Hospital-Based Sub-Acute Stroke Care and Secondary Prevention. Timothy Lukovits,, M.D.

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1 Hospital-Based Sub-Acute Stroke Care and Secondary Prevention Timothy Lukovits,, M.D.

2 Volunteer group members Shalini Bansil,, MD Summit NJ Ji Chong,, MD, NYC, NY Srinath Kadimi,, M.D. Fairfield, CT Steve Levine, M.D. NYC, NY Mary Amatangelo,, NP Boston, MA Kinan Hreib,, M.D. Burlington, MA Ed Feldman, MD Providence, RI John Belden, MD Portland, ME John Halperin,, M.D. NY

3 Summary The inpatient care of stroke patients provided in the Northeast is in many respects not optimal and improvement is being barred by ambivalence, limited resources, and geography. Tools, processes and collaboratives that allow us to more systematically assess and improve the care we provide THROUGHOUT the region are becoming available.

4 Our domain Organization of teams Order sets/practice guidelines Staff education Comprehensive dx evaluation Appropriate consultations Secondary prevention measures started in-hospital Antiplatelets within 48 hours Smoking cessation Lipids Warfarin for atrial fibrillation Diabetes management Diet/exercise Appropriate timing of prevention measures (BP) Appropriate use of CEA Identifying barriers to compliance Preventing complications Dysphagia, DVT, Pneumonia Appropriate inter-hospital transfers for specialty care (Neurosurgery, Interventional Radiology) Prevention and management of complications Safety Patient and family education Initiation of rehab plan Handoff to rehabilitation facilities or outpt providers (anticoagulation, BP) Timely follow-up with the right person Appropriate use of palliative care

5 It s time we raise our standards for where our stroke patients stay in the Northeast

6 BUT first we need to agree on where they will go and how to get them there (and what they really need for the trip) New York 2 (Grand Central) 2003 Spencer Tunick

7 Why is this so hard?

8 Barriers 1. Ambivalence 2. Limited resources 3. Geography 4. No plan

9

10 Relevant highlights from the 2006 meeting Initial reports from each state Canadian Stroke Network lessons (audits, TIA clinics) Tri-State Stroke Network audits (GA, NC, SC) NYS Rural Hospital (telemedicine) initiative Coverdell/SCORE

11 Overall process for writing Year 1 goals group Define guiding principles Begin assessment of inpatient care provided here using currently available resources Collect success stories

12 4 Guiding Principles (a la Schwamm) 1. ACCESS TO ORGANIZED CARE 2. SECONDARY PREVENTION 3. EDUCATION 4. SMOOTH TRANSITIONS

13 Assessing how we re doing: what s s currently available? Demographics state hospital association data AHRQ mortality rates Process of care Anecdotal reports Informal surveys Surrogates of quality stroke service designation, JCAHO certification, participation in GWTG- Stroke, Coverdell, SCORE, Health Dept data (NYS Demonstration project)

14 Hospital stroke surveys completed to date CT: some results reported NECC 2006 Mass.:? more than Coverdell hospitals Maine: NECC 2006 Hospital Capacity Survey,, I do not have results NH: reported NECC 2006 NJ? NY: +/- (NYS Demonstation Project results), Hospitals surveyed 2006 (I do not have) RI: to be reported NECC 2007 VT: in process

15 Stroke service designation or QI recognition programs State Stroke Centers JCAHO GWTG Approx # of Acute Care Hospitals CT N/A NJ 4*(CSC) NY MA ME N/A NH N/A RI N/A VT N/A Sources: JCAHO website 9/11/07, Z. Magdon-Ismail Ismail, AHA, * S. Bansil,, M.D., internet

16 Linking stroke centers and other hospitals: update on telemedicine in NYS

17 GWTG Stroke Tool results: Northeast 8/31/06-8/31/07 8/31/07

18 Why what have available is inadequate? we re missing what is happening at MANY hospitals in our region Ordering doesn t t mean done, follow-through with measures (smoking) we have relatively little input from patients and families we have very little information on the status of some key aspects of care that are more difficult to measure including education and transitions, CVA (confused vascular analyses), safety, and the care of hemorrhagic stroke

19 Year 3 goals Actually COMPLETE Year 1 goals Catalog success stories in our region and other regions PROTECT, Canada Stroke Strategy (SPIRIT) Educational programs, communication methods with rehab facilities and PCPs More details on the unique barriers for inpatient stroke care in our region (shortage of subspecialists, geography, opinions of non-believers ) Update on telemedicine efforts Detailed infrastructure and cost analysis for ideal system Some attention to ICH and SAH care Final recommendations

20

21 Let there be light

22 Appendix slides

23 Guiding principle 1: ACCESS TO ORGANIZED CARE A stroke system should use organized approaches including stroke teams, stroke units, and written protocols to ensure that all patients receive timely and effective subacute inpatient care. The prevention and treatment of early deterioration, stroke recurrence and common complications are critical. Continuity of care should be pursued with therapies initiated during the hyper-acute phase. Access to this organized care should be enabled through inter-facility and in the field protocols, as well as telemedicine where appropriate.

24 Guiding Principle 2: SECONDARY PREVENTION A stroke system should adopt approaches to secondary prevention that address all major modifiable risk factors and that are consistent with the national guidelines for all patients with a history or suspected history of stroke or transient ischemic events.

25 Guiding Principle 3: EDUCATION A stroke system should ensure that stroke patients and their families receive education about stroke risk factors, warning signs, and the availability of time-sensitive therapy, as well as the appropriate method for activating EMS in their area.

26 Guiding Principle 4: SMOOTH TRANSITIONS A stroke system should ensure a smooth transition from inpatient to outpatient care, including timely transfer of hospital discharge information to the subsequent treating physician and a clear method of appropriate follow-up.

27 NH Survey Results Number responding 93 CT Tech always available 84 Air ambulance tpa protocol Neurologist always available Data collection Angiography routinely available CME MD event 6 months Stroke Program 24hr MRI Community Ed event 6 months * * 44 * * 65 * 80 Neurosurgeon always on call Stroke Unit Response Team Clinical trials Stroke Clinic * * 16 * Percent

28 Positive effect of JCAHO certification

29 JCAHO certified as of 9/11/

30 State-designation of stroke centers/services * * *

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