Distinguishing the evolving role of the hospitalist in managing patients with stroke requires exploring a number of challenges, a couple of controversies, and some clear opportunities.
Hospitalists and their specialist colleagues face a number of challenges associated with stroke management, including the nature of provider teamwork, whether patients present within the window of time for thrombolytic administration, whether hospitalists should administer those agents, and also the care of patients with intracerebral hemorrhage (ICH).
Traditionally the neurologist has been the key clinician involved in the diagnosis and treatment of patients with stroke. And because a great many neurologists prefer to practice almost exclusively in the outpatient setting, a team of providers in the hospital must handle the current stroke care volume.
“Coming to the hospital can be a challenge for some of them, although there is a subset of neurologists who really like to be inside the hospital and look after acute issues with respect to neurology,” says Sandeep Sachdeva, MD, Swedish Medical Center in Seattle. “In our institution we’ve had enough neurologists, but most of them are busy with their outpatient practices so they’re not able to spend substantial time [in the hospital]. By default we have to look at the hospitalist program here as a resource for taking care of stroke patients.”1
Emergent evaluation and treatment of acute ischemic stroke is a hot-button issue, especially for community-based hospitals. Some neurologists can leave their office and attend to an acute ischemic stroke presenting to the emergency department, while others can’t. To address this issue some hospitals have developed stroke teams that usually consist of highly trained nurses/advanced registered nurse practitioners (ARNPs) working under the direction of a neurologist, as is the case at Swedish Medical Center. These stroke teams respond to acute strokes presenting in the emergency department and then assist the emergency department physician in expediting the patient evaluation and ensuring that no protocol violation occurs while emergent therapy, such as IV tPA, is administered.
The final decision for administering this medication rests with the emergency department physician and, in some instances, with the neurologist if he or she is able to evaluate the patient in the emergency department. Hospitalists must evaluate their comfort level, knowledge, and experience—and then discuss with their neurologists and emergency department physicians the development of—a care algorithm commensurate with national and local standards of care as it pertains to caring for patients who present with acute stroke.
With relatively little specialty support available, it becomes more important for communication between providers to be clear and reliable; and practitioners must determine the local standard of care.
“I think with stroke it’s a particularly vexing issue, especially when you get outside of metropolitan areas,” says Larry Goldstein, MD, director of the Duke University Stroke Center, Durham, N.C. “In metropolitan areas there may be hospitals with different capabilities that are not too far from one another. And it may make sense in that situation for one hospital to decide on their own: ‘We just don’t have the resources to be able to treat a specific condition, … and it might be better … for patients to not come here for that since we can’t offer the appropriate level of care for that condition.’”
But in rural and other less populated areas, he says “ … that community hospital may be the only game in town. And even though they … wouldn’t have everything that a tertiary care [or] quaternary care academic center would have, they could identify areas that are critically important for the acute care patients they are serving and develop the appropriate levels of competency in that area.”
What is the standard by which an individual hospitalist is expected to practice, especially concerning the administration of tPA?
In that regard—without a doubt—patient safety comes first. “Whenever there’s confusion in my mind, I always think … first, do no harm,” says Dr. Sachdeva. “If this is an urban area and other hospitalists are not [administering] tPA, then they are not expected to do so and that may not meet the standard of care for that area. Rural hospitals have successfully been giving tPA to patients with acute ischemic stroke.
The caveat here is that appropriate planning as well as training of caregivers has to take place prior to starting IV tPA administration. “Rural hospitals that have the IV tPA capability usually do so in collaboration with larger regional institutions, academic or otherwise, where services of neurologists and neurosurgeons are available,” says Dr. Sachdeva. “Size of the institution should not be an impediment to IV tPA administration.”
As baby boomers age, the demand for better stroke care will increase, and hospitals as well as caregivers need to be prepared to meet the expectations of patients.
David Thurber, MD, medical director of the Cary Hospital Medicine Service, a division of Wake Medical Center, Cary, N.C., speaks of the need for specialty backup at community hospitals.
