Communication/collaboration: Collaboration in the Durham VAMC occurs through multidisciplinary work groups, including all relevant disciplines. The SPC facilitated communication and integration of care. Communication with other SPCs and accessing community resources are invaluable.
Standardized care: Stroke policies and procedures ensure that care is not only evidence-based, but also consistent. Teams worked to develop policies, protocols, order sets, documentation templates, and standardized patient education materials. The SPC identified available resources, both within the hospital, as well as within the surrounding community and professional organizations to assist in developing these tools.
Performance measures and evaluation: Performance measures and program evaluations provide a means to evaluate the progress of already implemented strategies, assist in identifying further needs, and guide future plans. The DVAMC immediately began to monitor stroke care using a standardized set of metrics, and as the program developed further, additional performance measures were added, such as length of stay (LOS), postdischarge ED visits and readmissions, and stroke code treatment time goals.
Necessary Components
To ensure its comprehensiveness, the DVAMC Stroke Program was modeled after the American Heart Association (AHA) recommendations for necessary components of a stroke system: emergency medical system (EMS) response, acute in-hospital-based treatment, subacute and secondary prevention, rehabilitation, prevention and community education, and quality improvement initiatives.5 Although intended for larger community-integrated systems, the AHA model nonetheless provides a useful framework for the development of a hospital-based stroke program.
Emergency Medical Response
The establishment of collaborative networks with community partners is essential. The DVAMC staff worked closely with the local EMS providers, facilitating community collaboration. The hospital also maintains collaborative agreements with its medical affiliates for urgent and emergent treatments. The program director and program coordinator are involved in these relationships.
Acute Stroke Treatment
The first phase of system redesign for the DVAMC in response to the 2011 VHA directive included the formulation of an acute stroke medical center memorandum (MCM), or policy, which outlined the facility’s process for acute stroke evaluation and care. The DVAMC qualified as a limited-hours stroke facility (ie, a facility with the necessary personnel, infrastructure, expertise, and programs to diagnose and treat stroke patients emergently, including the administration of alteplase to appropriate candidates, limited to normal business hours).
Related: Stroke and Preventable Hospitalization: Who Is Most at Risk?
At the start of the Stroke Program, the DVAMC had only computed tomography (CT) services during daytime working hours and relied on on-call coverage during nonbusiness hours. There had been previous discussions regarding expansion of radiology CT services; however, development of the Stroke Program led to this expansion becoming a priority. Patients with symptoms of an acute stroke who might otherwise have been a candidate for treatment with IV alteplase or patients who had other symptoms warranting an emergent brain or other CT no longer needed to be transferred to another facility. Radiology Services worked with the Stroke Program, leading to the progressive expansion of CT availability to first include longer daytime coverage and in 2014, implementation of full 24/7 CT services, allowing the hospital to become a VHA primary stroke center.
In conjunction with the MCM, a stroke code team was also implemented. A stroke code facilitates the rapid evaluation and treatment of a patient with a suspected stroke who might be a candidate for acute revascularization by the neurology and critical care staff. Durham’s stroke code team consists of a neurologist, cardiac care unit resident and RN, SPC, escort services, CT technician, bed coordinator, and chaplain services. The SPC attends all stroke codes during normal working hours, collects real-time data, and obtains retrospective data from chart audits for codes occurring when the SPC is not available. By having protocols in place, the program is organized such that the SPC need not be present to facilitate care during each stroke code.
In the early stages of program development, a stroke code process was not used in the ED and was underused in the inpatient setting, making clear documentation and evaluation of acute stroke care and treatment times difficult, if not impossible. Throughout the first 15 months of the program implementation, monthly code activation use increased by 63%. The increase in stroke code team use led to improvements in acute stroke care and accurate determination of acute stroke treatment time goals.
The efforts of both the ED and radiology teams contributed to the improvements in “door-to-CT” and “door-to-CT results” times. Door-to-CT times are expected to improve further now that the facility has implemented CT services on a 24/7 basis. Currently, average door-to-CT time is 20.6 minutes, and door-to-CT results time is 42.4 minutes, both within the National Institute of Neurological Disorders and Stroke goals of < 25 minutes and < 45 minutes respectively.6 Time tracking was part of the program’s development, as this was not previously recorded. As a result, baseline door-to-CT times were not available, and a national benchmark for comparison was used. Part of the Stroke Program’s development was putting into place a process for tracking times.