Although that is also partially an institutional decision, “institutions can’t have it both ways,” he explains. “They can’t say well, we’re going to be taking care of patients with X, Y, or Z, but then not have the facilities and personnel available to be able to acutely treat and stabilize patients even if they do require more advanced care somewhere else.”
Dr. Sachdeva’s team had to cover a considerable knowledge gap to bring his colleagues up to speed and competence by talking directly to the hospitalists and arranging CMEs for them, as well as by encouraging them to get certified in using the National Institutes of Health (NIH) stroke scale.
“The key is for hospitalists to make sure when they’re taking on an area of patient care that they feel comfortable doing that and not themselves be the default for any medical or surgical conditions,” says David Likosky, MD, who is board certified in neurology and internal medicine, and is the director of the Stroke Program of Evergreen Healthcare, Kirkland, Wash.
One way to become better prepared to manage stroke is to familiarize oneself with the National Institutes of Health (NIH) stroke scale. Online training for the NIH Stroke Scale (approved for two hours of category 1 CME credit from the NIH) is available at www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf.).
Excellent resources for developing protocols include the American Stroke Association/American Heart Association, the work of the Brain Attack Coalition (a group of professional, voluntary, and governmental entities dedicated to reducing the occurrence, disabilities, and death associated with stroke—www.stroke-site.org/), and the Web site (www.strokecenter.org), produced out of Washington University in St. Louis. SHM (www.hospitalmedicine.org), which is in the process of creating a Web-based stroke resource room, which—at press time—was scheduled to be live by August 1.
—David Thurber, MD
Systems and Monitoring
Having the right systems in place enables smooth patient assessment and treatment. First establish a means for education in stroke care for hospitalists and all support staff. Other important systems include having protocols for admitting [patients] for stroke care; setting up communication pathways for various disciplines involved in stroke care; having systems to gather, analyze, and monitor data; and having particularly good teamwork and response time.
William Likosky, MD, director of the Stroke Program at the Swedish Medical Center, Seattle, strongly believes in systems and processes of care, whereby a well-designed system should not only be able to prevent mistakes by an individual caregiver, but also to facilitate optimal evidence-based care in every case. As an institution Swedish Medical draws inspiration from the Institute of Healthcare Improvement’s campaign to prevent 100,000 avoidable deaths nationwide in its hospitalized patients. Since its inception at Swedish Medical two years ago, the stroke program is credited with preventing 22 deaths.
Of course any protocol’s worth will vary according to the effectiveness with which it is implemented. Developing protocols and care pathways is an avenue for hospitalists to take a leadership role in implementing evidence-based care, in co-ordinating care between different services, and eventually affecting resource utilization, quality of care, and patient satisfaction positively.
Protocols or pathways fail when they’re not patient-centered, when input isn’t solicited from other caregivers during the development phase, or when their implementation is not monitored. To Dr. Sachdeva, “the main issue is how you implement [the protocol], how you monitor the implementation, and how you fix the glitches or the problems that usually ensue when you’re rolling out a new protocol.”