New stroke treatment: Cost-effective and good medicine
Is your facility up to the stroke team challenge?
A quick response and aggressive treatment in the emergency department (ED) can cut thousands of dollars off the back end of your treatments for stroke patients. But timing is critical minutes matter and researchers warn that some initially higher costs from medication and intensive care will result.
Administering recombinant tissue-type plasminogen activator (TPA) appropriately for acute ischemic stroke represents a win-win situation: Early treatment is not only good medicine; it’s good economics. A one-time dosage is pricey $2,000 to $2,200 and charges for 24 hours in the ICU must be added to that.
Typically, Medicare pays hospitals $5,000 to $6,000 for each stroke patient. Appropriate administration of TPA can result in improved outcomes, and further hospitalizations, rehabilitation services, and nursing home care costs are all reduced. Use of the drug reduces the average hospital stay by a day and a half. And only half the patients have to go on to nursing homes or rehabilitation units, as compared to the two-thirds who need that post-hospital care when left untreated.
The result is a net saving of $5 million for every 1,000 patients treated, according to data from the National Institute of Neurological Disorders and Stroke’s (NINDS) TPA Stroke Trial. This statistic considers the fact that use of TPA would increase initial hospital costs by $2 million, but there would be a reduction of $4.8 million in nursing home care costs and a further $2 million in rehabilitation costs.
Rehabilitation is one of the biggest expenses in stroke care. Up until the advent of TPA, most stroke care pathways state that as soon as patients are admitted, they should be evaluated for rehabilitation. A swallowing evaluation is a priority within 24 hours to make sure the patient doesn’t aspirate and get pneumonia on top of the stroke. "Stroke rehab runs between $900 to $950 per day for an inpatient," says Laura Sauerbeck, the clinical research coordinator at The Greater Cincinnati-Northern Kentucky Stroke Research Center in Cincinnati. When those figures are compared to TPA’s cost, the savings become obvious. When administered within safety parameters, TPA treatment has been shown to be beneficial regardless of patient age, gender, ethnicity, or presumed cause of stroke.1 "If TPA can improve a patient’s functional outcome within the time period that he’s under our care," explains Sauerbeck, "he or she can be discharged or sent on a shorter rehab path, and cost-effectiveness can be improved."
"And we’re talking not only about direct patient care cost," continues Sauerbeck. "We’re also considering the maintenance of the patient’s functional level. If he or she is not disabled and can go back to work, the cost-effectiveness is affected positively."
Length of stay in an acute care setting for acute ischemic stroke is now four days, then the patient is discharged to rehab or home. Four years ago, the length of stay was seven to 10 days. "My concern is that patients are being nudged out the door sooner, but not necessarily better," says Sauerbeck. Other problems can develop down the road, and patients stand at risk to be readmitted to the ED with complications due to the early discharge. Those problems contribute to cost-effectiveness issues.
The evidence is in. Stroke some call it "brain attack" must be treated as a medical emergency. No longer can clinicians wait, see, and hope for the best. For nine months now, clot-dissolving TPA has been available for this "new" emergency. Previously medical care for stroke has consisted of post-incident rehabilitation, not stopping the stroke in progress. TPA can spare patients living out their lives disabled.
Competently administering the drug is key. Can your facility muster to the task? From the looks of things, if your facility doesn’t have a stroke team, you’re going to have to put one in place as soon as possible.
Stroke teams are growing in popularity
Stroke teams are being rapidly created in facilities around the country. They are seen as essential to the accurate diagnosis of stroke and the appropriate administration of TPA. Caveat: The drug carries multiple contraindications, and a narrow, three-hour window of opportunity exists for intervention.
As teams are established, cardiac staffers are creating critical care pathway systems and protocols to deliver quick stroke care. An effective stroke team covers care from the point of pre-hospital recognition through discharge. Its goal is the rapid transport, triage, and treatment of eligible patients within three hours of symptom onset. It should implement necessary rehabilitation and educate patients and public on ways to prevent a second stroke.
Andrea Rogers, RN, is unit manager of the cardiovascular intensive care unit at Carondolet St. Mary’s Hospital in Tucson, AZ. She says, "From the time the patient is picked up in the field, an adequate history of the patient is essential to determine what treatment can be offered once he or she reaches the facility and even en route. Family and witnesses should be urged to tell the paramedics what meds the patient’s on and when the incident started. By the time the patient arrives at the hospital, that information should be in place." There’s such a narrow window during which these patients have to get to the cath lab to start giving medications, the earlier that history is taken, the better.
Once the patient reaches the ED, the stroke team is activated. The nurse and physician there evaluate the patient and establish onset of symptoms. Observing the contraindications for TPA, routine admission procedures are run, including vital signs, EKG, O2, and chemistries. The CT lab is alerted that a patient is en route.
CT scan critical link in care
"We started writing protocols and procedures," Rogers says, "so we can get patients to CT scans as soon as possible." Everything hinges on a CT scan, and obtaining a quick CT and corralling someone competent to read it are critical to any stroke team. CT determines what type stroke is presenting. Acute ischemic stroke is most common, occurring when blood flow to part of the brain is blocked. Hemorrhagic stroke is caused by bleeding from a ruptured blood vessel. Beyond defining the stroke, the CT can pinpoint the bleeding site in the case of hemorrhagic stroke.
CT can also eliminate stroke mimickers hypoglycemia, migraine, toxic exposure, drug or alcohol abuse, and diseases like meningitis.
