Your Path to Program Success: Expert Advice

Comprehensive Stroke Care: The Latest Boom for Hospital Expansions

Susan Heck, Senior Vice President, Corazon Consulting, Inc., Pittsburgh, Pennsylvania
Susan Heck, Senior Vice President, Corazon Consulting, Inc., Pittsburgh, Pennsylvania
Industry trends reveal that stroke care is the new ‘up-and-comer’ service, quickly moving onto the radar for many hospital leaders. As a result of growing consumer need due to an aging population, greater awareness prompted by the focus on stroke education and prevention, and interventional trends in the news, stroke centers are the latest boom for strategic hospital expansions. With nearly 700,000 strokes occurring each year, savvy hospitals must find ways to provide the most effective care for this patient population while optimizing space, expert staff and existing clinical infrastructure. Stroke as a leading cause of death and disability in the U.S. is an indisputable fact. The harsh reality and human toll of stroke can be seen with one trip to a local nursing home. Has the healthcare system failed this patient population? Have we become complacent in our approach to care, accepting the expensive costs of lifelong disability and long-term care? It’s time to change the stroke care paradigm. Based on our experience, this trend is just beginning. The development of Primary Stroke Centers advocating early recognition, rapid diagnosis and timely intervention are on the forefront of a new approach that must be embraced nationally in order to significantly improve not only the quality but also the availability of stroke care. There are currently 501 Primary Stroke Centers accredited by The Joint Commission in the U.S., nearly double the documented number from just two years ago (218 in 2006). Florida leads the pack with 68 accredited programs. One would speculate that Florida hospitals are ahead of the curve because of its large elderly population. Or perhaps the driving force behind accreditation is fueled by regulations that stipulate that EMS services must triage patients with stroke symptoms to an accredited stroke center. Currently, Florida, California and Massachusetts have state-mandated regulations for stroke transports. Will the remaining states wait for similar regulations to drive change? We believe that organizations should not wait for regulations, but instead must proactively reorganize care and resources to do what is in the best interest of the patient and the community at large. With the proliferation of primary stroke centers comes another movement: the organization of Comprehensive Stoke Programs that can mobilize services to intervene for the ischemic stroke populations. Industry standards support the need for a treatment decision made within three hours of “last known well.” For the ischemic stroke patient, drug therapy should occur as soon as possible, but interventional treatment can be delayed up to eight hours in some cases. Clearly, the role for community and mid-sized hospitals is expanding. The growing number of neurologists with interventional skills can fuel the migration of the comprehensive stroke service from the tertiary facility to the community hospital setting. In fact, looking back just 15 years reveals striking parallels to the early days of cardiac intervention. While there are significantly fewer comprehensive (interventional) stroke programs, there is no denying that this form of organized stroke care is necessary for a hospital to make an impact on the health of the community. In the cardiac specialty, significant progress has been made in terms of developing sophisticated technology and tools, changing medical training requirements to grow the numbers of talented sub-specialists and making strides in time-to-treatment. What might the next 15 years hold for the development of interventional stroke care if we apply a similar effort? Indeed, there are vast similarities between stroke care and heart care, which allows hospital professionals to transfer their skills to this growing sub-specialty. The greatest similarity between a ‘heart attack’ and a ‘brain attack’ is the need for immediacy of an intervention through a dedicated and tested process. These acute patients follow a parallel track, from admission through discharge, to follow-up and/or rehabilitative care. Clearly, principles that have been hard-wired into the care of the cardiac population can be modified and duplicated for the care of the stroke population. Learning from cardiac program implementation histories and capitalizing on a faster organizational learning curve can be possible with diligent planning efforts. The development of a stroke program cuts across many hospital departments and specialties. Stroke centers require a physician champion and collaborative practice, similar to the model Corazon recommends for integrated cardiovascular care delivery. In fact, comprehensive stroke centers can involve some or all of the following disciplines: • Neurology • Neurosurgery • Interventional neurology • Interventional neuroradiology • Cardiology • Service line leaders It is our belief that in today’s challenging world of limited access to capital, hospitals must critically evaluate their options for the development of a comprehensive stroke program. For hospitals just beginning to organize interventional stroke services, we encourage creativity that will lead to maximizing the use of existing resources. Our team often finds that sophisticated cath suites often have capacity to take on neuro-interventional services. Furthermore, highly-skilled cath teams can prove their abilities to learn new vascular beds as they stretch to take on peripheral interventions. Indeed, this group has the capacity to learn techniques associated with “coiling” procedures and support the neurovascular service, after some additional didactic education and hands-on training. Other options include developing the service within the special procedures lab in radiology or creating a separate neurovascular lab. Each of these options carries operational and political challenges. No doubt, committed administrative and physician champions are key — those who can wade through challenging implementation issues and make decisions in the best interest of the patient and the hospital. The opportunity for hospitals is great. With the majority of stroke patients presenting at non-tertiary facilities, leading-edge communities can take advantage of the clinical, financial and market benefits of implementing a Stroke Program or Center. For instance, Corazon clients report in excess of $3000 profit for tPA cases, nearly $18,000 for embolectomy cases, and most importantly, there are untold savings in rehabilitation costs. Also, the average contribution margin for some Stroke Programs is reported within the range of 15-20%, based on case mix and operational efficiencies. A recent Center for Disease Control study stressed the need for early diagnosis and treatment of stroke, along with risk-factor modification — much like the current approach for patients with coronary artery and/or vascular disease. Atherosclerosis can be the underlying disease process for heart attack and stroke. We believe there are significant opportunities for hospitals to leverage the dollars they spend in education for the public about risk modification and symptom recognition. While many organizations focus community education on the signs of a heart attack, many patients don’t know when they’ve had a stroke. The synergies between a stoke education and heart disease education program must not be ignored by hospitals that strive to make every dollar count. A well-designed community and physician education strategy can be valuable for improving the level of care, while also serving as a differentiator. Corazon believes that stroke care is leading edge, especially with its link to neurosciences, which is also a growing clinical specialty, and one that often relies on stroke care to remain viable. As managers and directors of cath labs, we encourage you to take the lead envisioning a stroke center of the future at your organization. With a strong history of adapting and embracing leading-edge technology, cath lab teams can truly forge the path for hospital-based stroke care. For more information about the benefits of implementing a formalized Stroke Program at your organization, contact Susan Heck at or call (412) 364-8200.