“For those people who practice in community hospitals, including myself,” he says, “it’s like being the pitcher on a baseball team: If you can’t field the outfield, you shouldn’t be pitching the ball because there’s nobody out there to catch it. So if you can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA. Your obligation is to try, as many community hospitals have done with invasive cardiac procedures, such as emergent use of percutaneous coronary artery intervention, to transfer the patient to a facility where those can be done in a timely fashion.”
What should hospitalists do if they are expected to administer tPA and are unsure of their skill level?
“I would take this issue back to the administration of the hospital,” says Dr. Sachdeva, “and come up with a plan where the neurologists or the emergency department physicians feel motivated to give tPA.”
The most important element to consider when making the decision of whether to administer tPA is the quality of the history. “If there is any doubt about the time or the mechanism of stroke onset, then as practitioners we are very well justified in not giving tPA,” says Dr. Sachdeva, who believes there are more lawsuits for not giving tPA than for giving it. But if you withhold tPA and justify the decision with appropriate reasoning, that certainly places the individual on steadier legal ground.
Training and Competence
Stroke management is not a universally strong topic in medical education. “Not every medical school requires a rotation in the neurosciences or exposure to stroke treatment,” says Dr. Goldstein, “and it’s the same thing in residency programs, depending on which residency program you go through, be it as an internist or as an emergency physician. … So it begins in medical school and follows through residency, but as we know, our training only begins in those formal settings. In medicine, training is a lifelong activity. Things change all the time. And it would [take] appropriate levels of continuing education directly related to cerebrovascular disease to be able to understand modern diagnosis and modern therapeutics.”
Another issue is whether an institution will receive patients for stroke treatment. “Just as hospitals credential people to [perform] procedures, not every hospital can offer every therapy to every patient at the same level,” says Dr. Goldstein. “The thing that is inappropriate is to force people to do things for which they’re not trained.”
Although that is also partially an institutional decision, “institutions can’t have it both ways,” he explains. “They can’t say well, we’re going to be taking care of patients with X, Y, or Z, but then not have the facilities and personnel available to be able to acutely treat and stabilize patients even if they do require more advanced care somewhere else.”
Dr. Sachdeva’s team had to cover a considerable knowledge gap to bring his colleagues up to speed and competence by talking directly to the hospitalists and arranging CMEs for them, as well as by encouraging them to get certified in using the National Institutes of Health (NIH) stroke scale.
“The key is for hospitalists to make sure when they’re taking on an area of patient care that they feel comfortable doing that and not themselves be the default for any medical or surgical conditions,” says David Likosky, MD, who is board certified in neurology and internal medicine, and is the director of the Stroke Program of Evergreen Healthcare, Kirkland, Wash.
One way to become better prepared to manage stroke is to familiarize oneself with the National Institutes of Health (NIH) stroke scale. Online training for the NIH Stroke Scale (approved for two hours of category 1 CME credit from the NIH) is available at www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf.).
Excellent resources for developing protocols include the American Stroke Association/American Heart Association, the work of the Brain Attack Coalition (a group of professional, voluntary, and governmental entities dedicated to reducing the occurrence, disabilities, and death associated with stroke—www.stroke-site.org/), and the Web site (www.strokecenter.org), produced out of Washington University in St. Louis. SHM (www.hospitalmedicine.org), which is in the process of creating a Web-based stroke resource room, which—at press time—was scheduled to be live by August 1.
—David Thurber, MD
Systems and Monitoring
Having the right systems in place enables smooth patient assessment and treatment. First establish a means for education in stroke care for hospitalists and all support staff. Other important systems include having protocols for admitting [patients] for stroke care; setting up communication pathways for various disciplines involved in stroke care; having systems to gather, analyze, and monitor data; and having particularly good teamwork and response time.
William Likosky, MD, director of the Stroke Program at the Swedish Medical Center, Seattle, strongly believes in systems and processes of care, whereby a well-designed system should not only be able to prevent mistakes by an individual caregiver, but also to facilitate optimal evidence-based care in every case. As an institution Swedish Medical draws inspiration from the Institute of Healthcare Improvement’s campaign to prevent 100,000 avoidable deaths nationwide in its hospitalized patients. Since its inception at Swedish Medical two years ago, the stroke program is credited with preventing 22 deaths.
