Keeping Up with Stroke Advances

Despite strides in neuroscience and stroke care, leading organizations are finding there are still improvements that can be made.

This article first appeared in the April 2015 issue of HealthLeaders magazine.

Hospitals and health systems have increased their focus on stroke care over the years, which in turn has helped contribute to reducing stroke deaths as well as improving outcomes for stroke patients; however, there are still significant gains that some hospital-based neuroscience leaders say can be made.

"We feel attention to stroke care is underrated," says Peter Rasmussen, MD, director of Cleveland Clinic's Cerebrovascular Center. "Proper stroke care is not universally available. Generally in the United States, it is not what it should be or could be."

In January, the American Heart Association released its annual update on heart disease and stroke data showing that, from 2000 to 2010, the annual stroke death rate decreased 35.8% and the actual number of stroke deaths declined 22.8%. That's a noteworthy drop, but, on average, someone dies from a stroke every four minutes. Getting to the patient quickly to diagnose what type of stroke is occurring is key, and the phrase many in neurology use is, "Time is brain."

Indeed. Strokes injure the brain, and the severity of the damage depends almost completely on time. Ischemic strokes, caused by a clot that blocks blood from getting to the brain, occur the most. In fact 87% of strokes are ischemic; 10% are classified as intracerebral hemorrhage (bleeding within the brain), and 3% are subarachnoid hemorrhagic (bleeding just outside the brain). When treated quickly, it means better outcomes for patients. For hospitals, it means shorter lengths of stay, and lower rehab costs.

The gold standard of clot-busting drugs, tissue plasminogen activator (tPA), is the key factor in timely treatment of stroke. The FDA-approved drug dissolves clots blocking blood to the brain, reducing what doctors call "door-to-needle time," which is the primary measure hospital leaders use to determine stroke care progress. Despite its effectiveness, tPA is used in less than 10% of ischemic stroke cases, and when it is used, most hospitals administer it outside the recommended 60-minute window. The drug is effective up to 4.5 hours after stroke onset, but the sooner it is given, the better the outcome.

To help improve their stroke measures, many hospitals have become certified by The Joint Commission as either primary or comprehensive stroke centers. The Joint Commission began its primary certification program in 2003. Hospitals must meet eight core measures every two years to receive primary certification. Hospitals took the stroke program seriously and, by 2007, the AHA and American Stroke Association recommended taking stroke patients to the nearest stroke center instead of just the nearest hospital.

In 2012, The Joint Commission developed its comprehensive stroke program, a tougher designation that identified hospitals that could take the most acute stroke patients and offer a broader range of services.

There are now more than 900 primary and more than 80 comprehensive stroke centers across the country, and The Joint Commission is adding another stroke designation later this year called the Acute Stroke-Ready Hospital Disease-Specific Care Advanced Certification program. It's meant to better prepare rural and community hospitals that are close to stroke patients but do not or cannot reach the primary or comprehensive stroke thresholds. It sets standards for giving an initial stroke assessment, diagnosing with either a CT or MRI, stabilizing patients and then transferring them to a primary stroke center.

Success key No. 1: Prioritize
OSF HealthCare, a Peoria, Illinois-based nonprofit Catholic integrated healthcare system with 10 acute care hospitals, more than 600 employed multispecialty physicians, outpatient services, and two schools of nursing, has attained both the primary and comprehensive stroke center designation.

Anthony Avellino, MD, MBA, CEO of the OSF HealthCare neuroscience service line and the Illinois Neurological Institute, says the system's flagship hospital, OSF Saint Francis, was one of the first to receive The Joint Commission's comprehensive stroke designation back in 2012.

"Stroke is a top priority for us," says Avellino. "I think the next two to three years is going to be the most critical time for healthcare reform for the next 20 years. Any system that can get down cost per procedure is going to see a payment transformation."

In 2011, stroke costs in the United States were $17.5 billion; per patient, the estimate is $4,692. The opportunity for cost savings is on the front end of stroke—that is, prevention, as well as curbing length of stay and length of rehab. Preventing a stroke is an educational venture, and Avellino says OSF HealthCare is constantly educating the community about risk factors. But the benefits of education are a long-term prospect, and healthcare systems are looking for ways to get costs down now.

Avellino says his team is currently developing a standardized stroke protocol for each of its hospitals.

"We should capture the same metrics at every hospital," he says. "The challenge is in our other hospitals; some are a lot smaller than our flagship, Saint Francis."

Saint Francis is OSF HealthCare's only comprehensive stroke center, and has focused on stroke care since the late 1990s, with processes and protocols—and plenty of staff—in place with nearly two decades of practice. To push out that knowledge to its other facilities will require more staff and leadership, Avellino says.

"We have hired a clinical outcomes integration director, and this person will work collaboratively to implement the protocols for standardization."

This position won't just roll out systemwide protocols for stroke, but also for other top-priority neuroscience programs Avellino has identified for 2015: spine, neuro-oncology, epilepsy, multiple sclerosis, neuro-trauma, and sleep.

