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Stroke Workgroup | | Assessment and treatment of stroke in Vermont Emergency Departments
Recommendations of the Stroke Workgroup - November 15, 2010
Executive Summary
Act 61 of 2009 charged the Vermont Association of Hospitals and Health Systems with convening a workgroup of neurologists, emergency department physicians and the American Heart Association to make recommendations to improve acute stroke care. In November of 2009, the workgroup issued a report that included a number of specific recommendations. The workgroup continued meeting in 2010 to pursue progress on those recommendations. This report is an update on those activities.
A number of specific “next steps” are identified in the report. The most significant of these is the implementation of the workgroup-developed tools and materials into local communities. To accomplish this, the management of the project needs to be turned over to an organization with quality improvement expertise and resources. Working with the Vermont Department of Health’s Office of Rural Health Access, committee members helped to secure federal grant funding to fund this next step. VAHHS staff are currently in discussions with the Vermont Program for Quality in Health Care (VPQHC) and the Office of Rural Health Access to develop a project plan.
To view the 2009 report, go to: http://www.leg.state.vt.us/reports/2010ExternalReports/252654.pdf
Definitions
Critical Access Hospital (CAH): A Critical Access Hospital is a hospital that is certified by the Centers for Medicaid and Medicare Services to receive cost-based reimbursement from Medicare. By definition they are small, rural hospitals. Key criteria for CAH certification include a rural location, an average length of stay of 96 hours or less and a maximum of 25 beds. Eight hospitals in Vermont are designated as a CAH.[1]
Physician Assistant (PA): A physician assistant (PA) is a healthcare professional licensed to practice medicine with the supervision of a licensed physician. Physicians have relatively broad delegatory authority, which permits flexible, customized team practice. PAs are licensed by the Vermont Board of Medical Practice which also licenses physicians. In hospitals PAs obtain clinical privileges through a system similar to the one used for physicians. PAs can prescribe medication.[2]
Picture Archiving and Communication System (PACS): PACS allow for the storage, retrieval, distribution and presentation of images.
Stroke: A fixed neurologic injury caused by a focal interruption of blood flow to the brain. Stroke encompasses both hemorrhagic and ischemic etiologies. For the purposes of this document, a transient ischemic attack (also known as a TIA) also falls under this rubric.
Teleradiology: Radiology done through the remote transmission and viewing of images.
Teleradiology is a subset of telemedicine.
Telemedicine: The use of medical information exchanged from one site to another via video and electronic submission, including consultative, diagnostic and treatment services.
Tertiary Care: Highly specialized medical care usually over an extended period of time that involves advanced and complex procedures and treatments performed by medical specialists in state-of-the-art facilities.[3]
Workgroup Composition
As outlined in the legislation, the workgroup included representatives of emergency department physicians, a representative from the Vermont chapter of the American College of Emergency Physicians (ACEP), neurologists from Fletcher Allen Health Care and Dartmouth Hitchcock Medical Center with stroke expertise, and the American Heart Association/American Stroke Association. The workgroup was chaired by an emergency department medical director and staffed by the Vermont Association of Hospitals and Health Systems. A list of committee members is available in Appendix C.
Status of 2009 recommendations
Overall, the workgroup has made significant progress on the recommendations.
1. The workgroup should remain active for at least another year to implement the recommendations below. A representative from the Albany Medical Center should be invited to participate and this report and subsequent deliverables should be shared with the Veteran’s Administration (VA) Medical Center in White River.
Status: The workgroup has continued to meet. Albany Medical Center has not yet been invited to participate, in part because of potential regulatory barriers to having their neurologists provide consultative services to community hospitals in their referral area. However, they should be included in the implementation phase of the project regardless of the regulatory barriers. Project deliverables have been shared with the VA Medical Center.
2. The workgroup should review the E-911 dispatch system for recognizing and responding to stroke symptoms from EMS calls by March 30, 2010.
Status: The workgroup reviewed excerpts of the Vermont Dispatchers Medical Desk Reference Manual at its January 11, 2010 meeting. Joining the meeting by phone was Sarah Ferris, Training & Communications Director of the E-911 Board. The committee did not make any recommendations for changes.
