A significant synchrony of process improvement, pharmaceutical advancement, and information technology development is evolving forward among some of the most advanced hospital organizations in the country these days. And that synchrony is improving outcomes in the treatment of acute ischemic stroke.
To begin with, studies are demonstrating the efficacy of intravenous tissue plasminogen activator (tPA), when used to treat patients who arrive in the emergency department (ED) within 60 minutes of their arrival, and when administered to patients within four-and-a-half hours of the onset of stroke symptoms. The challenge around that requirement for most patient care organizations continues to be a very complex process one: very often, by the time a patient arrives in the ED and a neurologist or other appropriate prescribing physician arrives at the point of care, that three-hour window has already closed, meaning that the use of tPA is often not possible.
However, clinicians at St. John Hospital and Medical Center (SJHMC), an 804-bed teaching hospital located in Detroit, have successfully built a reliable process for rapidly evaluating and treating patients with acute stroke, and have been able to dramatically reduce their door-to-treatment times and therefore substantially increase their use of tPA.
What’s more, the use of information technology has been a key component in the development of a single-call team notification program developed by SJHMC’s clinicians, and which has been supporting the hospital’s approximately 21-member cadre of neurologists, along with all their associated clinicians. The clinicians have been working with the Knoxville, Tenn.-based PerfectServe, and approximately two years ago went live with an IT-facilitated system that has led to the following results:
> A 90-percent reduction in neurologist response time, from 22 minutes to 2 minutes
> A 41-percent reduction in door-to-CT completion time, from 78 to 46 minutes
> An increase of up to four times the volume of tPA administration to patients with acute ischemic stroke in 2010, compared to in 2009
Recently, Paul A. Cullis, M.D., head of the neurology department at SJHMC, spoke with HCI Editor-in-Chief Mark Hagland regarding this innovative program. Below are excerpts from that interview.
What were you and your colleagues trying to achieve in your initiative?
We’re certified as a primary stroke treatment center, and we were trying to make the emergency department as efficient as possible in terms of administering tPA as efficiently as possible. And there were communication issues: no one knew who was on call for what; no one knew how to contact them; there was no efficient system in place for communication. We wanted the whole stroke team notified, and there was no way.At this point, the hospital was already adopting PerfectServe’s solution for physician contacting purposes in general. At some point about 10 years ago, we had already added PerfectServe as the communication system for our practice, so we were very familiar with it. So then when we started to build the stroke team and tried to begin communicating effectively, it turned out that PerfectServe was the perfect solution, because by contacting one number, we could reach everyone necessary.
Was it like building a phone tree?
Well, the initial call is what we call a code stroke. The secretary or health unit coordinator in the emergency department calls someone and sets off the code stroke alert. In the past, it was complicated, because they had to figure out whom to call based on the call schedule, had to figure out how to contact the person, and had to make sure the person had called back. PerfectServe automatically knows who’s on call, because I enter the name of the neurologist on call, since I know it; neurology, neurosurgery, radiology special procedures, the director of neuroscience, the stroke nurse, the CAT scan technician, all those people can change [depending on the moment in time].
In the past, you were losing valuable minutes, correct?
Right, because we only have four-and-a-half hours to administer tPA. So if a patient comes in in three-and-a-half hours, we have to do everything within an hour. The holy grail would be to administer within one hour, but in reality, it can take several hours to bring a patient in, work them up, do the CAT scan, etc., so if we have only one hour, it requires very intense management by the emergency medicine staff, constantly being aware of what’s going on.
So what amount of time savings is involved?
The communication system is probably saving a half-hour on the front end, because we have to notify everybody and start infusing the drug within an hour. And if it takes a half-hour just to notify everybody, there’s no way you’re going to get everything done within an hour.
Let’s talk a bit more about the metrics of your success.
The most important metric is that we’re now giving the clot-busting drug, tPA, to 8.8 percent of stroke patients. The national average is in the range of 1 or 2 percent, because most of the time, patients don’t get evaluated in time to get treatment; but because we’ve been able to shave time off, we’re able to give a much higher percentage of patients the TPA. We were at 2 percent earlier. In addition, for example, by deploying this new process, we were able to reduce the on-call neurologist response time by 90 percent, from 22 to 2 minutes. They had had a list, but nobody knew where the list was. One of the silly things that would happen was that they would pull a year-old list. Imagine you’re in an ED you have on-call lists for 20 specialties, and you’re relying on someone to give you updated lists for all of those specialties, and unfortunately, that just doesn’t happen. Now it’s all electronic, and it works well.
Can you articulate your satisfaction as the neurology chair in this important progress?
This has been very good for us, because we are constantly monitoring our metrics to make sure we’re providing the best care, and using an automated system like this makes it much easier to provide optimal care. There are myriad issues already; and this makes notification a non-issue.
Could there be any objection to this IT-facilitated process?
A lot of older doctors don’t like being called by a computer. And in order to make this work for you, you need to go in and create a notification pathway. And you tell PerfectServe how you’d like to be notified. PerfectServe calls me on my cell phone, except between 9 PM and 7 AM, when they also call my house. And if you set it up the way you’d like it, it’s not a problem. But a lot of doctors didn’t initially set it up in the way that was best for them, and they objected being called by a computer, and didn’t feel in control. But almost all of that ill will is now gone, because the hospital has been using the system for a while. I think most doctors are comfortable with it now.
What would your advice be for CIOs and CMIOs, with regarding to establishing a system like this?
I think this requires a change in culture; I think that in the past, physicians were used to having people call them and were used to doing things on a more personal basis; but as the world speeds up and we all have to do things more quickly, and the expectations increase, I think that it’s impossible to do all the things we need to do, using manual systems. It’s like in the old days when you would go to the bank and have someone manually enter your balance in a passbook; that just doesn’t work anymore. And the same is true with medical care; we can’t do things the old way anymore.