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Eliminating disparities in stroke outcomes

Hospitals work to standardize care at all times of the day and week

By Jessica Berthold

From the June ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebar: Stroke measures to strive for

Patients can’t control when they have a stroke, but the day and time they present at the hospital can still make a difference in their long-term outcomes. At the International Stroke Conference in February, U.S. researchers revealed studies showing that in-hospital mortality from stroke is higher on weekends and at nights than on weekdays, just as studies have repeatedly shown with U.S. cardiac care.

It’s actually not the first time such differences have been noted in stroke outcomes—Canadian and European studies have seen similar results—but the scope of the U.S. data made the findings more definitive. One study used data from 222,514 acute stroke admissions at 857 hospitals; another evaluated more than 2.4 million hospital admissions.

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Patients can't control when they have a stroke, but it might make a difference in their outcomes.

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In the first, 24% of hemorrhagic stroke patients and 5.2% of ischemic stroke patients died after entering the hospital on weekdays, compared with 27% and 5.8% of the respective patients who arrived at night and on weekends. In the second study, mortality for ischemic stroke patients was 7.3% on weekdays compared with 8.2% on weekends.

Many factors may be at play in yielding such results, but researchers did control for some, such as demographics, arrival mode, medical history and risk factors. These controls lend credence to the theory that care or staffing practices may simply be worse at night and on weekends, said David S. Liebeskind, MD, senior author of the second study and associate director of the University of California-Los Angeles Stroke Center.

“If this is related to the quality of care, then there is a remedy,” Dr. Liebeskind said. “If hospitals look at their staffing and care practices on weekends and off hours, they should be able to correct for any such differences.”

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More bodies on the floor

It’s obvious to Diana Fite, MD, a Houston emergency medicine specialist, that nighttime care suffers because there are fewer hospital employees, including specialists, around at night. Many hospitals don’t have a computed tomography tech in house on nights and weekends, which may delay how fast an ischemic stroke patient gets tissue plasminogen activator (tPA). Labs run more slowly. And in general, fewer eyes on a patient mean less opportunity to notice when something goes awry, she said.

“If someone starts to get into trouble on a floor, there may be nobody there watching, or no doctor nearby to step right in.” —Diana Fite, MD

“If someone starts to get into trouble on a floor, there may be nobody there watching, or no doctor nearby to step right in,” said Dr. Fite, who herself suffered a stroke and made a full recovery. “At night most of the doctors are generally in the ED, and they don’t come to the floors just because a nurse says someone isn’t doing so well. They go if a patient is code blue.”

The fact that family and friends usually visit during the daytime only exacerbates the time-of-day difference, she added. If a patient’s condition deteriorates during the day, the visitor tracks down a nurse in a flash. At night, the visitors are often gone or asleep.

Having volunteers come in and do rounds during the evening hours might help in catching problems with patients that otherwise would go undetected, Dr. Fite said.

Indeed, using volunteers may be one of the only ways to get more bodies in the hospitals, because it’s unlikely the facilities are going to hire more staff, said Lee Schwamm, MD, vice chairman of neurology at Massachusetts General Hospital and co-author of the first study on stroke mortality that was presented at the conference.

“If anything, we are only going to move over time to fewer people working on these [off-hour] shifts, not more. So we really have to rely on advances in information systems, and in reorganizing the way we deliver care,” Dr. Schwamm said. “If you want things to happen the right way every time, you need to build in systems that support and encourage that.”

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Creative staffing: A success story

Inova Fairfax Hospital in Falls Church, Va., has reorganized its use of staff to create a system that’s improved stroke care at the facility. Since the 833-bed hospital started using stroke response nurses in 1998, it has doubled its number of thrombolytic- and Merci-treated patients. Between 2006 and 2007 alone, the hospital tripled the number of patients treated with intravenous tPA. And there is no difference in outcomes by time of day.

The round-the-clock nurses are the first to evaluate all patients entering the ED with stroke, hemorrhage or transient ischemic attack (TIA) symptoms, and they also screen patients who are in-house and being considered for tPA. They are supported by the rest of a 24/7 stroke team comprising neurologists and nurse practitioners who act as consultants and who see the patients in need of tPA.

“The idea is for these nurses to see 100% of the strokes and TIAs with an eye toward evaluating them for intervention. Essentially the nurses stay in the ED, monitor patients in the waiting room and shepherd them through the whole process,” said John Wesley Cochran II, FACP, medical director of cerebrovascular services at the hospital. “Over the years we have greatly improved the percent of patients seen by stroke response nurses.

If a patient is in need of tPA or other treatment, he or she is admitted by an intensivist into the hospital’s 24/7 neurology intensive care unit, said Jason Vourlekis, FACP, director of critical care at Inova Fairfax.

