His team is looking at this issue at their institution to come up with appropriate algorithms regarding triage and care of patients with ICH.
Hospitalists and Stroke Management: Opportunities
One advantage of the hospitalist system in managing stroke is that hospitalists are readily available. Monitoring patients’ recovery for any emergent complications is also an important role for the hospitalist. Most often these complications are urinary tract infections, aspiration pneumonia, and deep venous thrombosis.
The team at Swedish refers to these high-risk complications as “dashboards,” likening them to the dashboard of an automobile that must be carefully watched.
Swedish Medical has seven markers for quality of care that the stroke team monitors. They have a statistician, people who gather the data, people who analyze the data, and those who then put the data in a graph format for the team to review trends reflecting quality of care.
This secondary prevention comes into play while coordinating care at the time of discharge. Hospitalists can start the ball rolling so a primary care physician or the facility to which the patient may next be transferred will continue the appropriate care for these patients.
Hospitalists could also take leadership role within their institutions in formulating pathways for emergent evaluation of strokes that occur in hospitalized patients.
“This is what most hospitalists should be able to do with adequate training,” says Dr. Sachdeva. “At the very least, hospitalists can positively impact stroke care by setting into place protocols, processes, and systems of care to ensure prevention DVTs, UTIs, aspiration pneumonias, and initiation of appropriate secondary prevention modalities for patients admitted with a diagnosis of stroke.”
Any institution that prevents these complications from developing should see an automatic benefit of those quality parameters in decreased length of stay, decreased utilization of resources, and improved patient satisfaction.
Follow-Up and Compliance
Having the undivided attention of the patient and his or her family at the time of hospitalization is a golden opportunity.
“We start patients on a vigorous, evidence-based secondary prevention regimen and by opening a dialogue with the patient and the family,” says Dr. Sachdeva. “Realize you’ve started something good; it needs to be followed up and reinforced on a regular basis either through their primary care provider or through a dedicated stroke follow-up clinic.”
The plan for handling a potential future brain attack is also outlined. One of the most noteworthy programs for secondary prevention of strokes is the one out of the University of California, Los Angeles called PROTECT—Preventing Recurrence of Thromboembolic Events through Coordinated Treatment (http://strokeprotect.mednet.ucla.edu/). (See p. 22.)2
Dr. Thurber, who is also president of the Piedmont Chapter of SHM, hopes that secondary prevention work by stroke teams around the country and the results of public education campaigns can help reduce the number of patients who present for stroke treatment outside the time window for thrombolytic therapy.
Communication with PCPs
If you have a dedicated group of primary care physicians that you work with, then they are, in effect, your customers. They should develop that program so they can give their input as how they would like communication and they can know what kind of care their patients will receive once admitted to the hospitalists or the hospitalist-neurologist team.
Call the primary care physicians at the time of discharge in order to convey the highlights of hospitalization and review key follow-up issues. Information can fall through the cracks, but the PROTECT program shows that this is rare if you use the tools provided as part of the program.1 Their data show that initiating secondary prevention modalities while the patient is hospitalized is important, but following up on them is just as important to good outcomes.