Those programs are tier 1 priorities. When Avellino arrived at OSF HealthCare last August, he did two things that set the neuroscience department on its current strategic path. First, he developed a one-page charter that outlined the purpose and mission of the neuroscience service line, and he separated the service line's priorities into three buckets, or as Avellino calls them, tiers.

"The tier 1 programs are ones we are already leading in, but want to solidify even more within a year," he says. "Tier 2 programs are one to three years out; tier 3 programs are three to five
years out."

The tier 2 programs include rehabilitation, neuromuscular, headache, movement disorders, neuro-vestibular, neuro-ophthalmology, and pain. The tier 3 priorities are building a memory and brain wellness center, developing a way to transition children with neurological disorders into adulthood, plus neuropsychiatry and complementary neuro-medicine.

"We are trying to find a way to horizontally and vertically integrate neuroscience care to produce the best possible outcomes at the lowest cost with the highest quality," he says.

Performance measures are also tied to the tiered priorities. Avellino wants to see improvements in patient satisfaction, safety, outcomes, and 30-day readmissions, among other benchmarks. One of the reasons stroke remains a top priority for Avellino is because improving the door-to-needle time for patients means improving downstream costs of rehab and readmissions. It is not easy, but it can be a significant cost-containment tool.

Avellino's focus on reducing how long it takes for a patient to receive tPA therapy seems to be working. In October 2013, it took OSF Saint Francis Medical Center staff 79 minutes to administer tPA. In September 2014, it was down to 41 minutes, and there were two instances when tPA was given to a patient in just five minutes.

There are plenty of opportunities for neurology to expand its outpatient services, particularly in spine and sleep.

"Outpatient services are key as we develop population health, collaborative care models," he says. "We should be doing simple spine surgery on an outpatient basis. We're not, but it's something we're going to explore next year."

Success key No. 2: Prepare
Other hospitals are aiming to reduce their time to initiation of tPA, but they also pay attention to research that shows an even quicker alternative.

The Miriam Hospital, a 247-bed private nonprofit hospital in Providence, Rhode Island, may be small, but it has big resources. The hospital is part of the Lifespan Health System, a five-facility system it helped create in 1994 along with Rhode Island Hospital. The Miriam Hospital is also an academic medical center, affiliated with the Alpert Medical School of Brown University.

"The Miriam Hospital has always been a specialty-focused, academic, community, and research-focused enterprise," says Tom Tracy, MD, senior vice president of medical affairs and chief medical officer for the hospital.

The combination of being a research center and a community hospital may be paying off soon, says Tracy. That's because three trials published in the New England Journal of Medicine showed positive outcomes for some ischemic stroke patients treated with a procedure that Miriam already performs sporadically.

"A subset of patients, when examined angiographically, are found to have occlusions along their middle cerebral vasculature, and there are now approved devices that can completely open those clots," says Tracy.

The procedure is called a mechanical thrombectomy, and the device Tracy is talking about is essentially a tiny clot-retrieval tool that is inserted into the arterial system and directed to the internal carotid and middle cerebral arteries, where the clot is captured and removed. A study known as MR CLEAN was done in the Netherlands among 16 hospitals with 500 stroke patients. Of patients who had a mechanical thrombectomy, 33% were able to function independently, which was greater than the 19% associated with the other patients.

The Miriam Hospital treats about 650 stroke patients annually, and Tracy says about 25% are eligible for this type of procedure.

Tracy says he scheduled multidisciplinary meetings for the entire team in March to determine how to handle the potential uptick in using this kind of procedure. The neuroscience team has performed it on some patients and the results, says Tracy, are encouraging.

"I was on call the other night, and the neuroradiologist did one, and I asked him how the patient was, and he said the patient left the hospital the next day," says Tracy. "It's amazing."

Tracy's desire to build a focused program around this new procedure is only possible, he thinks, because the hospital is already a certified primary stroke center.

"These patients," Tracy says, "are going to need to be in a comprehensive or primary stroke center that has all the time-sensitive neuroradiology resources, and that's going to be a problem for some hospitals. We are looking at the cost, logistics, and business plan. It helps a little bit that we are ahead of the game, but to make it a big program for the region, we have to look at it thoughtfully."

Success key No. 3: Present your case
Smaller community hospitals may not have the resources to respond quickly to the newest studies, but earning a primary stroke center designation is one way that they are working to meet the needs of their stroke patients.

For example, Lake Forest Hospital, a 201-bed community hospital in Lake Forest, Illinois, that is now part of the massive Northwestern Memorial HealthCare system in Chicago, had no stroke certification and no dedicated neurologists just five years ago.

Now, in large part due to its merger with Northwestern, it is a primary stroke center and has four neurologists on staff in the hospital.

"It was a different landscape five years ago," says Michael Ankin, MD, FACP, FCCP, chief medical officer of Northwestern Medicine Lake Forest. "I remember sitting down with the chairman of the department of neurology and I said, 'Listen, I need this, and this, and this,' and he looked at me and said, 'Look, you're going to have to eat chuck before you get sirloin.' "

What Ankin wanted was at least one neurologist dedicated to the Lake Forest facility. At the time, the hospital was at the mercy of the nearby neurology groups fitting that neurologist into their schedule, along with other hospitals in the area.

