Saving Brain: Building the LA Stroke Network
In Los Angeles County, a 4,752–square-mile urban–suburban sprawl that is home to an estimated 10 million people, no one knows exactly how many acute strokes occur each year or how well they are managed. Nationwide, stroke is the number-three cause of death; stroke-related medical costs in 2010 are estimated at $73.7 billion.1 Since the debut of the Los Angeles Stroke Center System in November 2009, however, the county has been poised not only to know exactly how many acute stroke patients it is delivering to hospitals, but how quickly and efficiently they are being treated. Most important, patients are more likely to get the care that they need. Radiology, of course, has a key role to play. Fernando Vinuela, MD, says, “We deal with a stroke as soon as possible because for each minute, a person loses 2 million brain cells.” Vinuela is professor of radiology, interventional neuroradiology division, at the Ronald Reagan University of California–Los Angeles (UCLA) Medical Center. UCLA Medical Center is one of 20 hospitals in Los Angeles County that have earned certification as primary stroke centers from the Joint Commission. This designation enables hospitals to apply to Los Angeles County’s Emergency Medical Services (EMS) Agency for inclusion in the Los Angeles Stroke Center System, which initially included only nine hospitals. Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine and director of the UCLA Stroke Center, says, “The American Heart Association (AHA) has been a driver in this process. It helped design a process to bring all stakeholders to the table.” Saver has played an integral role in the development of the stroke system in Los Angeles County and was the recipient of an award from the AHA for his continuing volunteer work for the organization. UCLA Medical Center created a prehospital stroke-screening scale, and UCLA Medical Center’s physicians used it to train the county’s paramedics to identify strokes. This ensures that a stroke patient will be taken to the nearest stroke center (instead of to the nearest emergency department). Bill Koenig, MD, is medical director of the Los Angeles County EMS Agency, which enrolls hospitals in the stroke system and is in the process of building a database to monitor the benefits of the system. No one in the EMS Agency knows exactly how many emergency vehicles are deployed by the county and by the 88 cities (and many unincorporated areas) that constitute the most populous county in the United States. In fiscal year 2008–2009, more than half a million people were transported to county emergency departments. An estimated 2,000 to 3,000 of those patients were having strokes. “The care of the patient is a continuum that starts in the field,” Koenig says. The benefit of having more hospitals in the stroke system is that EMS personnel don’t have as far to travel when transporting a stroke patient. The stroke system began with a one-tier network of primary stroke centers, but it is evolving into a two-tier system that will include comprehensive stroke centers, Saver says. Primary stroke centers are the first-choice locations for diagnosing a stroke, and they are able to deliver recombinant tissue plasminogen activator (tPA) intravenously. If the stroke-care team at a primary stroke center decides that a patient requires endovascular delivery of tPA or needs neurosurgery, however, the patient is transferred to a comprehensive stroke center. Comprehensive stroke centers offer vascular surgery and neurosurgery, and ideally, each would support five to 10 primary stroke centers. In 2005, the Brain Attack Coalition2 recommended key capabilities that comprehensive stroke centers should have. These include the presence of health-care personnel with specific expertise in neurosurgery and vascular neurology; advanced neurological-imaging capabilities, including MRI and various types of cerebral angiography; microsurgical and endovascular techniques, including clipping and coiling for intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and other infrastructure and programmatic elements, such as an ICU and a stroke registry. Meeting Requirements Of US hospitals, 1,200 are certified by the Joint Commission as primary stroke centers, Saver says. He estimates that the cost of running a stroke program can range anywhere from $8,000 to $150,000, depending on a hospital’s existing staff and technology. “The core thing that is needed is a nurse specialist who will anchor the program and enter data into the database, and that requires time,” Saver says. The money spent to run the program could be recouped, however, in shorter lengths of stay for stroke patients who have been successfully treated and in higher reimbursement, he notes. Debra Flaherty, director of neuroscience and rehabilitation at the 411-bed Northridge Hospital Medical Center, reports that the facility incurred startup costs that included time spent on the Joint Commission’s survey and the addition of two personnel: a stroke coordinator and a department specialist who enters data and creates spreadsheets, allowing the stroke coordinator to spend more time with patients. Program-maintenance costs stem from the need for ongoing education for nursing and ancillary staff. Providence Little Company of Mary Medical Center San Pedro hired a stroke-program manager, as well as a consultant to educate nurses and physicians on best practices, according to Karen Frederick, director of rehabilitation, respiratory therapy, and neurodiagnostics. In addition, the