3. The workgroup should adopt an evidence-based EMS stroke screening tool and standing orders for inclusion in the Vermont EMS statewide protocols and develop an implementation plan by March 30, 2010. The tool will be used primarily to facilitate communication between EMS services and hospitals while patients are en route. This work may lead to recommendations to optimize other EMS protocols that impact stroke care (for example drug infusions and intubations).
Status: The workgroup developed both an EMS screening tool and standing orders in consultation with Vermont EMS (see Appendix A and Appendix B) . Vermont EMS has agreed to add the standing orders to the statewide protocol manual available on their website but at this writing they have not yet done so. The committee did not recommend changes to other EMS protocols. The protocol manual can be found at http://healthvermont.gov/hc/ems/protocol.aspx.
Next Steps: The EMS protocols need to be updated with the standing orders document. EMS medical advisors should review the stroke screening tool and develop specific instructions for local ambulance services when a patient is identified as a likely stroke case. For example, in some communities they might be instructed to call in a “stroke alert” to the hospital in others they might be instructed to transport the patient to a tertiary care center. This is an essential element of the implementation phase of the project.
4. Implementation of the EMS stroke screening tool and treatment protocols should be led by EMS district medical advisors. This will allow each area to appropriately tailor EMS response to local factors such as proximity to a tertiary care center, the level of training of emergency department personnel (i.e., physician or PA) and availability of helicopter transport.
Status: This recommendation is a key element of the implementation phase of the project. It should be pursued in conjunction with the implementation of the emergency department acute stroke guideline described below in item 5.
5. The stroke workgroup should recommend nationally accepted, evidence-based guidelines for acute stroke care by August 15, 2010 for adoption by Vermont hospitals. These guidelines will be used to develop statewide treatment and transfer protocols between facilities and facilitate communication between hospitals and consulting neurologists. These guidelines will be promulgated by the stroke workgroup.
Status: The stroke workgroup and the emergency department medical directors committee have approved an acute care stroke guideline (see Appendix C). However, it is not yet clear whether every community hospital has the capacity to meet all of the guidelines (for example diagnostic testing) at all hours of the day.
Next Steps: An essential component of the implementation phase of the project will be working with local emergency department medical directors to consider each hospital’s individual situation and identify an appropriate course of action. VPQHC will consult with the workgroup as it identifies barriers to implementation and considers solutions.
6. The workgroup should explore the feasibility of, and barriers to, statewide implementation of teleradiology and telemedicine and develop recommendations by November 15, 2010. That exploration should include appropriate hospital information technology experts and the Vermont Information Technology Leaders (VITL). More widespread implementation of teleradiology and telemedicine would allow hospitals greater access to neurologic expertise in stroke care.
Status: It quickly became clear that the barriers to image sharing are related more to policy and operations concerns than to technology barriers so VITL’s assistance does not appear to be required at this juncture. In 2010, Central Vermont Medical Center worked closely with Fletcher Allen Health Care (FAHC) to set up a process by which images can be shared with FAHC neurologists. Dartmouth Medical Center (DMC) also began rolling out image sharing with Vermont emergency departments including Mt. Ascutney Hospital and Springfield Hospital.
Next Steps: Image sharing should be implemented between each Vermont community hospital and at least one tertiary care center.
7. The workgroup should work with tertiary care centers serving Vermont to better define the consultative expertise in stroke care they can provide to community hospitals and the attendant inter-facility treatment and transfer protocols.
Status: Neurologists at both Fletcher Allen Health Care and Dartmouth Medical Center have long provided consultation services to referring community hospitals. These arrangements are beginning to be formalized.
Next Steps: VPQHC should work with community hospitals and tertiary hospitals to develop treatment and transfer protocols for stroke and to augment tertiary neurology consultative services with image sharing. VAHHS should pursue lifting the regulatory barriers to the consultative services of Albany Medical Center neurologists.
8. The feasibility of a quality improvement-focused organization such as the Vermont Program for Quality in Health Care taking over the staffing of the committee should be explored before January 30, 2010.
Status: This has been explored and federal funding has been secured to support this work.
Next Steps: VPQHC and the Office of Rural Health, in consultation with the VAHHS staff, need to develop a contract and project plan.
9. The workgroup should monitor the progress of the Centers for Medicaid and Medicare Services (CMS) requirement that hospitals report on their participation in a “systematic clinical database registry for stroke care” scheduled for implementation in 2011. Statewide data on the incidence, treatment and outcome of stroke care, collected using a consistent methodology, are important to hospital’s quality improvement efforts. The workgroup should stay abreast of CMS efforts and help prepare hospitals for implementation of the national model.
