Best advice: 'Hire a stroke case manager'
Level playing field with severity-adjusted data
A stroke task force at the North Mississippi Medical Center in Tupelo has learned that a dedicated case manager is key to effectively managing patients with stroke. "Hiring a stroke case manager made a world of difference in the continual follow-up and monitoring," says Jan Englert, RN, director of the clinical efficiency department at North Mississippi. "If a caregiver varies a bit from the prescribed care, the case manager can go to the problem area and effectively manage it right where and when it occurs, not three to four days down the road during a meeting. A tight-knit group of communicators is probably one of the most effective ways of managing patients with a disease like stroke."
The facility has managed to save impressive numbers of dollars and keep patients happier than ever before by enlisting its physicians in a concerted effort to improve efficiency. The first thing the task force did was acquire data from physicians dealing with ischemic stroke so it could determine the resource utilization and outcomes of each. All physicians were given envelopes containing their identifying letters - that method ensured confidentiality when they viewed their reports.
The doctors agreed that while their performance wasn't bad, it could stand some improvement - they could reduce the incidence of aspiration pneumonia, for example, and improve several other inefficiencies, such as lag times on orders, rehabilitation evaluations, and discharge placements.
The neurologists' data showed shorter average lengths of stay than that of the internists - 8.8 vs. 10.7 days - and lower cost per patient - $6,862 vs. $7,360, but the internists' patients tended to be older and have more comorbidities - diabetes, congestive heart failure, and chronic obstructive pulmonary disease - so they received higher severity rankings. "The data is risk-adjusted," says Englert, "because we anticipate objections about some patients being older or sicker. With severity adjustment, that is no longer a concern. It levels the playing field."
The task force implemented a process improvement plan that included developing a care guide, creating a stroke unit, and hiring a stroke case manager for an enhanced stroke team. The eight-bed stroke unit, implemented in November 1997, utilizes telemetry and has a dedicated nursing staff. The care guide, implemented in May 1997, defines the first 24 hours of evaluation, after which the patient progresses through 48-hour phases that depend on his or her capabilities. A decision time is noted after the 24-72 hour phase and again at five days, and the goal is to discharge within the seven to nine day phase.
Stroke team should be proactive
The stroke team is multidisciplinary and includes a stroke case manager, rehabilitation case manager, social worker, psychologist, neurologist, nurse, pharmacist, dietitian, discharge planner, and occupational, speech, and physical therapists. The team meets weekly and discusses each patient's progress and continues to make process improvements, incorporating them into a clinical care guide.
The existing stroke team was not only enhanced - it was made more proactive than it had been. Anita Box, RN, stroke case manager for North Mississippi, explains that being proactive means talking with the family, letting them practice taking care of the patient, and generally planning and doing things that help the patient get out earlier. "The way nurses typically work is to wait for doctors to initiate consults," says Box. "Often if you wait till the last day, a family member will say, 'No, this is going to be too much for me. Mom can't come home.' Then you're faced with trying to get placement on the day you'd normally be discharging the patient." Now, instead of waiting for a consult from the doctor, the doctor asks the rehabilitation nurse to come in on day three and make her evaluation.
The stroke case manager works with the task force to efficiently move patients through the evaluation and management processes. They work hard to identify etiology as early as possible (within 24 to 48 hours) and plan the course of care (within 48 to 72 hours). Physicians expedite the diagnostic process by creating a standard list of tests and defining when and why they are performed. CT scans are now routinely performed on admission.
If, for example, a patient has a correctable condition, such as an internal carotid artery stenosis, carotid endarterectomy is considered. In addition, early recognition of atrial fibrillation stipulates specific treatment. If, by contrast, a patient has a hopeless massive intracranial hemorrhage, social work, pastoral care, and exploring placement options may be appropriate.
Rather than wait for individual physician consults, the stroke team reviews patients, and therapists complete their evaluation within 24 hours. They discuss potential options with the family based on their findings. The social worker reviews insurance coverage and the rehab physician determines the course - acute, subacute, or outpatient. The stroke case manager makes available to physicians the laboratory and study results, then makes sure their decisions are carried out.
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