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.”