The Development of a Stroke Systems of Care Model in Rural Illinois

Transcription

1 The Development of a Stroke Systems of Care Model in Rural Illinois Presenter: Wende Fedder DNP, RN, MBA, FAHA Executive Director, Neuroscience Institute Alexian Brothers Health System American Stroke Association State of the Art Nursing Symposium January 31, 2012 Advisor: Marilyn Wideman DNP, RN-BC Director Faculty Practice and Outreach Administrator Continuing Education Provider Unit Assistant Professor Community Systems and Mental Health Nursing Second Reader: Karen V. Lamb DNP, RN, GCNS-BC Associate Professor Rush University Medical Center College of Nursing

2 Problem Focus- Problem Major advances have been made in acute stroke care Still, Stroke Systems of Care are lacking in rural areas of Illinois Fragmentation of stroke care caused by lack of care integration Stephenson county is a rural county: Rural Definition: county census places population greater than 2,500 and less than 50,000 people per square mile (USDA 2010 ). Stroke 2005 Stroke Systems of Care

3 Problem Focus- Background Institute of Medicine report concludes health system fragmentation results in: Sub-optimal treatment Increased mortality Increased complications Non-compliance with national standards Inefficient use of resources To ensure that scientific knowledge is translated into practice, the IOM recommended establishment of coordinated systems of care (Stroke Systems of Care Schwamm. et al.. Stroke. 2005;36:690.)

4 Problem Focus- Background Higher Stroke Mortality in Rural Stephenson County Key Point: Stroke mortality higher in rural areas without designated stroke centers & supports IOM report on health system fragmentation Freeport Chicago/Alexian Rural areas Age-Adjusted Three Year Mortality April

5 Problem Focus - Background Fragmentation in Illinois-2002 Data were collected from 183 of the 202 facilities surveyed. Urban Chicago hospitals had greater access to more neurologists, neurosurgeons, and interventional neuroradiologists than rural areas Only 30 % had a stroke community awareness program Only 15 % had a stroke team Ruland, Gorelick et.al. Stroke. 2002;33:

6 Mission: Implementation & Process Analysis To develop a model of coordinated stroke systems of care between a rural hospital and certified Primary Stroke Center based on Joint Commission standards to reduce the fragmentation of stroke services in northern Illinois Short Tem Objectives: Develop low cost acute stroke tele-link for use in rural hospitals to transfer interventional stroke cases Educate rural EMS and hospital clinicians in best practices Improve patient quality outcomes in rural settings To prepare rural hospital for stroke designation

7 Planning Setting One Suburban Chicago Certified Primary Stroke Center with comprehensive Interventional Neuroradiology stroke services in Elk Grove Village Illinois (Alexian Brothers Medical Center) Setting Two Rural Stephenson County Emergency department in Freeport, Illinois. (FHN Hospital)

8 Phase 1 ~Set-Up Develop an tele link access line Educate clinical staff on acute stroke protocols Planning Develop marketing materials including a rolodex card with access line number Develop an ED triage plan for stroke at FHN Phase 2~Education Educate EMS and clinical staff Communicate stroke warning signs and 911 response to the community

9 Planning Economic influences Political environment As a result of the political and legislative changes

10 Implementation- Initial Planning Steps Completed in 2010: Obtained buy in from senior leadership 2009 Tele-link system between facilities 2009 Key stakeholders established 2009 Benchmarked with other Joint Commission hospitals Literature review Rural hospital hired Stroke RN Coordinator (budgeted) FHN Stroke Coordinator and ED Medical Director to Develop a Stroke Alert Process at rural site Educate Emergency Medical Services (EMS) in rural county Maintain Primary Stroke Center Certification at Comprehensive Stroke Center

11 Evolution of project Implementation Successes: What Worked? Monthly conference calls Rural hospital Stroke Center Coordinator hired System COOs met in person June 2011 Tele-link established (Stroke Urgent Transfer Line) FHN Stroke Alert process developed and launched November 1, 2010 (Tracy Love, Dr. Awender) Database identified and baseline data entered in January 2010 EMS education improved baseline stroke knowledge October 2010 Tour of Primary Stroke Center July 2011 Education Events (MD, EMS) March 2010, Feb /16/2010 FHN EMS Education Event FHN Stroke Coordinator, Tracy Love RN, BSN ABHS Neuroscience Ex. Dir: Wende Fedder DNP, RN, MBA, FAHA Legislative representation (regional and state 2011)

