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NINDS: Stroke Proceedings: Health Care Systems


Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Recommendations: 
Health Care Systems Panel

Significant changes and improvements in our health care system are necessary and are being demanded by patients and payors. Most recently, because of the rapidly changing world of stroke treatment, stroke care specialists are also demanding change. Stroke spans the continuum of health care and we believe it is an ideal illness to guide us through the transition to an improved health care delivery system in the United States.

The Health Care Systems Panel recommends a three-step model for a stroke care delivery system. In the first step we would develop the individual parts of the system; most of this is covered in the reports from the panels on Prehospital Emergency Medical Care Systems, Emergency Department, and Acute Hospital Care. The second step is to develop connections across the various parts of the system so that they work together. And the third step is to institute processes that make all elements of the system work smoothly and effectively.

To make this system work we must develop outcomes assessments that measure clinical quality, functional status, patient satisfaction, and cost. The panel participants agree that our goal is to maximize performance and quality of care, not ownership of the process by any particular specialty or group.

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Developing Leadership and Systems Analysis

The first step in creating an efficient system is to identify committed leaders who will act as champions. These people should come from each specialty that has an interest in stroke care. Examples include nursing, emergency medical services (EMS) physicians, emergency department (ED) physicians, neurologists, intensive care specialists, and rehabilitation specialists.

These champions will need not only institutional support, but also training in specific skills, including communications skills to become effective speakers, advocates, and teachers, and also to become good listeners who have the ability to understand the reality of the current health care environment.

To facilitate systems analysis, champions should use flow-charting techniques that will help them understand the nature of the individual components, decide on required modifications to the system, and implement these modifications to create the capacity to care for stroke patients.

Furthermore, these systems should be analyzed from the patient's point of view but should be built from the user's point of view, starting from the inside of the hospital and moving outward from the intensive care units to the EDs to the EMS systems and then to the patients and primary care providers.

Every hospital environment is a bit different and these unique environments will require special solutions and methodologies. The common goal for all, however, will be to deliver high-quality stroke care. As leaders in individual systems apply flow-charting techniques, they should also try to identify key personnel for the stroke teams. They will need to build larger multidisciplinary stroke teams to expand the circle of care. These teams should include all interested specialties, including trainees in these specialties.

Finally, these teams should practice their skills in caring for stroke patients to ensure that their first experiences are positive for both the patients and the care providers.

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How to Create and Sustain the Continuum of Acute Stroke Care: Steps That Need to be Taken at the Strategic Level

The Health Care Systems Panel agreed that it is very important to establish consistency of high-quality care as a primary goal and to do it in a way that will not affect the autonomy of local physicians, whatever their specialty. This will mean providing them with resources, education and training, and referral opportunities if they feel they need help with a given patient. Those who activate the acute stroke treatment system should work with the approach that "one call does it all," with everyone on the acute stroke team linked together with pagers or cellular phones. All members of the stroke team should receive regular feedback on their performance based on established criteria for quality care.

Health systems need to be integrated functionally, financially, and legally. Since stroke is a disease of multiple causes, we must focus on disease management regardless of physician specialty. We must break down walls between departments within institutions and health systems so that the focus is on disease management without regard to departmental "territory." We need to create and maintain linkages throughout the system so that patients are followed seamlessly from primary prevention through acute episodes through rehabilitation and subsequent care.

We need to establish a network of regional workshops where medical personnel can receive hands-on skills training in acute stroke care management. It may even be useful to establish certification or special added qualifications requirements for stroke care specialists. This leads to the issue of people-intensive systems versus technology-intensive systems. In the former case, we can accomplish much through national organizations and small group workshops. Technology-intensive systems can make use of telemedicine and telecommunications to help in sustaining the system. This may be an effective way to reach medical personnel in rural sites and underserved urban sites. Telemedicine might help to ensure standardized, streamlined care throughout the nation's hospitals and to centralize medical specialists. Establishment of electronic links to hospitals and physicians capable of providing on-the-spot rapid expertise deserves consideration when expertise is not rapidly available to treat stroke locally. Our ultimate goal would be to build systems that will allow us to treat patients and to accelerate development of new treatments and diagnostic technologies for stroke patients.

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Determining Acceptable Outcomes

Determining and measuring acceptable outcomes is a process in its infancy. Although we have made progress in identifying acceptable outcomes in stroke care, we still need to identify who will measure these outcomes and what reliable and valid measurement tools are available. We also need to decide whether to assess small groups of patients, individual institutions, groups of institutions, or regions.

Because the measurement process should be as efficient as possible, we need to agree on a minimum set of key indicators. We believe that the patient's interests must come first, so we need to identify big-impact items and choose indicators for which valid and reliable measurement tools already exist.

We believe that the indicators could follow the chronology of stroke care, and using that as a guide we can make several simple recommendations.

  • In the prehospital setting we need to first assess symptom recognition and the use of the 911 system.
  • In the emergency department we believe it is most important to assess time to evaluation and to treatment.
  • In the hospital setting it is important to assess whether detailed and comprehensive stroke protocols are in place.
  • After discharge we need to assess the patient's functional capabilities and assure that high-quality rehabilitation services are in place.
  • Overall, we need to institute comprehensive data collection and feedback. One suggestion is a "report card system" that establishes a sense of accountability for the care of the acute stroke patient. We can all agree that certification of stroke care centers is on the horizon.

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What Value do We Add to the System?

Thrombolytic therapy in the form of t-PA is no longer experimental. It is FDA approved and its use should be reimbursable. But other steps in the process necessary to make acute stroke care succeed also need to be funded. Stroke, at least acute episodes of stroke, appears to be a disease that requires a "reverse gatekeeper," a disease where specialists are necessary up front. In order to justify funding for this we need to identify cost savings that will result in a shift of resources to the most critical points in the stroke management continuum. We are encouraged that some success in this area has already been achieved. All available data suggest that when a comprehensive stroke care plan is in place and thrombolytic therapy is used, the length of hospital stay is reduced and outcome is improved.

It is our goal to maximize value by maximizing quality for the lowest cost. It is very important to state, however, that cost savings might not be universal but we need to support such a system because it is right for our patients.

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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated May 17, 2011