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Why hospitalists may be destined to become the first responders for inpatient stroke

November 2006

When the neurologists at Lehigh Valley Hospital started an acute stroke team a few years ago to respond to in-house stroke alerts, the team was almost immediately overwhelmed. In what felt like too many cases, neurologists were being asked to drop everything and respond to calls for which they weren’t really needed. Symptoms that looked to nurses like signs of stroke turned out not to be stroke at all.

That’s when the Allentown, Pa., hospital turned to its growing cadre of hospitalists. Starting this year, when nurses sound a stroke alert, the hospitalist-led rapid response team takes the call, not the neurology stroke team. The team’s hospitalist, respiratory therapist and critical care nurse triage the case and call the stroke team if they see any signs of stroke. In many instances, the rapid response team can take care of the emergency without having to call in neurology.

“These are all necessary calls, but not all are necessary for a neurologist,” explains Michael Pistoria, DO, Lehigh Valley’s chief of hospital medicine. The hospitalists have been so successful in caring for stroke patients, in fact, that the hospital is now looking at ways to expand their role. One possibility is to have the hospitalists admit stroke patients themselves instead of admitting them to the neurology service.

As it looks for ways to get its hospitalists more involved in stroke care, Lehigh Valley is far from alone. In a growing number of hospitals, hospitalists are joining “or replacing “neurologists as the first to respond to inpatient strokes. From staffing the rapid response teams that take the first alerts to serving as the primary physicians for stroke patients with complex medical problems, hospitalists are taking on an ever-growing role in the care of stroke patients.

The trend may defy the conventional wisdom, which says that stroke care is best delivered by neurologists. But faced with clinical advances that demand speed, along with a shortage of neurologists willing to rush to the hospital to provide care, hospitals and stroke experts alike say that hospitalists are the next best line of defense.

A revolutionary idea
In recent years, stroke care has been revolutionized by the concept of stroke centers. The concept is fairly simple: By labeling a collection of stroke-related endeavors “from investing in CT machines to designing in-house continuing medical and nursing education “as part of an overarching “center,” hospitals can focus all of their disparate resources on stroke care as soon as an ambulance rolls in or a nurse notices a mental status change.

In 2000, the Brain Attack Coalition, which is made up of several professional groups that focus on stroke treatment, published guidelines on establishing primary stroke centers and improving stroke care. The recommendations were important, neurology experts say, because they help hospitals bring together the various elements that make up state-of-the-art care.

According to Mark J. Alberts, MD, professor of neurology at Northwestern University Medical School and a contributor to the Brain Attack Coalition, the key guideline components are admitting patients to designated stroke units, having an acute stroke team available around the clock, and using neurologists or neurointensivists, particularly those trained in vascular neurology.

While the coalition’s guidelines focus on the role that neurologists should ideally play in managing stroke, the fact is that there simply aren’t enough neurologists to treat the nation’s hospitalized stroke patients. Community neurologists now focus more on outpatient care, and many are unwilling or unable to come to the hospital every time a patient has a stroke.

Playing to hospitalists’ strengths
That shortage is so severe that many experts say that hospitals are going to have to turn to hospitalists for help. “The only model that I can see to deal with the inadequate stroke care in the community right now is to utilize hospitalists and bring them into the team,” says David Palestrant, MD, assistant professor of neurology in stroke and neurocritical care at Columbia University in New York.

And while stroke care may evoke visions of using the clot-busting drug tPA, which usually falls into the purview of neurologists’ care, the drug is used in a relatively small percentage of stroke patients. David Likosky, MD, a hospitalist internist and neurologist who is executive director of the Evergreen Neuroscience Institute at Evergreen Hospital in Kirkland, Wash., says that top-quality stroke care for most patients is accomplished through efforts to streamline systems, develop pathways and protocols, and generally “make sure that the same thing is done appropriately for every patient” to prevent complications, promote secondary prevention and smooth discharge.

Because Dr. Likosky, who is also director of the stroke program at Evergreen, says those areas “play more to the strengths of hospitalists than neurologists,” he sees a bright future for collaborations between neurologists and hospitalists when it comes to stroke care. “The neurologists are the experts in cerebrovascular disease,” he explains, “and the hospitalists are the experts in how the hospital works.”

Making the most of team care
A good example of how hospitals are putting together these elements can be found at the primary stroke center at Kaiser Permanente Santa Clara Medical Center. The hospital has extended the expertise of its five adult neurologists by extensively involving all 40 of the medical center’s hospitalists.

When a stroke patient arrives at the hospital’s emergency department, it’s often the hospitalists who are called first. A neurologist is added if the patient appears to be a candidate for tPA.

The hospitalists admit these patients and are the first to respond, along with their rapid response team, to code gray calls (for inpatient strokes). For particularly complex cases, they use a special pager to call neurologists, who respond within 15 minutes, day or night. Neurologists also review all stroke admissions in routine rounds on the stroke unit. A hospitalist and a neurologist co-direct the hospital’s stroke unit.

One of the goals of putting stroke care under the framework of a “stroke center” is to raise the profile of best stroke-care practices. A secondary goal is to put all providers on notice that they have to work together.

“Formalizing the stroke center has really improved the collaboration,” explains Diane Craig, MD, a hospitalist at Santa Clara. “Our neurologists took a strong leadership role in implementing the stroke center, and we now have a well-oiled multidisciplinary team.”

To meet their growing responsibilities, the hospitalists at Santa Clara attend eight hours of CME annually specifically on stroke. Continuing education for nurses also has been ramped up.

The hospitalists have learned to be more aggressive in admitting patients with transient ischemic attacks. In addition, they have a great deal of support from the neurologists “especially on weekends, when hospitalists used to be reluctant to call neurologists.

As a result, overall quality of stroke care has improved in terms of faster therapy, fewer complications and lower lengths of stay. “The communication among all the members of the team is much better,” explains Ted Tasch, MD, chief of neurology at Santa Clara. “Everybody is on the same page, and everything happens faster and more smoothly.”

Finding a place on the stroke team
To make them more comfortable with their emerging role, experts like Dr. Likosky say that hospitalists will need some additional education. He says that additional training should probably include recognizing atypical strokes, identifying patients who are candidates for more aggressive therapies, and providing basic care more consistently to prevent complications and re-admissions.

Sandeep Sachdeva, MD, the lead hospitalist on the stroke team at Swedish Medical Center in Seattle, agrees that most hospitalists probably are not receiving all the skills they’ll need to care for stroke patients during residency, but he says those skills can be learned. As proof, he points to the fact that the stroke care program at Swedish “which relies heavily on the collaboration of neurologists, nurses and hospitalists “earned the Joint Commission on Accreditation of Healthcare Organizations’ prestigious Codman Award in 2005 for disease-specific care.

To bring its hospitalists up to speed, Swedish now requires all hospitalists to review a self-learning module that Dr. Sachdeva created and that summarizes key points in stroke care. They also complete a test after their review.

Swedish’s work with its hospitalists has been so successful that 25 “stroke-savvy” hospitalists attend on the stroke floors at its two hospitals. They even take primary responsibility for straightforward post-tPA patients.

These generalists regularly consult a special acute stroke team made up of four mid-level practitioners, three specially trained nurses and five physicians taking call by rotation. That includes four neurologists and Dr. Sachdeva, the hospitalist.

In creating a designated stroke center, Swedish also had to invest in costly new equipment, including an extra CT scanner for one of the emergency departments, and hire more staff. But those investments have paid off in fewer complications, declining mortality rates and reduced lengths of stay for stroke patients, from an average of 4.7 to 3.2 days.

Standardizing the basics
The real value of designated stroke units like the one at Swedish, Dr. Sachdeva explains, is standardizing key elements of stroke care, including appropriate DVT prophylaxis, swallowing assessment and risk prevention against falls. “When these simple things are done for every patient,” he says, “they add immensely to the quality of care and bring down complication rates.”

While stroke units are typically led by neurologists, Dr. Sachdeva adds, there is no reason why general medicine hospitalists working with protocols, standardized order sets and skilled nurses can’t do the bulk of the work in these units.

What matters, he explains, is training. That’s why nurses who work in the stroke unit at Swedish learn how to properly do swallowing screens, for instance, while hospitalists are kept up to date on the latest evidence on temperatures, blood sugars and blood pressure, areas where mistakes are often made. And everyone is taught to avoid Foley catheters at all costs.

“I can’t remember the last time we had a urinary tract infection and sepsis in a stroke patient,” Dr. Sachdeva says. “I can’t remember the last aspiration pneumonia that happened because we didn’t do a stroke swallow screen.” Swedish’s stroke program started in 2001.

“We didn’t do anything fancy,” he explains. “We just did simple things more consistently. You don’t have to be a trained neurologist to do certain basic stroke care right. These are things hospitalists can do really well.”

Another thing hospitalists at Swedish are taught: when to call for help. “They know that the stroke team will respond within five minutes of being paged,” says Dr. Sachdeva, “so they feel reassured that they are being backed up.”

Growing demand
As hospitalists around the country are being called upon to take on a greater share of stroke care, experts say it is shaping up to be a big growth area for the specialty. Across the country, Dr. Likosky explains, there is a community expectation that hospitalists will be capable of treating basic stroke and will need a neurology consult only for the most complicated cases or maybe for tPA.

“The emergency department is calling us because the hospitalist is expected to be the solution for all inpatient medical problems,” he says. “The community neurologists don’t want to cancel an afternoon of clinic to rush to the hospital.”

That has been the experience at Lehigh Valley. Dr. Pistoria characterizes the discussion about which service “neurology or hospital medicine “should be the one to regularly admit stroke patients who come in through the emergency department as “being driven by both sides.” Now that the hospitalists have experience taking acute calls, he explains, they are considering more ways to partner with neurologists to provide more stroke care.

“Volumes have picked up and both the neurosurgeons and neurologists would like to move more into the traditional consultant role,” Dr. Pistoria says. “We see it as potential business for our group.” The partnership between hospitalists and neurologists has already produced impressive results, with almost 10 percent of in-house stroke alerts being treated with acute intervention (IV/IA tPA or Merci devices).

“The most effective way to improve stroke outcomes is to have the hospitalists involved, and to make sure they have the education and knowledge to do that,” says Dr. Tasch of Kaiser Permanente in Santa Clara. “Neurologists are the experts, so we ought to be leading the charge on stroke care in the hospital, but we are not the only ones who can do this.”

Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.

A new breed of hospitalist: the neurohospitalist

Just over two years ago, David M. Brown, MD, was a neurology attending at Mount Sinai Medical Center in New York. Now, across the country in Newport Beach, Calif., he is one of a new breed of hospital-based physicians “a neurohospitalist.

“This is an evolving specialty,” explains David Likosky, MD, a hospitalist and neurohospitalist at Evergreen Hospital in Kirkland, Wash. The specialty has developed because of “the perceived poor availability or interest of neurologists in inpatient care” in some communities.

For neurologists, relatively low reimbursement makes canceling an afternoon of office appointments not worthwhile. At the same time, many neurologists were drawn to the specialty because of its outpatient focus.

The development of hospital medicine came at the perfect time for Dr. Brown, who wanted to leave academia and return to southern California. While he was looking for a community setting, he didn’t particularly want to work in an outpatient practice.

At the same time, he says, Orange County, Calif.’s Hoag Hospital had experienced conflicts about coverage and concerns over how responsive community neurologists were to stroke calls. They’d also seen success with their hospitalist model.

“So they thought why not try that with a neurologist,” says Dr. Brown, whose expertise is in neurologic emergencies. “They had the idea of having a neurohospitalist, which really spoke to me.”

A year after coming to Hoag as its stroke specialist, Dr. Brown recruited a colleague, an epilepsy specialist, and launched Newport Neurohospitalists. A year later, he says, they have plenty of business and hope to add neurohospitalists with other types of expertise as demand grows.