hospital paid for the stroke-program manager to visit a Providence hospital in Oregon to study its existing stroke-program protocol. Although stroke certification and participation in the stroke system did not require that the department’s CT program be accredited by the ACR®, the radiology department paid for fees related to CT accreditation. The cost–profit ratio hasn’t yet been measured by the hospital, but the value of the program is apparent to Frederick: “The profit is in the improved quality of care,” she says. Implementing stroke programs would be easier if these projects were eligible for government funding, but hospitals shouldn’t expect funding from the state of California. There have been various bills under consideration that would fund stroke programs, but they were not passed, Saver says, because of economic conditions. He adds that for many organizations, implementing a primary stroke center would have either a neutral or a positive impact on the hospital’s bottom line. Radiology’s Role Radiology plays a key role in a hospital’s response to stroke, but even radiology departments that are part of an established stroke program require adaptive changes for stroke certification. Barry D. Pressman, MD, chair of the department of imaging at the S. Mark Taper Foundation Imaging Center and Department, says that Cedars–Sinai® Medical Center’s program had been in place for about seven years before the institution became a certified stroke center. Nonetheless, the radiologic technologists still had to undergo retraining to ensure that scans would be performed in a more timely manner. Radiologists worked with the technologists, primarily to teach them how to choose patients’ target arteries and veins more quickly in the course of procedures. Technologists are now able to turn around CT scans in 10 minutes, Pressman says. Training is ongoing, and if radiologists see an error, they immediately work with the technologist to ensure that it is corrected. Pressman concedes that the technologists have a more difficult job than radiologists. “Nothing is more important than the training of the technologists in getting this process to work,” he says. Cedars–Sinai Medical Center also introduced a 64-slice CT scanner in the emergency department to minimize patient-transport time and to enable technologists to perform CT angiography and CT perfusion studies for stroke patients in the emergency department. In accordance with the Joint Commission’s policy, the hospital took steps to ensure that each radiologic technologist has the ability to perform scans efficiently and effectively and that a technologist is available around the clock. Providence Little Company of Mary Medical Center San Pedro not only retrained radiologic technologists, but cross-trained others in the department to perform CT scans to ensure that the hospital met Joint Commission coverage requirements, Sandra Edson, RT, director of imaging and cardiovascular services, reports. Technologists with advanced technical skills and an interest in professional growth were chosen for cross-training (which was supervised by radiologists), she says. The department also provided education on stroke protocols for the imaging staff. “The additional training basically involved making sure they were familiar with the signs and symptoms of a stroke and the limited timeframe we have to perform the study and have it read,” Edson says. For primary stroke centers that do not provide the interventions found at a comprehensive stroke center, turnaround time for brain scans is even more critical because the patient might need to be transferred. Though Northridge Hospital Medical Center currently is a primary stroke center, Flaherty says that the organization plans to implement interventional-radiology services in about six months to a year. This will require new equipment. The addition of interventional radiology alone will not qualify the hospital to be a comprehensive stroke center, but it is a step in that direction. Until Northridge Hospital Medical Center achieves that status, the hospital has a transfer agreement with UCLA Medical Center. Providence Little Company of Mary Medical Center San Pedro also is a primary stroke center. Members of the four-radiologist practice that covers the hospital have advanced training in neuroradiology and interventional radiology; although three of them have experience in catheter-directed thrombolysis, they do not expect to perform that procedure at the hospital. Measuring Success A linchpin of the stroke program is a commitment to recording data, preferably concurrently with care, at specified care milestones. Data to be collected include the date and time that the patient was last known to be well, that prearrival notification was received, that the patient arrived, that the stroke team was notified, that the stroke team reached the patient’s bedside, that CT/MRI studies (including scout-image acquisition) were performed, that tPA was ordered, and that tPA was administered intravenously. Other figures recorded include the time elapsed before tPA administration (with a goal of an hour or less), before CT/MRI scanning (with a goal of 25 or fewer minutes), and before stroke-team notification (with a goal of 15 or fewer minutes). “That step is a new procedure for our department. Our triage procedures have not changed,” Edson says. “In the radiology department, we now track exactly when the patient arrives in our department and when he or she leaves, and that number is part of the overall tracking process.” Koenig