"We have to make sure it’s a bleed," Rogers says. "A headache, slurred speech, or a deficit on one side doesn’t always mean stroke. It could be a medication side effect or even a brain tumor. And you can’t safely give anticoagulants if it’s not really a stroke."
"A hemorrhagic stroke can mimic an ischemic stroke," says Sauerbeck. "Until a CT scan is done, you don’t know. It would be tragic to administer TPA to a patient with hemorrhagic stroke. The age of a stroke can be judged by a scan too."
As soon as TPA administration is warranted, a physician reviews patient data, repeats the neurologic examination, and reconfirms that symptom onset is still within three hours. (See algorithm, p. 28.) Then administration can begin, keeping a close watch on vital signs and other indicators necessary for the safe use of the drug.
The patient stays in the ICU for 24 hours for intensive monitoring. Until recently, it was rare for a patient to be admitted to an ICU except in the case of hemorrhagic stroke because of an airway concern. The patient can then be transferred to acute care. (See related article on what acute care nurses have to watch for, p. 29.) The length of stay in the acute care setting can be four days, then the patient is discharged to rehab or home.
Patient education is crucial
As with all cardiovascular conditions, patient education is critical, including healthy diet, exercise, and prophylaxis with anticoagulants for patients with atrial fibrillation. (See the related story on warfarin, p. 31.) People in the community should be educated to identify a patient with slurred speech, facial droop, or a weakness on one side of the body. There’s a 95% confidence level that such a patient is positive for acute stroke.
A stroke team is multidisciplinary. Key individuals from different departments of your institution as well as pre-hospital staff are involved in its development.
Rogers says her facility started addressing its need for a stroke team a couple of months ago. "We currently have a project team in place that is working on educating the community and the EMS and paramedic systems."
The Greater Cincinnati-Northern Kentucky Stroke Research Center has an effective stroke team in place.
"Our team has done extensive public and pre-hospital training in stroke recognition," says Sauerbeck. "EMT and paramedic personnel can reach us for advice on accurate recognition and can notify us that a possible stroke victim is on the way to the ED. That way, we can prepare and meet the patient as he arrives. CT scanners are geared up and ready. The pharmacy knows to be prepared. The ED personnel’s training in thrombolytic protocols is refreshed."
The Research Center was involved in the TPA clinical trial. The protocol was strict and specific. "Out of those trial protocols came our clinical care pathways and standards of care after the drug was approved," says Sauerbeck.
Jeanne Sandecki, RN, a quality improvement coordinator at Promina-Gwinnett Health System in Lawrenceville, GA, says her facility is putting a stroke team in place now and has already administered TPA to a couple of patients under the management of the neurovascular case manager.
"Our stroke team developed out of one of our coordinating care teams and is meeting for the first time right now," says Sandecki. "We’d been looking into developing a stroke team for six months and felt we had to move forward as quickly as possible. Our neurovascular case manager and a neurologist put the team in place and will monitor its progress. The team is multidisciplinary and includes a general medical surgical nurse and neuro nurse as well as ED personnel so there’s a continuum of care while the patient is here."
Staffing up for stroke
Increased staffing needs for this new emergency treatment of stroke may cause you some problems. "One of the concerns I have as a nurse manager is this," says Patricia Mahoney, RN, coordinator of emergency services at Richmond (VA) Memorial Hospital. "Up till now, there wasn’t a lot we could do for stroke patients. Treating strokes the way we treat cardiacs urgently is very labor intensive. Administering TPA is a two nurses-to-one patient procedure, and staffing may become a real problem."
As a practical matter, however, only about 5% of stroke patients reach a hospital in time to be treated with TPA. "We haven’t yet had a candidate who met criteria for the drug," Mahoney notes. "Richmond Memorial is an inner-city hospital, and we see lots of people with stroke among our large African-American population. But we have yet to be able to administer TPA."
The timing criterion is the main eliminator.
"Patients don’t come in soon enough after onset," continues Mahoney. "They’ll say, When I went to bed last night, I had a little tingling in my side, but I figured it would go away so I went to sleep.’ When they wake up the next morning, they have left-sided paralysis, weakness, or slurred speech. Unfortunately, the whole night has gone by, and it’s too late for therapy."
The clock is running
Reports from the Greater Cincinnati-Northern Kentucky Stroke Research Center are similar. "Our facility sees 1,500 to 2,000 ischemic stroke patients per year," Sauerbeck says. "We’ve only been able to treat about 3% of those. The major reason is that people come in too late." In the case of a myocardial infarction, pain motivates the patient to get help, and they come sooner. Stroke is silent."
Her facility surveyed stroke patients regarding why they delayed coming for help. Sauerbeck reports, "Those who delayed coming said they didn’t understand the importance of what was happening to them. By the time they suspected stroke, it was too late."
The National Institute of Neurological Disorders and Stroke (NINDS) stresses the need to educate the public to recognize stroke, train physicians in administering TPA and other new neuroprotective agents, and change the health care system so it’s organized to deliver care rapidly once the response is primed. "We have one treatment in hand and others in the pipeline," says John R. Marler, MD, medical officer, NINDS Division of Stroke, Trauma, and Neurodegenerative Disorders in Bethesda, MD.
The institute is developing a protocol for implementing new methods of treating stroke. As Cost Management in Cardiac Care goes to press, the protocol is not yet ready for publication. Look for an update in future issues.
Reference
1. Lyden PD, Rapp K, Babcock T, et al. Ultra-rapid identification, triage, and enrollment of stroke patients into clinical trials. J Stroke Cerebrovasc Dis 1994; 4:106-113.
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