12 Evolution of project Implementation Barriers: What didn t work? Limited rural hospital neurology coverage was a challenge Transferred patients inconvenienced by distance EMS education schedule (call occurred during education course) FHN Hospital 10/2010

13 Evolution of project Effectiveness of marketing and/or business plan: Benefits- Overall Positive Collaboration between facilities built the foundation of a stroke system of care Reduced costs for stroke physician coverage (INR) and multi-million dollar biplane equipment Increased access to tertiary care for patients in rural counties Improved EMS knowledge of stroke Improved outcomes for patient Raised awareness of collaboration and access to expertise (marketing efforts) FHN staff: Tracy Love RN, BSN, Dr. Awender, Doug Toepfer EMT, Denise Book, RN

14 Implementation- Marketing External Stroke of Good Fortune New partnership speeds treatment to stroke patients in rural Illinois. New partnership speeds treatment to stroke patients in rural Illinois July 14, 2010

15 Implementation- Internal Marketing

16 Short Term Objectives: Summary Met- Improved patient clinical outcomes at rural hospital after Stroke Alert Process implementation including door to CT time Met- Increased patient access to acute care treatment (intravenous and intra-arterial) Met- Increased EMS knowledge in rural county

17 Results and Outcomes Analysis Stroke Performance Measures DVT Prophylaxis FHN Jan 2010 BASELINE FHN July 2010 Short Term Objective 1 Improved patient clinical outcomes at rural hospital since Baseline (used with permission from FHN) FHN August 2010 FHN September 2010 FHN October 2010 FHN November 2010 FHN December % (0/1) 100% (1/1) NA (0/0) 100% (2/2) 100% 100% 100% Discharged on Antithrombotics 100% (3/3) 100% (2/2) 100% (1/1) 100% (1/1) 100% 100% 100% Anticoagulation for Atrial Fibrillation NA NA (0/0) NA (0/0) NA (0/0) NA (0/0) 100% 100% tpa Considered/Admi nistered NA NA NA NA 0% (0/1) NA NA Antithrombotic Medication within 48 hours 100% (1/1) 100% (2/2) NA (0/0) 33.3% (1/3) 100% 100% 100% Lipid Profile-LDL Documented 0% (0/1) NA (0/0) 0% (0/1) 50% (1/2) 0% (0/2) 100% 33% (1/3) Screening for dysphagia 0% (0/2) 0% (0/8) 0% (0/1) 0% (0/7) 0% (0/4) 22% (2/9) 25% (2/8) Patient education 0% (0/4) 0% (0/4) 0% (0/1) 0% (0/1) 0% (0/1) 37% (3/8) 75% (3/4) Smoking Cessation 100% (1/1) 100% (1/1) NA (0/0) NA (0/0) NA (0/0) 33% (1/3) 100% Rehabilitation considered 0% (0/1) 87.5 % (7/8) 100% (1/1) 100% (6/6) 100% 77% (7/9) 85% (6/7) % of Door to CT <= 25 min 0% (0/6) 33% (3/9) 0% (0/2) 22% (2/9) 50% (3/6) 46% (6/13) 62% (5/8) Conclusion: Trends improving in 7 of 10 outcomes measures since baseline

18 Results and Outcomes Analysis Short Term Objective 2 Increased patient access to acute care treatment (intravenous and intra-arterial) Conclusion: Increase access to advanced treatments ** Ave stroke census 15/mo at FHN * Total Tele-link Calls = 157

19 Results and Outcomes Analysis Short term Objective 3 Increased EMS knowledge in rural county * National Stroke Association EMS Rapid Response Program Survey Used Pre Post Significance Level Question #2 (Brain Attack definition) 25% 25% Not sig. Question #11 (Public Education) Question #13 (Right sided stroke symptoms) 45% 73% p= <0.5 73% 100% p= <0.5 Conclusion: Significance reached in 2 out of 15 questions post education program