reports that Los Angeles County is currently building a database that will include additional metrics and enable hospitals to benchmark their performance against that of other facilities in the stroke system. “The Joint Commission data are not all that we want; we want some additional data fields that involve paramedic care and the paramedic patient,” Koenig says. “That is an overlay we are putting on the stroke system.” In total, the county will be tracking about 25 data points, some of which will be automatically provided by the Get With the Guidelines database. “We are currently working with the AHA to integrate our database with their database, so that only one group of data has to be entered by stroke hospitals,” Koenig explains. “The Joint Commission, in general, doesn’t look at the system aspects. It is primarily interested in hospital-by-hospital information. We are interested in the big picture: How long is it taking paramedics to get stroke patients there? How fast are the patients treated once they get to the hospital? From a systems standpoint, the Joint Commission doesn’t put all of that together.” From the county’s perspective, Koenig says, the success of the program will be assessed based on triage errors (whether these involve underestimation or overestimation of the severity of the patient’s problem); aggregate neurological outcomes, based on data collected by the individual hospitals for the Joint Commission; and response times at the facilities—such as time elapsed before the performance of CT exams. Practice Demands UCLA Medical Center and Cedars–Sinai Medical Center are well-endowed, luminary sites with established stroke programs and large radiology practices equipped to provide 24/7 coverage. The demands on a four-person practice would be expected to be somewhat greater. Nonetheless, David Feldman, MD, medical director of the radiology department at Providence Little Company of Mary Medical Center San Pedro, reports that the burden on the practice has not increased since the stroke program debuted, and the practice has not had to change its staffing model. “The stroke program is still relatively new, but our practice is not expecting a significant increase in volume as a result of being part of the stroke network,” he says. “Like the vast majority of radiology groups in the United States, we use limited night coverage via teleradiology service. Our radiologists are on call every night and frequently consult. This did not change with the new stroke program. There was no need to change our staffing model to accommodate the stroke program.” According to Edson, the volume of stroke patients that the hospital receives has remained steady, thus far, at 10 to 15 stroke patients a month. “Our medical center was the first in the Los Angeles South Bay region to receive accreditation as a stroke center, but it was several months before ambulances were required to divert stroke patients to stroke centers,” she notes. “By that time, the other two main medical centers in our region had also attained their own accreditation, so we can’t say that being part of the network has increased our volumes at all.”  She continues, “That, however, was not our motive. Our motive in pursuing accreditation was to ensure we were providing the highest level of care possible to our patients.” Feldman agrees that the benefits of participating in the stroke system come from the satisfaction of living up to high care standards. “A major benefit of the stroke program is verifying that we are providing the absolute best patient care possible,” he says. “Our practice benefits from being part of this network because it meets our demands to provide the best medical service that we can.” He adds, “Our protocols and best practices are freely available for the asking. The stroke program has been well received by the local physicians and community, and we are enthusiastic about being part of this program, which standardizes service excellence and increases the chances of an excellent outcome. It’s exciting to be such an important part of that process.” Preliminary Diagnosis When Los Angeles County paramedics identify a stroke patient, they notify the nearest primary stroke center. When the receiving hospital receives that call, the stroke team immediately prepares for the patient’s arrival. At Cedars–Sinai Medical Center, the call-to-action term is code brain, which immediately mobilizes the stroke team (including the imaging and neurology departments). Upon the patient’s arrival, the emergency-department physician evaluates the patient and determines when he or she was last known to be well. If the onset of the stroke was less than 3–3.5 hours earlier, the patient is a candidate for intravenous tPA therapy; if the stroke’s onset was between 6.5 hours and 8 hours earlier, the patient is a candidate for endovascular treatment, Pressman says. Starting when the emergency department calls code brain, the radiology department has less than 45 minutes to perform and read a diagnostic brain scan—usually including a CT angiogram of the neck and brain and a brain perfusion study—to determine whether the patient is actually having a stroke, and if so, whether the stroke is ischemic or hemorrhagic. If the stroke is ischemic, the angiogram will be used to determine whether there is a blocked major vessel, Pressman says. Radiologists must also determine whether strokelike symptoms are being caused by another problem, such as a subdural hematoma, a tumor, drug use, or a cardiac disorder. Many hospitals perform CT