Complicated process needs multidisciplinary team
Stroke centers with specialized stroke teams have the potential to improve outcomes and decrease lengths of stay (LOS) for facilities that previously have relied solely on pre-hospital and emergency department (ED) infrastructure.
This certainly has proven true at the Univer-sity Hospital of Cincinnati, which was one of the pioneers in establishing a stroke center. "We have been treating [stroke] patients aggressively since the late 1980s, which is very unusual," says Arthur M. Pancioli, MD, FACEP, associate professor of emergency medicine and vice chairman of the department of emergency medicine at the University of Cincinnati College of Medicine, who came to the facility in 1991.
"It all comes down to the fact that stroke is a very complicated disease process and requires a multidisciplined team," he explains. "It has been shown many times in the literature that a formalized stroke team provides better care."
In many ways, the most appropriate way to treat stroke is no different than the optimal way to treat any complicated disease process, Pancioli continues. "A classic example is trauma, where you have a dedicated center," he notes. "So much of the modeling is similar, although the disease processes are vastly different."
Pancioli notes that over the years, the Cincinnati stroke center has improved outcomes, decreased mortality, and reduced morbidity. "Clearly, organized systems are going to have reduced length of stay relative to acuity. Quite often, major centers have longer lengths of stay than those centers that treat patients of lower severity, but relative to statistics that are adjusted for stroke severity, the patients [treated by stroke centers] do better."
In the mid-1990s, for example, Cincinnati compared its LOS data to its typical benchmarks such as UCLA. "With a typical team, we were able to reduce length of stay relative to our benchmark partners in that particular system," he says.
In many institutions, Pancioli notes, a stroke center is more of a system and a team than it is an identifiable, physical place within the facility.
"Very few places have a geographically located stroke center," he says. "Rather, you have a multi-disciplined team, a defined champion, and representatives from all the important disciplines. The organization of the group is vastly more important than [having] four walls."
Bearing that in mind, one of the keys to the success in Cincinnati is that "we have an absolutely marvelous neuroscience department here," says Pancioli. In addition, there is the emphasis on multidiscipline care. At Cincinnati, that includes neurology, emergency medicine, radiology, neurosurgery, PT, and rehab, occupational therapy, speech therapy, nutrition, social work, which is absolutely critical, he says; "and, of course, nursing care has to be dedicated to the cause."
Then there is the actual response protocol. "One thing that’s getting an awful lot of attention now is first being capable of taking care of acute patients," Pancioli points out.
This requires complex decision making that must be done rapidly. "For that, we have a long-established acute stroke team so that 24/7’ one of our physicians is immediately available by page," he says.
"One number goes to all the team, then there is a signal back that the doc has received the page and responded that he either will treat, or that he is occupied and is a no-go. Also, the whole team knows the call went out and when a response signal has not come back. If a second signal comes without response, we all call back. In any event, you need the availability of a primary consultant who can assemble the whole team."
On an ongoing basis, there is a team in-hospital that meets regularly to address the stroke team census, the progress with each patient, and what is going on with the acute stroke population in the hospital. When it comes to recovery, "That’s where we have to have significant coordination and communication between the physicians, the nurses, and everything in between," Pancioli says.
The pathway for acute stroke care is an essential ingredient in the formula for success, he says. "In an ideal world, when the patient hits the door, the pathway is put with them."
Pancioli is a firm believer in the need for written protocols. "People who consider pathways or protocols to be cookbook medicine’ ought to be saying, I like to individually forget individual things for individual patients,’" he asserts. "What a protocol provides is a way of not forgetting anything. We are all human — we all forget things. Simply put, a recipe makes sure all the right ingredients end up in the pot."
In treating stroke patients, it is critically important to "do the things that you know affect mortality," says Pancioli. "It’s like treating an MI and making sure the patient got an aspirin, and if not, why not," he explains.
So, for example, the stroke team will check such items as whether the patient went home on anticoagulant medicine, whether dysphasia screening was done before the patient started to eat, whether they received some form of DVT/PE prophylaxis, and so on. "After all, we know it kills people," Pancioli says. "You look at the things that have a literature basis for improving mortality and reducing morbidity, and you count."
At Cincinnati, tools such as the Paul Coverdale Registry Data collection forms and the Centers for Medicare & Medicaid Services’ Fixed Scope of Work are relied on. "These are things benchmarkers should be looking at," he asserts.
Getting a stroke center up and running and making it successful is, unfortunately, easier than it looks, he says. "I’ve been part of a number of initiatives to take stroke centers to the streets,’" Pancioli says.
"It’s difficult to do because you have to change a behavioral paradigm. You have to motivate people, explain why a stroke center is beneficial, and ask for resources. If you can find a stroke champion, show the literature, explain the benefits, and find a good protocol [there are many available on the web, he says] and get everybody at the table, you’ll win."
Need More Information?
For more information, contact:
• Arthur M. Pancioli, MD, FACEP, Associate Professor of Emergency Medicine, Vice Chairman, Department of Emergency Medicine, University of Cincinnati College of Medicine. E-mail: Arthur. firstname.lastname@example.org.