Response and Feedback
Another imperative of any stroke program is its response time. “We monitor very closely our emergency department evaluation times for patients coming in within the window for giving tPA,” says Dr. Sachdeva. “We are strict about this because we want every patient to be evaluated within 45 minutes—anybody who is a candidate for possible intervention with acute thrombolytics—either IV or IA. Those times are monitored, and any time that 45-minute window is missed, we have an individual conversation with the people who were responsible, not as a confrontation, but [to ask], ‘What can we do to help you?’ And each time we do that we learn something new.
“Usually in these cases, there were things that were happening that were out of control and sometimes you can control them and sometimes you can’t,” he says. “Next time we try to manage the variables better. So we do have a hands-on continuous monitoring process that is not intrusive, and it gives us an idea of how we are holding up with certain quality parameters.”
Teamwork and Communication
One of the important systems is how well all involved work as a team. “Most of the time, IV tPA is given in the emergency department and the emergency department doctors now are very comfortable giving IV tPA with the telephonic help from a neurologist,” says Dr. Sachdeva. “But they also receive assistance from the stroke nurse, who consults on every stroke patient who is a candidate for emergent intervention in the emergency department.”
Swedish Medical maintains dedicated stroke nurses who act as facilitators to ensure everybody holds up their end of the bargain in stroke care. This includes a combination of nurses and nurse practitioners. But ultimately it is the emergency department physician’s decision in consultation with the neurologist by phone.
Part of their facilitation involves negotiating to cut down on time. “We don’t … rush our patients, but we cut down on avoidable delays,” says Dr. Sachdeva. “We try to get all the pertinent workup done as fast as we can, and then collate the data, make sure the data are disseminated to the parties that need the data, and decisions are made and appropriate treatment algorithms applied.”
These dedicated nurses are available in person for any acute stroke that falls within the window for an emergent intervention. “But if it is [an] acute stroke outside the window,” says Dr. Sachdeva, “they will consult telephonically to help you get certain things started, and then consult on the patient the next business day. They are available 24/7 both to the emergency department and to any floor area of the hospital. Anyplace that stroke can happen … they are there in a heartbeat. And the stroke nurses have been invaluable in assisting the hospitalists in day-to-day care of the stroke patients as well as in educating patients and their families.”
Controversies in Stroke Management
Although many hospitalists are uncomfortable treating ischemic strokes, far more may show discomfort at the idea of treating hemorrhagic strokes.
“Bleeding within the head carries a morbidity and mortality that sometimes is exaggerated in terms of its perception,” he says, “and once again, one has to look at the training that was given to most hospitalists during their residency. It was insufficient with respect to managing intracranial hemorrhages.”
Treating hemorrhagic strokes has traditionally been the preserve of neurosurgeons. “Some neurosurgeons are of the opinion that if there is no indication for surgical intervention for a particular ICH case, then the patient should be on the medical service,” says Dr. Sachdeva. “The medical side is feeling thoroughly unprepared to handle these.”