20 Summary EMS Run Times- Stroke Education program and summary of EMS- long-term outcome EMS run times average time 61 min Geography delays Volunteer EMS delays Weather delays Dispatch stroke education EMS Ed Dispatch Notified Time Arrive at Destination Call Time Altered Level of Consciousness 10/16/ :45 22:22: min 11/07/ :02 13:53: min 11/10/ :27 13:15: min 12/01/ :47 15:56: min 02/19/ :17 02:27: min 03/10/ :47 01:40: min 11/18/ :03 14:44: min 01/09/ :41 14:44: min 03/31/ :50 09:54: min 04/09/ :47 13:43: min Grand Total: 13

21 Outcome Analysis of Short Term Goals Gaps between expected and actual outcomes: No increase in TPA treatment despite ED process improvements, but may be too soon to analyze considering the rural hospital only sees 15 stroke patients a month - Stroke volume flat in rural hospital (more patient education needed) More appropriate calls made to UTL, thus more appropriate transfers made to PSC EMS education needed and EMS unsure of Brain Attack definition Patient education partners (Genentech and American Heart Association) more diluted in rural areas

22 Budget- On Target for Rural Hospital Rural Hospital Results: On Budget Stroke Center Coordinator hired as budgeted at Rural Hospital Stroke volume at rural hospital on budget Primary Stroke Center (hub) has seen a slight increase in volumes due to appropriate transfers for interventional care

23 Results/Outcomes Analysis Increase focus on patient and community education of stroke warning signs and calling 911 in rural counties Marketing efforts directed at the community need to be further implemented now that infrastructure is built EMS education will need to be repeated by FHN staff based on EMS availability

24 Recommendations Rural Hospital Partner with nursing and EMS schools to educate about stroke Further develop a community based marketing campaign Complete Joint Commission application at rural hospital in 2012 Participate in EMS Regional Stroke Meetings (Region 1) Primary Stroke Center Transfer project to newly hired clinical nurse specialist in stroke (July 1, 2011) Complete a Nurse Specific CE Course on Stroke Beyond Three Hours treatment in June 2011 Collaborate with IL Critical Access Hospital Association Overall, buy in from key stakeholders has been critical

25 Recommendations Shared Recommendations Share pilot model for stroke system of care Continue to education efforts Understand new telemedicine guidelines Share tele-link program with nursing students Share model for other states (state and national) present findings Seek additional funding through grants

26 Planning: Lessons Learned Partner with national organizations on stroke to start stroke community education at the beginning of the project during planning phase Implementation: Plan multiple education programs for EMS in the event they are called out for an emergency, Utilize technology such as Skype to hold meetings, rather than driving out to facility Evaluation: Share results with all stakeholders to start knowledge transfer process Share results with stakeholders along the way, rather than at the end of the project to keep staff engaged in the progress Monitor the mortality rates of rural partners over the long run to maintain interest

27 Long-term Objectives and Future Goals 1. Improve rural hospital clinical staff knowledge (RN) TBD- Presentation 2. Improve patient and community knowledge of stroke- TBD 3. Improve EMS run times TBD 4. Reduce rural county mortality in next CDC survey 5. Patient education mailing on stroke warning signs (patients are not calling 911 fast enough)

28 Conclusion/Impact : Increase ability for rural hospital ED clinicians to manage acute stroke and the emergency department EMS and FHN clinical staff better educated about acute stroke care in rural Illinois Improved cost effective patient access to tertiary center after tele-link development Improved patient outcomes at FHN hospital after Stroke Coordinator hired at rural hospital Second neurologist hired at rural hospital to assist with acute stroke evaluation

29 Acknowledgements Dr. Marilyn Wideman, Rush University College of Nursing Dr. Karen Lamb, Rush University College of Nursing Dr. Phil Gorelick, Medical Director, Stroke Center Alexian Brothers Health System Tracy Love, FHN Stroke Coordinator Dr. Awender, FHN ED Medical Director Doug Toefler, FHN EMS Coordinator Alexian Brothers Health System Neuroscience Institute and Stroke team (Tim Malisch MD, Franklin Marden MD, Ginger Reilly, Nurse Practitioner, Liz Kim, CNS)