"We are 25 miles from the downtown campus," says Ankin. "That's 25 miles of urban city rush-hour traffic. I needed people embedded in this hospital the majority of the time."

Ankin didn't get the four neurologists all at once. First came the work to be certified as a primary stroke center, which he describes as a good process that developed a close cross-section of team members from neuroscience, radiology, and the emergency department.

"If you aren't a certified stroke center, then the liability is that the paramedics bypass you," he says. "It was important to be certified. The number of early strokes we see has increased considerably."

Another infrastructure addition since merging with Northwestern is telestroke at a freestanding emergency room in the nearby town of Grayslake.

Telestroke, like other telemedicine efforts, is gaining popularity and is seen as a way to alleviate a shortage of physicians in rural areas while increasing access to doctors for emergencies, such as stroke. The telestroke program is relatively new to the Lake Forest campus, as are the increases to Ankin's neurology staff, but he is hopeful that it's a sign of more resources to come.

"I think that now that the treatment of stroke is a time-limited event, the idea of developing infrastructure for a patient is really a team effort," he says. "And now I have four full-time neurologists on staff at this 200-bed hospital. I'm not quite sure where I am on the spectrum of meat, but I am well beyond the chuck stage."

Success key No. 4: Mobile care units
Large health systems and community hospitals alike have seen the benefits of attaining The Joint Commission's stroke center designations. But what happens when a health system hits a wall?

Cleveland Clinic, the nonprofit, academic medical center that has reach in Canada and Abu Dhabi as well as expanding partnerships with medical centers across the country, maxed out at how much time it could shave off of getting tPA into a stroke patient.

"At Cleveland Clinic, we're rich in resources, and despite that, 55 minutes is about as good as we can do," says Rasmussen, the director of Cleveland Clinic's Cerebrovascular Center.

To get the door-to-needle times lower, the hospital invested about $1 million in a mobile stroke treatment unit—essentially an ambulance that's outfitted with a mobile CT scanner and a five-person team that takes the stroke treatment to the patient. Instead of waiting for the patient to come through the emergency room doors, the clot-bust shot of tPA comes through a patient's front door.

"In the mobile stroke treatment unit, our times are down to 20-25 minutes," says Rasmussen, who is heading up the mobile stroke treatment unit project. Cleveland Clinic and Memorial Hermann Texas Medical Center are using the highly specialized units.

The systems got the idea for moving stroke treatment out of the emergency room from observing a similar unit in Germany.

"I was invited to lecture in Berlin," says James Grotta, MD, director of stroke research in the Clinical Institute for Research and Innovation at Memorial Hermann Texas Medical Center based in Houston. "I took advantage of the opportunity."

He is studying the cost-effectiveness of using a mobile stroke unit to treat patients.

"We want to know if we treat patients earlier, how much better will they be?" says Grotta. "In an individual person, if it makes someone better, it's priceless, but we have to show there's enough of a widespread benefit, and we are trying to make some estimate of the reduction in cost."

Grotta's study aims to detect a 15% reduction in long-term costs, which would be a huge savings. "Similar to all other mobile stroke unit centers, we've seen substantial reductions in the time it takes to get patients treated," he says.

Cleveland Clinic's unit does not have a neurologist on board like Memorial Hermann's does. Instead, Rasmussen says it uses a telestroke unit along with a CT technician, an RN, an EMT, a paramedic, and a program manager who is cross-trained as a CT tech and EMT.

"We're not tying up a doctor resource," says Rasmussen. "We know, from prior experience, that a telestroke neurologist is 98% accurate."

It's that 2% miss rate that keeps Grotta riding in the unit with his team in Houston.

"Just last night I had a patient and he had a subdural hemorrhage in his brain," says Grotta. "The teledoc missed it, so we're measuring how often there is disagreement between the neurologist and the teledoc."

Another key difference is that Cleveland Clinic is getting reimbursed for administering tPA from its unit. Grotta isn't. The reimbursement issue will be a key factor in whether these mobile stroke units are financially viable. "Units in Berlin, Cleveland, and Houston vary in size and cost, ranging from $650,000 to more than $1 million, depending on bells and whistles," Grotta says. "Wherever the mobile stroke unit operates, local traffic patterns and geography will determine the area it can cover."

Both health systems are just getting started measuring what seems to be a promising treatment for stroke. Cleveland Clinic's mobile stroke treatment unit has transported 155 patients and Memorial Hermann's, close to 100.

Rassmussen says outcomes are positive enough and hopes mobile stroke units are part of the future of stroke care. Grotta says implementation is going smoothly, but more research is needed.

"It's not, 'What is the cost?' It's 'What is the cost to society without one of these units?' " says Rasmussen.

"The bottom line is that this will save time; it's logical that it will, therefore, improve outcomes and be cost effective," says Grotta.

Reprint HLR0415-7