Stroke units: Not just for big hospitals anymore

Evidence is mounting that they result in better care and little if any additional cost.

Stroke units are often thought to be the province of large, resource-intensive academic medical centers. But evidence is mounting that having a geographically distinct stroke unit at a smaller community hospital results in better care and little, if any, additional cost.

In January, researchers at the University of Alberta in Edmonton, Canada, published a paper in Stroke comparing patients at 2 community hospitals in the same health system, all of whom were admitted for stroke between 2003 and 2009. One of the hospitals, Grey Nuns in Edmonton, established a geographically distinct multidisciplinary stroke care unit (SCU) in 2007, while the other hospital did not and served as a control. The researchers compared outcomes for patients admitted to either hospital before and after establishment of the SCU.

Photo by Thinkstock
Photo by Thinkstock.

Patient mortality at Grey Nuns decreased from 17.1% to 8.3% after SCU implementation, while mortality remained at about 19% at the control hospital in the same timeframe. Patients treated at the SCU also were more than twice as likely to be discharged home independently, without increasing length of stay, compared to the control hospital.

Brian H. Buck, MD, MSc, assistant professor in the division of neurology at the University of Alberta in Edmonton and one of the study's authors, said that the standardized nature of care in SCUs may be what makes a difference in outcomes. “Standardized protocols and order sets provide structure, and you develop an expertise among all the staff, not just physicians, but nurses, rehabilitative staff, and others,” he said in an interview with ACP Hospitalist.

Other research also bears out the advantages of having an SCU. In a Cochrane review published in the August 2008 Stroke, researchers analyzed 31 trials that compared stroke unit care with alternative services, including 26 trials that compared stroke unit care to care in general wards. The researchers found that patients with acute stroke were more likely to survive, return home, and regain independence if they received care in a designated SCU. A June 2011 Acta Neurologica study found door-to-needle time for thrombolysis fell from 62 minutes to 38 minutes after a community hospital implemented an SCU, mostly due to a change in CT-to-needle time.

“With very little change and no new infrastructure or technology, community hospitals can have an impact,” Dr. Buck said. “Most of the interventions that make a difference are things every hospital can do.”

Working with what you have

The simple act of grouping stroke patients together provides a sort of visual cue to clinicians to follow proper protocols, noted David A. Miller, MD, assistant professor of radiology and neurosurgery and director of the Stroke Center at Mayo Clinic Florida in Jacksonville.

“If everyone knows that rooms 204 through 210 are a stroke unit, it becomes second nature to do certain things. The nurse knows that by entering one of those rooms, she'll need to do dysphagia screening before giving oral medications,” Dr. Miller said. “You also have a core group of physicians and nurses taking care of those patients on a regular basis. They get used to it and they get better at it.”

Usually, community hospitals that wish to implement an SCU can do so with the staff and resources currently in place, said David Likosky, MD, ACP Member, a neurohospitalist and medical director of the EvergreenHealth Neuroscience Institute at EvergreenHealth in Kirkland, Wash.

“Stroke care is not an esoteric service or one that requires a lot of new and specialized technology or equipment, like a bone marrow transplant service would,” Dr. Likosky said. “It's more about making sure staff has the skills to provide the care.”

Professional groups offer guidance on the type of skills needed in an SCU (see sidebar, next page). The National Stroke Association advises that an acute stroke team should include, at minimum, a physician and another clinician like a nurse, physician's assistant or nurse practitioner, with expertise in diagnosing and treating cardiovascular disease. The American Heart Association, meanwhile, says that professional staff in an SCU should receive at least 8 hours per year of educational credit (or an equivalent amount of nursing and allied health educational credits) in areas related to cerebrovascular disease.

Because there are some overlaps between stroke care and cardiac care, such as the need for blood pressure management and telemetry, clinicians accustomed to caring for cardiac patients may be well-suited to SCUs. Indeed, at Evergreen Medical Center, the stroke unit staff members also care for cardiac patients.

“In smaller hospitals, it may not be necessary to have full-time staff dedicated to just [cardiac care or stroke care],” Dr. Likosky said. “But there are different wrinkles and nuances [in stroke care] that staff must be aware of, so by necessity they will need to be cross-trained.”

For example, staff must be able to spot signs of neurologic changes, know to screen for dysphagia before giving stroke patients oral medications (to minimize the risk of aspiration), and consistently provide patient and caregiver education for aftercare, he said.

Finding staff with expertise and time to devote to stroke care may be a challenge in smaller hospitals. “Academic medical centers have large groups of on-site trainees, residents, and fellows who often act as first-line responders for hyperacute strokes, whereas community hospitals don't,” said Dr. Buck. “In situations like that, you need to engage emergency room physicians.”

The role of neurologists

Many community hospitals don't have neurologists on-site, but that doesn't mean they can't have stroke units, noted S. Andrew Josephson, MD, director of the neurohospitalist program and medical director of inpatient neurology at the University of California, San Francisco.

“There may be one or two neurologists who cover several local hospitals. Internists or hospitalists with an interest in caring for stroke patients could then lead or co-lead efforts in caring for those patients” when neurologists aren't around, Dr. Josephson said.

Partnering with other hospitals to share resources, as through telemedicine for consultation, can be a great strategy to augment specialty care, he added. Telestroke, which often involves real-time audio and video conferencing, transfer of high-quality images, and sometimes robots, can be costly, but it doesn't have to be. At its most basic, it can comprise simply talking on the phone to a neurologist and transferring images via computers the hospital already has.

Research indicates telestroke care can be cost-effective for rural hospitals without neurologists on staff. A January 2013 modeling study in Circulation: Cardiovascular Quality and Outcomes predicted better patient treatment and a small cost savings for hospitals that participated in a telestroke network. Such networks increase the number of patients who get thrombolysis and can potentially avoid unnecessary patient transfers, a June 2009 Cerebrovascular Diseases article noted.

Making a case for an SCU

Although establishing an SCU may not require many physical modifications to the hospital, there will likely be a need to sell the idea to administrators. This is where hospitalists in internal medicine can shine, said Dr. Likosky.

“Internal medicine hospitalists are the most adept at hospital systems and setting up programs. SCUs need a physician champion and internal medicine hospitalists can fill that role, working closely with neurologists or neurohospitalists,” Dr. Likosky said.

Focus on how the unit will improve care, Dr. Miller advised. “Resources are finite everywhere, so if you are arguing for a stroke unit to your board or administration, emphasize that this is an area where you use certain established protocols and standards of care that don't require an investment in infrastructure,” he said.

The overall number of people who have strokes is a strong justification in and of itself, Dr. Josephson noted. “Whenever you invest in a systems-based change, it potentially takes resources away from other things. But stroke is very common, and the evidence is there that these units provide better outcomes, so yes, it is worth devoting resources to,” he said.

In some ways, setting up a stroke unit is easier in a community hospital, Dr. Likosky said. “If you want to make the case, you don't need to go through multiple layers or get academic approval. Chances are you already know the people and have a working relationship with them.”