Stroke outcomes: The right measures make improvements possible

Small hospital saves big bucks with AHA measurements

The aging of America is exacerbating the already horrendous problem of stroke. This illness kills 150,000 annually, while costs approach $30 billion for treating the more than 500,000 stricken each year. Unfortunately, much of this pain and expense can be attributed to the haphazard way we treat stroke. And this variation in treatment, as is frequently the case in health care, stems from our failure to recognize best practices and measure our outcomes accordingly.

Before standardizing their stroke care, clinicians at the North Missis sippi Medical Center in Tupelo were losing up to a million dollars a year on this one diagnosis.1 In 1995, the medical center was treating 356 ischemic stroke patients at an average cost of $7,111 per patient. Average length of stay (LOS) then was 9.9 days, and the death rate was 11%.

Once guidelines and other improvements were adopted, only 26 of the 399 stroke patients treated died, dropping the death rate to 6.5%. The average LOS decreased to just over a week - 7.2 days - and the average nonadjusted cost per patient dropped by more than 12% to $6,246. Additionally, the facility saved money by avoiding common complications of stroke such as aspiration pneumonia, urinary tract infections, and decubitus ulcers. (See article on avoiding aspiration pneumonia, p. 22.)

"It's the [W. Edwards] Deming principle that if you reduce variation, you improve quality, and decreased costs follow," says Jan Englert, RN, director of the clinical efficiency department at North Mississippi.

In 1994, North Mississippi's peer review organization, the Mississippi Foundation for Medical Care, did a chart review of the facility's work using basic, predetermined criteria - CT scan, emergent hypertension treatment, deep vein thrombosis prophylaxis, etiologic evaluation, and stroke prevention therapy. "That review became our springboard for improving stroke care here and implementing the Stroke Initiative Task Force," says Anita Box, RN, stroke case manager for North Mississippi, a position that was created at the recommendation of the task force.

In 1993, the 647-bed tertiary care facility lost more than a million dollars on stroke patients. The state of Mississippi is at the center of the "Stroke Belt," a section of the Southeast with the highest incidence of stroke-related deaths in the country, and the facility accepts referrals from an integrated rural system that serves a 22-county multistate region. It receives an average of 400 cases per year. The task force's primary goal was to improve care by increasing adherence to nationally accepted guidelines.

"We took the American Heart Association guidelines and developed protocols with our own physicians," says Englert. "We provided physicians with that gold standard and compared it to their outcomes. We said,'This is what the AHA and our experts say you should do, and this is what you are doing.'"

The AHA guidelines stress screening patients for and then measuring outcomes in physical and mental disability, language impairment, depression, rehabilitation potential, and functionality in daily living. (See pp. 24-25 for a list of the measurement instruments included in the AHA guidelines.) Typical outcomes measures would be for mortality, mental and physical impairment, LOS, activities of daily living, motor function, discharge home, and follow-up.

"Hiring a stroke case manager made a world of difference in the continual follow-up and monitoring," says Englert. "If a caregiver varies a bit from the prescribed care, the case manager can go to the problem area and effectively manage it right where and when it occurs, not three to four days down the road during a meeting. A tight-knit group of communicators is probably one of the most effective ways of managing patients with a disease like stroke."

The first thing the task force did was acquire data from the facility's physicians dealing with ischemic stroke so it could determine the resource utilization and outcomes of each. All physicians were given envelopes containing their identifying letters - that method ensured confidentiality when they viewed their reports. The doctors agreed their performance could be improved. They could reduce the incidence of aspiration pneumonia, for example, and improve several other inefficiencies, such as lag times on orders, rehabilitation evaluations, and discharge placements.

The neurologists' data showed shorter average LOS than that of the internists (8.8 vs. 10.7 days) and lower cost per patient ($6,862 vs. $7,360), but the internists' patients tended to be older and have more co-morbidities - diabetes, congestive heart failure, and chronic obstructive pulmonary disease - so they received higher severity rankings.

The task force implemented a process improvement plan that included developing a care guide, creating a stroke unit, and hiring a stroke case man ager for an enhanced stroke team. The eight-bed stroke unit, implemented in November 1997, utilizes telemetry and has a dedicated nursing staff. The care guide, implemented in May 1997, defines the first 24 hours of evaluation, after which the patient progresses through 48-hour phases that depend on the patient's capabilities. A decision time is noted after the 24- to 72-hour phase and again at five days, and the goal is to discharge within the seven- to nine-day phase.

The stroke team is multidisciplinary and includes a stroke case manager, rehabilitation case manager, social worker, psychologist, neurologist, nurse, pharmacist, dietitian, discharge planner, and occupational, speech, and physical therapists. It meets weekly, discusses each patient's progress, and continues to make process improvements, incorporating them into a clinical care guide.

The existing stroke team was not only enhanced - it was made more proactive than it had been. Box explains that being proactive means talking with the family, letting them practice taking care of the patient, and generally planning and doing things that help the patient get out earlier.

"The way nurses typically work is to wait for doctors to initiate consults," says Box. "Often if you wait till the last day, a family member will say,'No, this is going to be too much for me. Mom can't come home.' Then you're faced with trying to get placement on the day you'd normally be discharging the patient." Now, instead of waiting for a consult from the doctor, the doctor asks the rehabilitation nurse to come in on day three and make her evaluation."

The stroke case manager works with the task force to move patients efficiently through the evaluation and management processes. They work to identify etiology as early as possible, within 24 to 48 hours, and plan the course of care within 48 to 72 hours. Physicians expedite the diagnostic process by creating a standard list of tests and defining when and why they are performed. CT scans are now routinely performed on admission.

If, for example, a patient has a correctable condition, such as an internal carotid artery stenosis, carotid endarterectomy is considered. In addition, early recognition of atrial fibrillation stipulates specific treatment. If, by contrast, a patient has a hopeless massive intracranial hemorrhage, social work, pastoral care, and an exploration of placement options may be appropriate.

Rather than wait for individual physician consults, the stroke team reviews patients, and therapists complete their evaluation within 24 hours. They discuss potential options with the family based on their findings. The social worker reviews insurance coverage, and the rehab physician determines the course - acute, subacute, or outpatient. The stroke case manager makes available to physicians the laboratory and study results, then makes sure their decisions are carried out.


1. Newell SD, Englert J, Box A, et al. Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998; 29:1,092-1,098.