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The Role of Hospitalists in Stroke Management

The discharging physician must partner with the primary care providers to maintain the momentum with respect to secondary prevention, re-enforcing education, and monitoring for development of side effects from the medications initiated during hospitalization.

Future Trends

Given the trends of an expanding hospitalist system, increasing time limitations for specialists, the relative dearth of neurologists, and uninviting circumstances for practice and compensation, neurologists will need to partner with a group of physicians who are structured to be available 24/7.

In his coauthored letter to the editor of Stroke, published in June 2005, Dr. Likosky challenged neurologists to avoid being “asleep at the wheel” in stroke prevention.1 “If neurologists want to be the ones taking care of stroke patients,” he said, “then they need to decide what role they want to play, because otherwise it’s going to be taken over by hospitalists, which may be the most appropriate thing.”

Conclusion

Challenges and opportunities characterize the work of hospitalists involved in stroke care. Good, ongoing training is imperative as are effective institutional systems and efficient monitoring of those systems. Protocols can be adapted to best serve an individual institution; the nature of their implementation and the teamwork or lack thereof will make the difference in the benefit to medical and institutional outcomes.

Recommendations for best performance in stroke care include keeping open channels of communication and good feedback systems, discussing controversies in order to seek resolutions and improve systems, and using the advantage of access to patients and their families to best begin follow-up and secondary prevention efforts. TH

Writer Andrea M. Sattinger will cover the malpractice crisis in healthcare in future issues of The Hospitalist.

References

  1. Likosky DJ. Who will care for our hospitalized patients? Stroke. 2005;36:1113-1114.
  2. Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217-1222.

PROTECTing Stroke Patients

The role of hospitalists in UCLA’s program

Hospitalists have a substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

Bruce Ovbiagele, MD, director of UCLA’s PROTECT program, spoke to The Hospitalist about the lessons and future objectives of the program.2

“For our program, we have a primary stroke service. However, we are trying to extend this to the whole of the UCLA Medical Center because, of course, there are stroke patients who are admitted to the hospital in different services [and] these patients are not benefiting from the kind of follow-up that we [do] within the PROTECT program. Most hospitals don’t have a primary stroke service and patients are admitted to the general medicine ward[s] anyway, so the hospitalists have a very substantial and an important role to play in enhancing the follow-up of stroke patients, particularly in hospitals that don’t have the primary stroke service.

“Not only that, but because many of the primary care physicians who will probably be seeing these patients for follow-up … are primary care physicians themselves, the rapport between the hospitalists and these patients, at least in my experience, tends to be much better than if they went a neurologist who would try to convey information to the primary care physician. For whatever reason, there seems to be a much better and more accepted communication between the internists or family care physician or hospitalist and the primary care physician on the outside. So we have good compliance rates, but this is within our system, which is primary stroke, making sure that we have the patients follow up with the neurologists. But in the real world—not a tertiary medical center or when they don’t have a primary stroke service or don’t have a neurologist seeing patients very consistently on the inpatient service—this might be a little bit of an issue. So in that kind of institution, the hospitalist is just perfect [for initiating secondary prevention].

“There have been so many lessons [from the program], but more than anything else [we’ve learned] that involving the patient, educating the patient, empowers the patient and is really the best tool for improving outcomes. … Once the patients know what the goals are, they are willing to participate in their own care to an extent that is quite remarkable. Of all the things we’ve learned, that has been the eye-opener for us. Also, once you can key in with somebody in the family, you find that that is really the most effective tool in making sure that compliance is optimal.”

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