Choosing Your Level of Care

• Andy Jagoda, M.D., Arthur M. Pancioli, M.D., Andrew W. Asimos, M.D., William G. Barsan, M.D., Kevin Baumlin, M.D., William Dalsey, M.D., Kathleen A. Delaney, M.D., Edward Goldman, J.D., Margaret Gradison, M.D., Markku Kaste, M.D., Ph.D., Walter J. Koroshetz, M.D., Thomas G. Kwiatkowski, M.D., Marc Mayberg, M.D., Robert M. McNamara, M.D., C. Crawford Mechem, M.D., Daniel Morelli, M.D., Hal Unwin, M.D., David Wang, M.D., David W. Wright, M.D.

• NINDS Task Force December 13

INTRODUCTION

• Stroke is a big problem

• Limited resources

• Community variability

• “Standard of Care” - Varies

• Choosing YOUR level of Care

THIS DOCUMENT IS DESIGNED TO:

• Advocate assessment:– An internal assessment – An external assessment

• Use assessment to optimize care provided by the institution

• Where appropriate optimize patient care via transfers

The Task Force Believes that Data support:

• Guidelines / clinical pathways improve care

• Multidisciplinary teams improve care

• High volume leads to improved outcomes

Trauma Centers Work

• Data from trauma literature dating back as far as 1977 – documents multidisciplinary trauma teams improve outcome and reduce mortality for multi-traumatized patients

We are asking medical centers to:

• Choose your level of care and state it explicitly

• Improve existing care (Process Improvement)

• Optimize patient care via transfer when appropriate

This Task Force Was Fortunate

• This topic may have controversy

• This may have Real Implications

We had an Attorney

We had an Attorney

• Words like “Pursuant” briefly made it in

Disclaimer

• With regard to the ATTORNEY (hereby defined as : the only person in the room with J.D. after his name) and his participation with this EFFORT (hereby defined as : that which went continued into the early morning hours), in order to maintain plausible deniability of the attorney’s INVOLVEMENT (hereby defined as : keeping us out of trouble) all words such as PURSUANT were ultimately eliminated.

We are asking medical centers to:

• Choose your level of care and state it explicitly

• Improve existing care (Process Improvement)

• Optimize patient care via transfer when appropriate

• WHAT DID WE SAY?

Stroke Centers

• Because treatment of the acute stroke patient is so time sensitive and requires a multi-disciplinary approach 24 hours a day, 7 days a week, the Task Force supports the notion of establishing Primary Stroke Centers to improve access to modern stroke care.

Written Protocols

– Streamline Care– Foster systematic and expeditious care– Minimize complications

Multidisciplinary Team Care

• Works in Trauma

• Works in Stroke

• High Volume– Do is often –> Do it Well– (Hearts, Carotids)

Critical Elements

• EMS

• Emergency Department Basics

• Primary Stroke Centers

• Inpatient Care

• Comprehensive Stroke Centers

EMS

• All care begins prehospital

• Prehospital care improves time to treatment

• Patients should be taken to highest level of available and appropriate stroke care based on local availability and hospital declaration of capability

Emergency Department Basics

• All Emergency Departments should have certain minimum capabilities

• A, B, C, D

• Stabilize (plus)

• Transfer

Primary Stroke Centers

• Hospitals must choose whether or not to be a Primary Stroke Center

• If they do, Capabilities consistent with the BAC recommendations for Primary Stroke Centers must be in place

Inpatient Care

• Many Critical elements required to prevent complications of Stroke

• Evaluation of etiology

• “Stroke Unit” model has the most supporting evidence

Comprehensive Stroke Centers

• Summary of pending BAC document of the comprehensive stroke centers

• Patients with special cerebrovascular needs are admitted or transferred to institutions with special expertise.

IMPLICATIONS

• Implications of implementing or attempting to implement this continuum of stroke care – Must not be underestimated

• Personnel

• Political

• Capital

VISION FOR THE FUTURE

• Vision for where we would like to see stroke care in 5 years– Population aging– There are systems that work– These systems have chosen their level of care

and chosen to undertake a process of improvement of Acute Stroke Care

– Each Region unique

The Task Force Believes

• Despite such regional and community resource variability, a stroke care process improvement process should be established at every healthcare institution.

One Goal

• the Task Force recommends the goal of having 80% of the healthcare institutions in the nation establish a stroke care process improvement initiative by 2005.

CONCLUSIONS

• Stroke places enormous and ever-increasing demands upon the healthcare system.

• Limited resources and increasing patient volume require careful personnel and monetary allocation decisions.

• Marked community variability in available resources requires medical centers to look both internally and externally to optimize the care of the acute stroke patient.

CONCLUSIONS

• This Task Force recommends that medical centers assess their level of stroke care.

• Evidence-based practice guidelines and performance- improvement measures should be used by institutions caring for stroke victims to maximize their effectiveness, given their level of resources.

CONCLUSIONS

• The hospitals’ level of care should be explicitly stated so that patients and prehospital providers can make appropriate decisions regarding the site of care.

CONCLUSIONS

• Communities and regions should assess available stroke care resources and create cooperating stroke networks to match patient need to available resources.

• Transfer protocols should be written to ensure that patients receive the necessary available care in a timely fashion.

CONCLUSIONS

• Finally, this Task Force endorses the concept of the designation of Primary and Comprehensive Stroke Centers that optimize the use of multidisciplinary teams to improve the outcome for acute stroke patients.