“At a lot of other hospitals, which don’t have in-house critical care 24/7, the patient may go to the ICU under the care of a hospitalist. Because we use intensivists, our stroke team doesn’t interact directly with our hospitalists,“ Dr. Vourlekis said. “Our patients go to a hospitalist once they are out of the ICU.”

Hospitalists also attend monthly meetings held by the stroke team, as well as educational events, Dr. Cochran added.

“We enjoy working with hospitalists and find their consistent, evidence-based style very helpful,“ Dr. Cochran said. “They are key members of the stroke team.”

Until last October, the six stroke nurses also had floor duties elsewhere. But since the hospital sees about 1,300 stroke patients a year, the stroke team was able to support dedicating nurses solely to stroke patients.

“At smaller hospitals they have stroke response nurses who are also the nurses in the neurology unit and/or the ER, since it’s hard to justify multiple full-time positions if you don’t have the volume,” Dr. Cochran said. “Our nurses screen as many as 20 patients a day.”

One benefit of designating specific nurses to handle stroke screening and response is that physicians feel they have an ongoing relationship—and sense of trust—with the nurses who deal with stroke patients, Dr. Cochran said.

“[The doctors] know who we are dealing with when we get a phone call. We know the nurse has done the exam in a way that he or she will have gotten the information we are interested in,” he said.

Inova Fairfax Hospital’s approach to stroke—which also includes 24/7 access to MRI, computed tomography and neuro-critical care—has yielded some interesting results. Not only is there an absence of the “weekend effect”—where stroke patient outcomes are worse on weekends—there is actually an anti-weekend effect. In a study presented at the International Stroke Conference, Dr. Cochran and colleagues found a slightly lower mortality rate in male ischemic stroke patients seen on the weekends and holidays, compared with weekdays.

“We cannot explain this difference—perhaps men with milder strokes wait until the weekend to appear in the ED and therefore have self-selected to have a better outcome,” said Dr. Cochran. “We are investigating this phenomenon to see if we can determine its cause.”

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Collaboration as path to success

The dozens of hospitals in the greater Cincinnati-Northern Kentucky area also don’t see a discrepancy in stroke care during nights and on weekends versus the weekday—at least by a couple of measures—but the result is achieved in a very different manner than at Inova Fairfax.

Specifically, the time-to-treat after ischemic stroke onset is essentially the same at the Cincinnati-area hospitals on the weekends as it is during the week, a study presented at the stroke conference found. Stroke patients are also just as likely to receive tPA on a weekend as a weekday at these hospitals, it found.

The hospitals’ unique system of sharing health care providers may help explain the results. Every facility has access to a multidisciplinary stroke team for consultation at all hours of the day and night, thus allowing for a certain standardization of care. The roving team includes 14 stroke neurologists and emergency physicians who handle initial stroke team calls and four interventional neuroradiologists and neurosurgeons who are activated when patients require interventional arterial angiography or surgery. The physicians, along with seven acute care research nurses, cover 16 hospitals in person and 25 by phone.

“Hospitalists seem very willing to work with us,“ said Dawn Kleindorfer, MD, a neurologist on the stroke team and coauthor of the study presented at the conference. “I often co-admit with them, and we work together taking care of the patients.”

Because the stroke team, which has existed in one form or another since 1988, is funded by various research grants, it’s limited as to the specific interventions for which it can consult. For the most part, those consultations involve ischemic stroke, said Dr. Kleindorfer.

“In general, the history of the team is for consulting on patients who are being considered for treatment with intravenous tPA. Because we cover so many hospitals and a population of 1.3 million, we can’t do quality care for every stroke at every hospital,” Dr. Kleindorfer said. “So we come in and help with the acute intervention, until the risk of intervention is gone or diminished, then we sign them over to the local neurologist.”

One of the more surprising, and encouraging, results from the stroke team study is that treatment didn’t differ at smaller community hospitals versus academic hospitals, she added.

“We went into it thinking that a lot of these smaller community hospitals would be different, that even with our input, surely the 200-bed hospital wouldn’t be as fast at treating with tPA, or would have different rates of calling us. But we didn’t find that,” Dr. Kleindorfer said. “It is encouraging because a lot of stroke patients are treated at community hospitals.”

Only a few other communities around the nation have stroke teams like the one in the Cincinnati region, and they tend to be smaller. In part, that’s because the drive between hospitals in the Cincinnati area is fairly easy, compared to other cities. As such, there is an increasing interest in setting up stroke telemedicine teams, Dr. Kleindorfer said.

“Most of the time, these teams are Internet-based and members can log on to whatever computer is nearby. On the other end, there is a computer set up in the emergency department of the hospital in need of consultation,” she said.

Another barrier to creating a shared stroke team is the expense: Dr. Kleindorfer’s team is partially funded by NIH research grants, an option that obviously isn’t available to everyone. Still, hospitals in a given community could agree to contribute funds to maintain a communal stroke team, she said. The latter may be more financially feasible now that the DRG codes have changed and hospitals receive more money for tPA treatment, Dr. Kleindorfer said.