Of course any protocol’s worth will vary according to the effectiveness with which it is implemented. Developing protocols and care pathways is an avenue for hospitalists to take a leadership role in implementing evidence-based care, in co-ordinating care between different services, and eventually affecting resource utilization, quality of care, and patient satisfaction positively.
Protocols or pathways fail when they’re not patient-centered, when input isn’t solicited from other caregivers during the development phase, or when their implementation is not monitored. To Dr. Sachdeva, “the main issue is how you implement [the protocol], how you monitor the implementation, and how you fix the glitches or the problems that usually ensue when you’re rolling out a new protocol.”
Response and Feedback
Another imperative of any stroke program is its response time. “We monitor very closely our emergency department evaluation times for patients coming in within the window for giving tPA,” says Dr. Sachdeva. “We are strict about this because we want every patient to be evaluated within 45 minutes—anybody who is a candidate for possible intervention with acute thrombolytics—either IV or IA. Those times are monitored, and any time that 45-minute window is missed, we have an individual conversation with the people who were responsible, not as a confrontation, but [to ask], ‘What can we do to help you?’ And each time we do that we learn something new.
“Usually in these cases, there were things that were happening that were out of control and sometimes you can control them and sometimes you can’t,” he says. “Next time we try to manage the variables better. So we do have a hands-on continuous monitoring process that is not intrusive, and it gives us an idea of how we are holding up with certain quality parameters.”
Teamwork and Communication
One of the important systems is how well all involved work as a team. “Most of the time, IV tPA is given in the emergency department and the emergency department doctors now are very comfortable giving IV tPA with the telephonic help from a neurologist,” says Dr. Sachdeva. “But they also receive assistance from the stroke nurse, who consults on every stroke patient who is a candidate for emergent intervention in the emergency department.”
Swedish Medical maintains dedicated stroke nurses who act as facilitators to ensure everybody holds up their end of the bargain in stroke care. This includes a combination of nurses and nurse practitioners. But ultimately it is the emergency department physician’s decision in consultation with the neurologist by phone.
Part of their facilitation involves negotiating to cut down on time. “We don’t … rush our patients, but we cut down on avoidable delays,” says Dr. Sachdeva. “We try to get all the pertinent workup done as fast as we can, and then collate the data, make sure the data are disseminated to the parties that need the data, and decisions are made and appropriate treatment algorithms applied.”
These dedicated nurses are available in person for any acute stroke that falls within the window for an emergent intervention. “But if it is [an] acute stroke outside the window,” says Dr. Sachdeva, “they will consult telephonically to help you get certain things started, and then consult on the patient the next business day. They are available 24/7 both to the emergency department and to any floor area of the hospital. Anyplace that stroke can happen … they are there in a heartbeat. And the stroke nurses have been invaluable in assisting the hospitalists in day-to-day care of the stroke patients as well as in educating patients and their families.”
Controversies in Stroke Management
Although many hospitalists are uncomfortable treating ischemic strokes, far more may show discomfort at the idea of treating hemorrhagic strokes.
“Bleeding within the head carries a morbidity and mortality that sometimes is exaggerated in terms of its perception,” he says, “and once again, one has to look at the training that was given to most hospitalists during their residency. It was insufficient with respect to managing intracranial hemorrhages.”
Treating hemorrhagic strokes has traditionally been the preserve of neurosurgeons. “Some neurosurgeons are of the opinion that if there is no indication for surgical intervention for a particular ICH case, then the patient should be on the medical service,” says Dr. Sachdeva. “The medical side is feeling thoroughly unprepared to handle these.”
His team is looking at this issue at their institution to come up with appropriate algorithms regarding triage and care of patients with ICH.
Hospitalists and Stroke Management: Opportunities
One advantage of the hospitalist system in managing stroke is that hospitalists are readily available. Monitoring patients’ recovery for any emergent complications is also an important role for the hospitalist. Most often these complications are urinary tract infections, aspiration pneumonia, and deep venous thrombosis.
The team at Swedish refers to these high-risk complications as “dashboards,” likening them to the dashboard of an automobile that must be carefully watched.
