Effort Seeks to Standardize Care Across VAMCs
By Annette M. Boyle
INDIANAPOLIS — Since the publication of the VHA directive on treatment of acute ischemic stroke (AIS) in November 2011, VA medical facilities nationwide have responded by adding structure to their stroke programs, increasing interdepartmental and prehospital communication about stroke patients and raising the awareness of staff of the importance of timely care. Still, many facilities struggle to fully implement the guidelines three years after their release, largely because of shortages in both professional and administrative staff.
About 15,000 veterans are hospitalized annually for strokes, 85% of which are acute ischemic strokes (AIS). Stroke care poses significant costs from onset through rehabilitation and ongoing assistance. Acute inpatient care for new strokes cost the VA about $111 million, while post-acute inpatient care adds another $75 million and follow-on care adds another $88 million in the first six months post-stroke. Between 15% and 30% of stroke patients suffer permanent severe disability, and 40% have moderate functional impairments.
The American Hospital Association predicts that the prevalence of stroke will double by 2020 as the baby boomer generation ages. Male veterans have an 81% greater risk of stroke than other men of similar age, health, race and socioeconomic status. Given the large proportion of veterans in this cohort and their elevated risk, the implications for the VA are daunting.1
To meet the growing need for stroke care and to provide a single standard of care for similar VHA facilities around the country, the directive created three classifications of stroke centers and required that all sites that provide stroke care implement policies based on the American Heart Association/American Stroke Association Guidelines and the National Institute of Neurologic Disorders and Stroke Thrombolytic Therapy with Tissue Plasminogen Activator (r-TPA) Stroke Study.
A primary stroke center has the staff, expertise and infrastructure to diagnose and treat stroke patients 24/7 and has a stroke unit within the facility staffed by medical personnel with specific training in stroke care. A limited-hours stroke facility can meet the needs of stroke patients, including administering tissue plasminogen activator (tPA), on an emergency basis during regular business hours but refers patients to another stroke center outside those hours. A supporting stroke facility cannot consistently care for acute stroke patients and does not administer tPA but has robust transfer agreements in place for in-hospital stroke and acute stroke diversion
A team from the VA Stroke Quality Enhancement Research Initiative (QUERI) interviewed 107 clinicians including emergency department (ED) chiefs, neurology chiefs, neurologists, ED nurse managers and nurses and other staff at 38 sites by phone or in person in late 2013 to assess the impact of the directive on facilities and stroke care. In addition, the team interviewed 16 regional Veterans Integrated Service Network (VISN) leaders. Of the 38 sites, nine were primary stroke centers (P), 24 were limited hour facilities (LH) and five were supporting facilities (S).
“The goal of the directive was to standardize acute stroke care across the system, regardless of structures, processes and resources available,” said Teresa M. Damush, PhD, implementation research coordinator for the VA’s Stroke QUERI and associate research professor of medicine at Indiana University School of Medicine in Indianapolis.
Lack of on-site clinical leadership posed a significant challenge to implementing the directives. The research team found that “reluctant” clinical champions struggled to implement protocols across all the VA’s clinical services for acute stroke care. The stroke teams also noted that an effective nurse champion played an important role in linking services and people, implementing change and measuring results. At all levels of care, the stroke teams reported the need for more systematic nurse training in triage and initiation of stroke protocols.2
According to an article published in the Journal of General Internal Medicine, the directive did raise awareness of acute stroke services across the facilities, but the challenges faced and solutions developed by stroke teams varied significantly by size of institution. While most primary centers were able to provide CT services around the clock and others cross-trained X-ray technicians to ensure full 24/7 coverage, some encountered resistance from radiology services and delays in computed tomography (CT) readings.3
Nearly 4 out of 5 primary facilities developed stroke order sets and templates to facilitated rapid stroke evaluation and track quality of care data, but some reported delays in uploading of these documents to the electronic medical records system by IT. One-third of primary facilities reported a lack of time and staff devoted to quality data collection. Other shortages, particularly of nurses, also disrupted the implementation of the stroke protocol, although some sites were able to add stroke team members and other resources.
At limited-hour facilities, implementation of the directive frequently required additional structure, such as adoption of a formal acute stroke protocol, formal patient transfer agreements with local hospitals or more defined training and communication among stroke team members. Some LH sites implemented programs similar to those seen at primary centers such as stroke order sets, cross-trained X-ray techs and use of mock codes to practice stroke protocols.
These hybrid facilities — primary sites during the day, supporting sites on nights and weekends — often partnered with university affiliates to conduct reviews of their protocols and ensure that shared neurology residents could follow the same protocols in both organizations.
The majority of LH sites reported challenges with access to neurology and radiology services. They frequently noted that data collection created a burden for the team, particularly in the absence of a dedicated person to conduct the manual chart review required.
One-third of LH sites told the QUERI investigators that they had trouble with the local emergency medicine services diverting stroke patients to nearby stroke centers and bypassing the VA, resulting in facility administration not allocating resources of additional staff to support the directive. One-third of these sites also noted that they urgently needed to improve their timely response to patients who present with acute stroke within the treatment window.
As at the LH sites, lack of access to neurology and radiology services created barriers for implementation of the stroke directive at supporting sites. Two of the supporting facilities overcame the imaging issue by training all their radiology technicians to be CT technicians so they could provide the necessary 24-hour, in-house CT coverage.
Other challenges for supporting sites were a lack of staff and a stroke champion and diversion of stroke patients to nearby stroke centers. As a result, some facilities reported that “in light of the low volume of acute stroke patients, the ability of the staff to maintain competency in the stroke protocol was of concern,” noted the authors.
Overall, Damush pointed out that “the most significant improvement across the VA system was establishing a local coordinated and timely response once a potential patient with an acute ischemic stroke was identified at the local facility. For the Primary and Limited Hours [sites], it often resulted in calling a ‘stroke code’ or a ‘rapid response code’ which enacted all the key personnel to immediately respond to that patient.” Supporting sites established transportation agreements in advance to help with timeliness.
The directive does not address the greatest challenge in stroke care, noted many of the respondents. As one said, “We need to reach our patients to recognize stroke symptoms and come into the VA right away.”
1Finkelstein J, Mutambudzi M, Cha E. Association between veteran status and stroke prevalence: A population-based analysis. 2013 American Public Health Association Meeting. November 2013. Poster 285934.
2Stroke Fact Sheet. QUERI. VA. July 2014.
3Damush TM, Miller KK, Plue L, Schmid AA, Myers L, Graham G, Williams LS. National implementation of acute stroke care centers in the Veterans Health Administration (VHA): formative evaluation of the field response. J Gen Intern Med. 2014 Dec;29 Suppl 4:845-52.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.