studies for stroke diagnosis because they are quickly completed. If it is determined that the patient is having an ischemic stroke, IV tPA can be administered or endovascular clot dissolution or removal can be performed. If a hemorrhagic stroke is occurring, a CT angiogram might be performed to determine the source of the hemorrhage, Pressman says. CT exams are the diagnostic modality of choice at Providence Little Company of Mary Medical Center San Pedro. “CT brain scans are the most commonly used procedure,” Edson says. “They can be completed fast and provide images that can detect an abnormality.” There are still variations in the way that stroke programs function, even though they all must meet the same Joint Commission criteria. Each organization has created a unique system best suited for its stroke team and for the hospital. For example, UCLA Medical Center uses MRI exams for diagnosis in stroke patients, although CT scans are used for patients with pacemakers, Vinuela says. Frederick adds, “The protocol has to fit the stroke program, the demographic, and the hospital.” The Feedback Loop One undisputed benefit of participating in a stroke program is the availability of data on every step of care, from arrival to treatment. This gives providers feedback that can be benchmarked against national numbers. Providence Little Company of Mary Medical Center San Pedro already has made changes to the best practices that it implemented just over a year ago, adjusting physicians’ stroke order sets (protocols), revisiting the symptoms of ischemic and hemorrhagic strokes, and providing more bedside information to caregivers and patients, Frederick says. The organization also created nurse champions: ICU and telemetry nurses who help drive best practices and assess the components of good stroke care while the patient is still in the hospital. The stroke team’s efforts have improved its rate of providing what it defines as defect-free care from 62% to 93% over the course of a year, according to Frederick. The data collection required by the Joint Commission helps stroke teams gauge everything from response time to the quality of patient care and education. It also provides them with invaluable information that reveals both strengths and weaknesses in their protocols and performance. M.J. Hampel, MPH, MBA, senior associate director of the Joint Commission’s Disease-Specific Care Certification Program, says, “There are three components necessary to have a successful program: standards, guidelines, and performance measures.” Hospitals commonly make the mistake of focusing only on one of these components, which is when issues arise. Hampel recommends collecting data concurrently because this provides the organization with more opportunity to identify concerns that someone along the chain of care might have missed. Flaherty says that Northridge Hospital Medical Center collects as much concurrent data as possible, but it collects information retrospectively as well. This is analyzed and used to make ongoing improvements in the operational flow, including the turnaround time for radiology. An improvement that will be implemented in the future is telephone contact with stroke patients to determine whether they have additional needs after leaving the hospital. Data collected by radiology departments are used for the betterment of stroke teams and contribute to the data that are provided to the Joint Commission, but these data are also used by the departments themselves. At Cedars–Sinai Medical Center, the information is discussed at weekly vascular meetings. Pressman says, “We constantly review what we are doing.” UCLA Medical Center’s radiology team also works collaboratively to review all of the stroke-program data. Vinuela says, “We are the center of patient management—the centerpiece of treatment.” Many hospitals in the stroke program would agree that both earning certification as primary stroke centers and joining the Los Angeles Stroke Center System have created new avenues for improvement. Certification and the system, Pressman says, have “brought a uniformity to the way patients are treated and brought speed and accuracy to the process. The data show there is an increase in positive results. The bottom line is improved patient care.” Until its database is up and running, the county is measuring success by the number of hospitals that participate in the stroke system. Koenig is proud of the fact that the initial nine-hospital stroke system has grown to include 19 (26%) of the county’s 72 acute-care hospitals. The system’s goal is 80% participation. “We’re really excited about it,” Koenig says. “One of our concerns is the use of resources in the system to take patients great distances to stroke centers. If you make the paramedics drive 30 miles, it’s a lot more resource intensive than if they drive five miles. The more stroke centers there are, the less likely it is that the paramedics will have to be taken out of their service area to transport the patient.” Meanwhile, Koenig says, radiology coverage has improved in the stroke system. “Radiology has to provide a stat reading on the CT exams and that, in some places, wasn’t always the case,” Koenig says. “You had the emergency physicians reading the CT exams. Because of the importance of reading a CT exam to the administration of thrombolytics, the model now is to have radiology involved. I think the emergency physician welcomes that.” Additional Reading - Achieving Certification Erin Burke is a contributing writer for Radiology Business Journal.