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Stroke program wins first Codman award for DM

Minimizing variance through staff training

The Joint Commission on Accreditation of Healthcare Organizations has named Swedish Medical Center in Seattle the winner of the inaugural Ernest Amory Codman Award in the disease-specific care category, for establishing a comprehensive program that deploys a coordinated team to assure comprehensive, timely, and efficient acute stroke care.

The program, initiated in 2001, has:

  • reduced the mortality rate by 12%-16% from "already low" levels;
  • reduced the cost of care significantly;
  • cut average length of stay by 1.4 days;
  • improved patient satisfaction;
  • performed in the top 10% nationally in compliance with American Heart Association (AHA) guidelines for stroke care.

"The program was started to bring into Swedish Medical Center advances in diagnostic testing and therapy that had been going on in some leading institutions in the country, but which for the most part had not percolated down to most medical centers," explains William Likosky, MD, medical director for the stroke program at Swedish Medical Center. "The idea was to offer guideline-driven care to all patients — not just to some patients whose doctors might be familiar with the guidelines."

The reality, he says, is that most patients with stroke are admitted by someone who admits perhaps one or two stroke patients per year. "Therefore, there is a lot of variability in the doctor component; the same could be said for the nursing component, and the nursing unit component," Likosky asserts.

Tools readily available

The good news, says Likosky, is that the tools necessary to achieve his goal were readily available. "The American Heart Association and the American Stroke Association have been producing recommendations for care over the past five or six years," he notes. "These are very good guidelines, available for the taking, with regard to treating ischemic stroke, intracerebral hemorrhage, who might benefit from thombolytic therapy, and so forth."

Along with these guidelines, he continues, you must have certain structures in place to ensure the desired outcomes. "You have to train people; you also have to have a CT scan available 24-7’ with trained personnel and units organized to take care of stroke patients," he asserts.

So, each nurse received eight hours of training in key areas such as the swallow screening (developed by Swedish Medical), deep-vein thrombosis prevention, and urinary tract infection prevention.

"They were trained to the point where you could not be admitted by a nurse here who was not trained in this," says Likosky.

The actual providing of care was restricted to three or four units, he continues. "We instituted the guidelines and assured they were followed."

As for the physicians, a stroke team was developed from among those physicians who specifically wanted to take care of stroke patients. "We provided literally hundreds of hours of available training," reports Likosky. "For example, everyone is trained and certified in the NIH stroke scale."

He notes three key areas that have contributed to the program’s success. "We have measured our outcomes using the AHA’s Get with the Guidelines’ database," Likosky says.

"This is marvelous — it defines the processes of care and allows you to compare your performance with others. This way, you are actually benchmarking against some of the top institutions in the country."

The second component is the use of the Dart-mouth Compass of Outcomes. "This is a way of looking at the relationship between quality of care, cost of care, and staff enablement in patient satisfaction," Likosky says. "Quality is very much related to training of staff; the better trained they are, the better your quality becomes. At the same time, if you watch expenditures — i.e., if people are not in the hospital as long, if they are treated more quickly — you will also improve quality."

Third, the facility employs the "bundles of care" concept developed by the Boston-based Institute for Healthcare Improvement. "This is based on the concept that if you want to minimize error, you must know how many processes need to be done, because your most likely errors are errors of omission," Likosky asserts. "So, if you have 100 processes of care, you need to know who’s responsible for each of them."

Of course, he points out, these processes can be interdependent; for example, you cannot plan a discharge properly if the respiratory therapist has not let you know when the patient can leave. "We developed contracts, so that each of the processes is assigned to a group, and that group does the process each time," says Likosky. "However, they have the right to ask other groups for what they need in order to do their jobs correctly."

Finally, he adds, compliance is tracked regularly. For example, the program ensures that stroke patients receive expedited evaluations in fewer than 45 minutes when warranted.

"We have a nurse practitioner at the bedside virtually instantaneously, who works with the physician to immediately then create a plan of evaluation and therapy — all of which is fully in place within two hours," Likosky notes. "If we get all the guidelines right, we are less likely to have errors."