Swedish Medical has seven markers for quality of care that the stroke team monitors. They have a statistician, people who gather the data, people who analyze the data, and those who then put the data in a graph format for the team to review trends reflecting quality of care.
This secondary prevention comes into play while coordinating care at the time of discharge. Hospitalists can start the ball rolling so a primary care physician or the facility to which the patient may next be transferred will continue the appropriate care for these patients.
Hospitalists could also take leadership role within their institutions in formulating pathways for emergent evaluation of strokes that occur in hospitalized patients.
“This is what most hospitalists should be able to do with adequate training,” says Dr. Sachdeva. “At the very least, hospitalists can positively impact stroke care by setting into place protocols, processes, and systems of care to ensure prevention DVTs, UTIs, aspiration pneumonias, and initiation of appropriate secondary prevention modalities for patients admitted with a diagnosis of stroke.”
Any institution that prevents these complications from developing should see an automatic benefit of those quality parameters in decreased length of stay, decreased utilization of resources, and improved patient satisfaction.
Follow-Up and Compliance
Having the undivided attention of the patient and his or her family at the time of hospitalization is a golden opportunity.
“We start patients on a vigorous, evidence-based secondary prevention regimen and by opening a dialogue with the patient and the family,” says Dr. Sachdeva. “Realize you’ve started something good; it needs to be followed up and reinforced on a regular basis either through their primary care provider or through a dedicated stroke follow-up clinic.”
The plan for handling a potential future brain attack is also outlined. One of the most noteworthy programs for secondary prevention of strokes is the one out of the University of California, Los Angeles called PROTECT—Preventing Recurrence of Thromboembolic Events through Coordinated Treatment (http://strokeprotect.mednet.ucla.edu/). (See p. 22.)2
Dr. Thurber, who is also president of the Piedmont Chapter of SHM, hopes that secondary prevention work by stroke teams around the country and the results of public education campaigns can help reduce the number of patients who present for stroke treatment outside the time window for thrombolytic therapy.
Communication with PCPs
If you have a dedicated group of primary care physicians that you work with, then they are, in effect, your customers. They should develop that program so they can give their input as how they would like communication and they can know what kind of care their patients will receive once admitted to the hospitalists or the hospitalist-neurologist team.
Call the primary care physicians at the time of discharge in order to convey the highlights of hospitalization and review key follow-up issues. Information can fall through the cracks, but the PROTECT program shows that this is rare if you use the tools provided as part of the program.1 Their data show that initiating secondary prevention modalities while the patient is hospitalized is important, but following up on them is just as important to good outcomes.
The discharging physician must partner with the primary care providers to maintain the momentum with respect to secondary prevention, re-enforcing education, and monitoring for development of side effects from the medications initiated during hospitalization.
Given the trends of an expanding hospitalist system, increasing time limitations for specialists, the relative dearth of neurologists, and uninviting circumstances for practice and compensation, neurologists will need to partner with a group of physicians who are structured to be available 24/7.
In his coauthored letter to the editor of Stroke, published in June 2005, Dr. Likosky challenged neurologists to avoid being “asleep at the wheel” in stroke prevention.1 “If neurologists want to be the ones taking care of stroke patients,” he said, “then they need to decide what role they want to play, because otherwise it’s going to be taken over by hospitalists, which may be the most appropriate thing.”
Challenges and opportunities characterize the work of hospitalists involved in stroke care. Good, ongoing training is imperative as are effective institutional systems and efficient monitoring of those systems. Protocols can be adapted to best serve an individual institution; the nature of their implementation and the teamwork or lack thereof will make the difference in the benefit to medical and institutional outcomes.
Recommendations for best performance in stroke care include keeping open channels of communication and good feedback systems, discussing controversies in order to seek resolutions and improve systems, and using the advantage of access to patients and their families to best begin follow-up and secondary prevention efforts. TH
Writer Andrea M. Sattinger will cover the malpractice crisis in healthcare in future issues of The Hospitalist.
- Likosky DJ. Who will care for our hospitalized patients? Stroke. 2005;36:1113-1114.
- Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217-1222.