Status: CMS ultimately did not require hospital participation in a stroke registry through although several of Vermont’s larger hospitals are participating voluntarily. Unfortunately, many smaller hospitals have found that the national registries that are currently available are overly burdensome.
Next Steps: VPQHC will work with ED medical directors and quality improvement professionals to develop consensus on a data collection tool that can track essential indicators that will allow the workgroup to evaluate the success of the project. The tool will be compatible with the registries already in use by some Vermont hospitals.
2010 recommendations
1. VPQHC and the Office of Rural Health, in consultation with VAHHS staff, should develop a project plan for the implementation of the stroke project. A plan should be in place by January 15, 2011. The plan should include working with medical advisors to customize the stroke alert for their communities, implementing the EMS stroke standing orders, helping hospital emergency departments become connected to neurology consultation services (including via teleradiology), implementing the emergency department guidelines and measuring the success of the project.
2. VAHHS should pursue lifting the regulatory barriers to the consultative services of Albany Medical Center neurologists.
3. The stroke workgroup should reconvene in mid-2011 to review the status of the implementation phase of the project.
Appendix A: EMS Stroke Screening Tool (pdf)
Excel Version - Appendix A: EMS Stroke Screening Tool
Appendix B: EMS Stroke Standing Orders (pdf)
Excel Version - Appendix B: EMS Stroke Standing Orders
Appendix C: Emergency Department Stroke Guideline (pdf)
Appendix D: Full Text of the Charge to the Workgroup Outlined in Act 61 of 2009
The Vermont Association of Hospitals and Health Systems (VAHHS) is requested to convene a group consisting of emergency room physicians from around the state, including one representative from the Vermont chapter of the American College of Emergency Physicians and at least one representative from the Vermont Emergency Department Medical Directors Committee; neurologists from Fletcher Allen Health Care and Dartmouth Hitchcock Medical Center who specialize in the treatment of strokes; and one representative from the American Heart Association/American Stroke Association. No later than November 15, 2009, VAHHS is requested to provide a report to the House Committee on Health Care and the Senate Committee on Health and Welfare, recommending ways to integrate timely, effective stroke treatment in Vermont considering evidence-based treatments accepted by the American Academy of Neurology or the American College of Emergency Physicians, or both. The report shall include:
(1) information about the capacity of each hospital to provide emergency treatment of strokes following the guidelines accepted by The Joint Commission (TJC), including the services that each hospital offers, the types of relevant providers available at each hospital and the hours of availability, and the challenges posed by emergency transportation systems in Vermont;
(2) recommendations about additional services or infrastructure necessary to ensure that all Vermonters are able to receive the recommended treatment for strokes; and
(3) draft recommendations for the triage, stabilization, and appropriate routing by emergency medical service providers of patients who suffered a stroke, and coordination and communication between hospitals and between treating physicians.
Appendix E: Workgroup Members
Mark R. Depman, MD
ED Medical Director, Central Vermont Medical Center
Stroke Workgroup Chair
Jill Mazza Olson, MPA, FACHE
Vice President of Policy and Operations, Vermont Association of Hospitals and Health Systems
Stroke Workgroup Staff and Key Contact (802-223-3461 x104; jill@vahhs.org)
Andrew Bushnell, MD
VT ACEP and Fletcher Allen Health Care Emergency Medicine
Christopher Commichau, MD
Neurology, Fletcher Allen Health Center
Steve Fisher, MD
ED Medical Director, Gifford Medical Center
Stephen Leffler, MD
ED Medical Director, Fletcher Allen Health Center
Richard Meyer, MD
ED Medical Director, Mt. Ascutney Hospital and Health Center
Nicole Lukas, MA
Director of Advocacy and Public Health
American Heart Association/American Stroke Association
Tim Lukovits, MD
Neurology, Dartmouth Hitchcock Medical Center
Paul Newton, MD
ED Medical Director, North Country Hospital
Christopher Schmidt, MD
ED Medical Director, Brattleboro Memorial Hospital
J.F. Subasic, MD
Neurology and Emergency Medicine, Copley Hospital
[3] Merriam-Webster on-line dictionary
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