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Physician, know thy hospital

Even if a hospital is unable to get together a regional stroke team or stroke response nurses, a lot can be accomplished by simply observing one’s own practices and crunching the data. Hospitals should evaluate their stroke outcomes at different times, to see if and what kind of differences exist, several experts said.

“As health care providers, there is an imperative to be introspective and ask ourselves about any differences between days , nights or weekends, and also look at the finer details such as different individuals attending to a particular hospital at different times of day,” said Dr. Liebeskind. “A lot of variability may exist, and it’s important to standardize our care.”

Such self-evaluation could yield new established protocols, such as ensuring that all stroke patients are on a monitor, or that the patients are in a part of the hospital with nurses who have a high understanding of stroke, said Dr. Fite.

“The more regimented you are, the less deviation you have from what you should do,” Dr. Fite said. “If you start out with a set parameter for every single stroke patient, then you are less likely to miss something.”

In the cardiology realm, such efforts are well under way, said Dr. Schwamm. Many cardiac teams have a standard protocol for cardiac arrest resuscitations that involves assigning everyone on the team a specific role—whether it be opening the airway or putting in the CV line—and a specific place around the bedside. This way, a team member knows immediately if someone is missing, and what that person’s task is.

The same approach could be applied to standard stroke procedures like administering tPA, he said. While some staff might object, saying they know the procedures well enough and that standardization makes the job more tedious, such thinking is misguided, Dr. Schwamm said.

“Airline pilots probably know how to fly planes pretty well by now, but they still do the preflight checklist,” Dr. Schwamm said. “They don’t seem to feel that their pilot autonomy is constrained by that.”

Besides, standardization is the wave of the future, thanks to the increasing sophistication of hospital computer systems, he added. At Massachusetts General Hospital, a computerized order entry system alerts doctors if they try to prescribe medication to which a patient is allergic, for example. The same kind of system may well be developed to prompt physicians and nurses to act in accordance with best stroke practices, Dr. Schwamm said.

“What I see in the future is computerized information systems that are able to both look at the way we document patient care and extract from that various rules and reminders,” Dr. Schwamm said. “So when we are admitting a stroke patient, it will show us the 10 things we need to do, and we either do them or we explain why we aren’t doing them in a particular case.”

Information systems like this can feel like an imposition or an extra burden to health providers, Dr. Schwamm admitted. But it doesn’t have to be that way.

“When they are done well, they don’t feel like a restriction on your autonomy. What they feel like is a set of helpful reminders,” Dr. Schwamm said. “The beauty of the system is that it sets expectations for everyone involved in care, and it is much easier to recognize when something isn’t being done. If every patient is expected to have aspirin and you don’t prescribe it, the nurse might turn to you and ask about it.”

Admittedly, it will take a while before such computer systems can be developed and implemented at hospitals, Dr. Schwamm added.

“Computerizing is sort of the last step. The process starts with walking through something you do on a regular basis and trying to recognize where there are opportunities to standardize things and make them more uniform between you and your colleagues,” Dr. Schwamm said. “It starts with a pen and paper.”

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Stroke measures to strive for

In January, The Joint Commission and American Heart Association/American Stroke Association approved performance measures for certifying primary stroke centers. These can serve as a guide to exceptional care to which all hospitals can aspire. The Standardized Stroke Measure Set, also known as the Harmonized Measures, says that:

• Non-ambulatory patients with an ischemic or hemorrhagic stroke should start receiving DVT prophylaxis by the end of day two in the hospital.
• Ischemic stroke patients should be prescribed antithrombotic therapy upon discharge.
• Ischemic stroke patients with atrial fibrillation should be given anticoagulation upon discharge.
• Acute ischemic stroke patients who arrive at the hospital within 120 minutes of symptom onset should have IV tPA initiated at the hospital within 180 minutes of symptom onset.
• Ischemic stroke patients should receive antithrombotic therapy by the end of day two in the hospital.
• Ischemic stroke patients with LDL cholesterol greater than 100, with LDL not measured, or who are on a cholesterol reducer prior to admission should be discharged on cholesterol-lowering drugs.
• Ischemic or hemorrhagic stroke patients should undergo screening for dysphagia with a simple valid bedside testing protocol before being given any food, fluids or medication by mouth.
• Ischemic or hemorrhagic stroke patients—or their caregivers—should be given education or educational materials during the hospital stay. All of the following should be addressed: personal risk factors for stroke, warning signs for stroke, activation of emergency medical system, need for follow-up after discharge, and medications prescribed.
• Ischemic or hemorrhagic stroke patients with a history of smoking cigarettes should be given smoking cessation advice or counseling during their hospital stay. Caregivers who smoke should also be counseled. Anyone who has smoked cigarettes in the last year is considered a smoker.
• Ischemic or hemorrhagic stroke patients should be assessed for rehabilitation services.

More information on these measures is available online.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated