When someone suffers a stroke, every second counts.
The faster medical personnel can transport, diagnose and treat a stroke victim with a drug designed to open clogged brain arteries and limit damage, the greater the likelihood of survival and improved outcomes.
Both the winning entry and runner-up in the 11th Annual Excellence in Risk Management Awards competition examined how stroke victims are treated and how treatment response times could be improved. By a narrow margin the judges awarded Saint Agnes Medical Center in Fresno, Calif., the top honor. But they also recognized OSF St. Joseph Medical Center in Bloomington, Ill., giving the hospital an honorable mention.
Judge Marsha Studer, vice president of risk and insurance services for Minneapolis-based Allina Health System, was impressed by how quickly the two entrants responded to changes mandated by hospital accrediting agencies to improve stroke-management processes.
"Coming from the trenches as a nurse, I know what kind of work it entails to achieve coordination of care between different parts of an organization to meet accrediting guidelines," Studer says. "And these two organizations were able to integrate changes across several different departments to improve productivity and implement best practices."
Judge Charles Dunn, senior partner at the Houston law firm Dunn, Kacal, Adams, Pappas & Law, says stroke management, in addition to its clinical benefits, is a good way for hospitals to protect themselves and reduce liability. "Stroke management is a good risk-management subject because treatment decisions for long-term-care patients are a growing factor in lawsuits," he says.
The Saint Agnes team viewed stroke management primarily as a quality-of-care issue and had been working for four years with a multidisciplinary team to refine the medical center's practices in treating stroke victims. Several years ago Saint Agnes began sponsoring an annual community education forum.
Harvey Edmonds, a neurologist, also recognizes stroke care's potential as a risk-management tool.
"When the benchmarks suggest that stroke victims be treated with (a clot-buster drug) within 25 minutes of arrival in the (emergency room), and you're not doing it for 45 minutes, this could certainly generate litigation if the outcome is not favorable," says Edmonds, the quality-improvement leader at Saint Agnes.
Saint Agnes officials realized that if they could bring their response time-how long it takes to get the patient to the CT scanner to make a conclusive stroke diagnosis-to below the guideline figure, it would not only provide better patient care and improve outcomes but reduce exposure to a growing threat of malpractice litigation.
The Saint Agnes project team succeeded, dropping its average response time to 14.8 minutes in August and 26 minutes since the program's inception. That's down from 37 minutes in the six months leading up to the project's launch. The hospital also reduced its readmission rates-patients suffering additional strokes or other complications after an initial stroke-in four of the past six months, and it saved up to $500,000 annually in overtime through process improvements and workload adjustments.
Edmonds says the stroke-management project was approved about 18 months ago. The stroke-treatment response time has become a quality measure for which the hospital's president is held accountable.
Saint Agnes hired Inger Saxe, a biostatistician and quality-improvement expert, to serve as an outcomes leader for the hospital's quality resource department and to co-direct the project with Jonathan Caldwell, an ER physician at the hospital. St. Agnes later sent four employees and four physicians to a stroke outcomes program at Intermountain Health Care in Salt Lake City to learn from quality guru Brent James, M.D.
"We selected key people who are focused, motivated and interested in improving patient care to be staff educators and project champions," Saxe says. "We wanted to make sure we were very inclusive in brainstorming solutions and getting a buy-in from all stakeholders."
Early on, Edmonds says the group sought physician participation, understanding that the program could not succeed without them.
Saint Agnes also changed the way it staffed its CT department. "It turned out radiology was using an on-call system to pay technicians after hours," Edmonds says. "By turning the department into a round-the-clock operation, we ended up with significant savings."
He says staffing the CT department on every shift also meant technicians were available immediately on site, further reducing the delay in treating stroke victims.
Kathleen Haig, risk manager and director of quality resource management at OSF St. Joseph, says her team was naturally disappointed to lose by such a close margin but thrilled to receive an honorable mention.
"This was a perfect example of teamwork, not just from the medical staff, but throughout the continuity of care in the emergency department, nursing, the lab and case management," Haig says. "This taught us what we can achieve if we work together."