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NINDS: Stoke Proceedings: Lewandowski
Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996
Developing Leadership and Systems Analysis
Christopher Lewandowski, M.D.
Henry Ford Hospital and Health Sciences Center, Detroit, Michigan
An integrated health care system has the ability to provide for the care of the patient across the entirety of a disease process, including prevention, acute care, chronic care, and secondary prevention. Integration allows investment in one area to produce benefits in other areas. An increase in initial hospital costs due to acute treatment can be recouped by decreased rehabilitation or nursing home costs. Patients must be able to access the appropriate subunits of the system in the appropriate time-frame in order to receive proper care. For the patient with an acute stroke these components include prehospital care, emergency care, hospital care, and rehabilitation. Further, patients must receive guidance from the primary physician (or other patient educator) so that they and their families know when and how to access care. Patients also expect that their care will be arranged in an efficient and seamless manner.
Patients who are not part of an integrated health care system can still expect the same quality of care if the subunits are brought together by medical leadership and if care paths are developed for the rapid identification and treatment of acute stroke.
Identifying leaders to act as "champions" for acute stroke patients may not be an easy task. These people need sufficient conviction, commitment, and energy to overcome the inertia of current practice. Hospital and prehospital leadership (emergency medical services [EMS] directors, chiefs of staff, chairmen, medical directors, and nursing directors) should assist in identifying those who would best fit the role of champion in their institution. Conviction and commitment will often come from a thorough understanding of the current concepts of acute stroke treatment and the desire to help patients who until recently had no opportunity to receive acute care.
Champions must be able to effectively communicate the goals of acute stroke care to all involved. At least one person should be identified from the prehospital system (EMS), the emergency department, the hospital staff of stroke experts, and the department of nursing to form a core group or team. These individuals must work together to develop systems to manage stroke patients efficiently across the various phases of care.
The first task of the team should be to analyze their current system of acute stroke care, identifying the resources needed to care for patients in the desired manner. Analyzing the three phases of care from the patients' point of view helps to create a system that is efficient. In addition, the systems should be analyzed from the inside out, that is, starting with the hospital phase, proceeding to the emergency phase, and finally moving outward to the prehospital phase. Understanding the patients' and caregivers' needs in the subsequent phase of care allows for anticipation and facilitation of these needs. For example, it is important for emergency department staff to understand how and when to access intensive care for patients with stroke. Likewise, if EMS can transport a family member or a witness with the patient, it allows for more accurate and rapid determination of the time of onset of stroke symptoms. This will create a greater understanding of the needs of each component, and opportunities to meet the needs of the ensuing phase will not be missed.
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At some participating centers in the NINDS t-PA Stroke Study (1), the method of system analysis used flow-charting to gain a clear and detailed understanding of the processes involved (1). This understanding helped identify delays to treatment as well as opportunities for improved efficiency.
Flow charting uses a series of symbols connected by arrows, which point in the direction of progress, to describe a process. Ovals are used at the beginning and end of the process, diamonds are used for decision points, and rectangles are used for actions. Written descriptions of the particular event are placed inside the figures. This method allows for highly detailed analysis ( Figure 1A and 1B ).Furthermore, it identifies key personnel who participate in the processes (such as nurses, unit clerks, laboratory technicians, CT technicians, dispatchers, pharmacists, EMS personnel, and various physicians) or who may be added to the team to assist in process modification, educational efforts, and subsequent stroke patient care. Therefore, process problems are identified and modified by involving those who carry out the process before any patients are ever treated.
Processes in the system should be simple and easy to use, and should not unduly burden the patient care systems already in place for stroke or other diseases. Furthermore, they should be designed to function under the most difficult situations. Individualized processes must be developed at each location because of the wide variety of medical practices: single hospital sites, multiple hospital sites, teaching hospitals (private and university), Veterans Administration hospitals, and community hospitals of varying sizes. Acute stroke treatment can be carried out in a wide variety of settings, and it is unlikely that any two systems will be identical.
The definition of the team also varies depending on the human resources available. Usually, stroke teams include a small number of individuals who are available for the evaluation, treatment, and management of every identified stroke patient. This core team will train a large number of prehospital, emergency, and hospital personnel to rapidly identify, screen, and support stroke patients. In its broadest sense the team should include all individuals who participate in the direct and indirect care of the acute stroke patient. All individuals who fulfill a specific role should receive feedback on their performance as well as patient outcome. Therefore, when developing systems, documentation procedures should be incorporated that permit system analysis, feedback, and the evaluation of quality indicators such as time to treatment.
Once the team has been assembled, the patient management systems are in place, and all involved have been trained, a series of practice cases or patient simulations should be instituted. This will expose previously unrecognized obstacles to rapid and efficient care. All efforts should be made to ensure a smoothly functioning system prior to treatment of the first case so that chances of a good outcome and a positive experience are maximized. Initial success in patient management is critical to the development of team pride and sense of accomplishment. As this sense of accomplishment grows, acute stroke care principles and methods will be incorporated into the daily and routine practice patterns of all health care workers involved in stroke care.
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- Tilley BC, Lyden PD, Brott TG, et al (and the NINDS rt-PA Stroke Study Group). Total quality improvement methodology reduces delays between emergency department admission and treatment of acute ischemic stroke. Arch Neurol, in press, 1997.
Figure 1A. Patient flow chart.
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Figure 1B. Patient flow chart.
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Last Edited: June 19, 2008
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892