (e.g. admission to appropriate inpatient unit at designated stroke centre, repatriation to community hospital or transfer to another tertiary hospital)
5 Appendix A Current Gap in Allied Health Staffing in Comparison to Best Practice Recommendations (Source: M. Meyer, D. Jermyn 2013) Based on current staffing, the gap in resources at each stroke centre for caring for its current stroke volumes is outlined in Appendix B: Health Sciences North Additional Allied Health Staffing ( s) to Meet PT OT SLP PTA OTA CDA Acute ,047 Rehab ,696 s $268,743 Timmins and District Hospital North Bay Regional Health Centre Sault Area Hospital Additional Allied Health Staffing ( s) to Meet PT OT SLP PTA OTA CDA Acute ,514 Rehab ,366 s $102,880 Additional Allied Health Staffing ( s) to Meet PT OT SLP PTA OTA CDA Acute ,522 Rehab ,362 s $197,884 Additional Allied Health Staffing ( s) to Meet PT OT SLP PTA OTA CDA Acute ,912 Rehab ,412 s $281,324 NE LHIN Additional Allied Health Staffing ( s) to Meet PT OT SLP PTA OTA CDA Acute ,995 Rehab ,836 s $850,831
6 Appendix B Acute Care Consolidation Volumes Based on historical data, the total volume of acute patients requiring transfer to a designated stroke centre would be as follows*: Designated Stroke Centre Avg. Yearly Inpatient Acute Volume Additional Acute Care Transfers Anticipated New Yearly Acute Volume Community Hospitals in Stroke District HSN Elliot Lake, Espanola, Manitoulin Island, Parry Sound* TDH Chapleau, Hearst, Kapuskasing, Smooth Rock Falls, Cochrane, Iroquois Falls, Matheson, Kirkland Lake, James Bay Coast NBRHC Englehart, Temiskaming, Mattawa, West Nipissing, Parry Sound* SAH Blind River, Wawa, Hornepayne s * West Parry Sound Health Centre inpatient volumes (44 patients/year) are not included in above figures as the majority of these patients would transfer to the designated stroke centre in Huntsville as part of the North Simcoe Muskoka LHIN Stroke Care consolidation. Inpatient Rehabilitation Consolidation and Move Towards Provincial Benchmark Based on historical volumes and a move towards the provincial benchmark of 42% of acute stroke patients (not including TIA) being admitted to inpatient rehabilitation, the anticipated new volume of rehabilitation patients at each of the designated stroke centres would be as follows. Designated Stroke Centre Avg. Yearly Inpatient Rehab Volumes Potential Additional Rehabilitation Transfers Anticipated New Yearly Volume Inpatient Rehabilitation HSN TDH NBRHC SAH s
7 Appendix C: Additional Allied Health s to Consolidate Care and Provide Best Practice Care: Acute and Rehab Units North East Regional Values Discipline Acute Acute Rehab Rehab PT , , ,890 OT , , ,890 SLP , , ,442 PTA , , ,765 OTA , , ,765 CDA , , , $251, $300, $552,312 Consolidation of Care Breakdown of Funding per Designated Stroke Centre Site % Consolidated Acute Volume Additional Acute Funding % Consolidated Rehab Volume Additional Rehab Funding Funding HSN 33% 83, % 69,479 $154,485 TDH 32.6% 82, % 73,088 $155,088 NBRHC 29.6% 74, % 120,611 $195,065 SAH 4.8% 12, % 37,599 $49, % $251, % $300,777 $552,312 Appendix D: Allied Health Funding to Meet Best Practice: Current Volumes + Consolidated Volumes Site Additional Funding For Current Volumes Additional Funding For Consolidated Volumes Additional Funding to Meet Best Practice HSN 268, ,485 $423,228 TDH 102, ,088 $257,968 NBRHC 197, ,065 $392,949 SAH 281,324 49,670 $330,994 s $850,831 $552,312 $1,405,139 Appendix E: Recommended Allied Health Staffing s for Acute and Rehab Stroke Units at Designated Stroke Centres based on best practice recommendations staff dedicated to treating inpatient stroke population only Acute Stroke Unit
8 Site PT OT SLP PTA OTA CDA HSN TDH NBRHC SAH Rehab Stroke Unit Site PT OT SLP PTA OTA CDA HSN TDH NBRHC SAH