Best Practice Submission
Baptist Health System Primary Stroke Center Program
Point of Contact: Deb Motz, MS, BSN, RN (210) 297-8550,
DSMOTZ@baptisthealthsystem.com
Project Group: BHS Regional Stroke Coordinator, Regional Quality Department, and
Director of Rehabilitation Services
Executive Summary: As recently as 2008, San Antonio had no local hospitals with a
coordinated stroke protocol in place to ensure the timely provision of high quality emergency
and acute care to stroke patients. Baptist Health System implemented a stroke care system based
on the standards and guidelines set forth by the Brain Attack Coalition and the American Stroke
Association in 2008, which has dramatically improved the quality of stroke care and education
available in the San Antonio community.
Objective of the Best Practice: The Brain and Stroke Network of the Baptist Health System
strives to reduce disability and death from cerebrovascular disease by providing timely access to
emergent medical care and high quality acute stroke treatment and rehabilitative services while
promoting primary and secondary stroke prevention.
Background: In 2008, a prominent citizen in San Antonio suffered a stroke and had to be
airlifted to Austin, Texas to receive care because no immediate, emergency stroke care was
available in San Antonio. This event highlighted the need for quality stroke care in San Antonio
and served as a catalyst for the rapid development and implementation of a coordinated stroke
program by Baptist Health System.
Literature Review: Approximately 795,000 people have a new or recurrent stroke each year,
ranking stroke as the fourth leading cause of death and the leading cause of disability in the
United States. In 2010, the estimated total of direct and indirect costs of stroke in the United
States was $53.9 billion. The National Institute for Neurological Disorders and Stroke has
recommended that all hospitals caring for acute stroke patients develop a Stroke Plan, using
evidence-based guidelines and standardized protocols, to address stroke care from pre-hospital
recognition through discharge, including patient education and secondary prevention. According
to American Heart Association data, more than half of stroke patients are not treated in
accordance with accepted secondary prevention guidelines and miss potentially life-saving and
function-sparing therapies. Establishing a primary stroke center at a community hospital resulted
in a significant increase in patients receiving thrombolytic therapy for ischemic stroke, offering
the potential of improved patient outcomes and reduced healthcare costs.
Implementation Methods: On their most recent Primary Stroke Center Certification Survey in
August 2011, the Joint Commission (TJC) surveyors cited the following components of the BHS
stroke program as best practice:
1. Tissue Plasminogen Activator (tPA) Process: tPA is the only FDA approved
pharmacologic treatment for acute ischemic stroke and has been shown to improve patient
outcome if initiated within 3-4 hours of symptom onset. A multidisciplinary team at BHS
used LEAN tools to reduce the time from Emergency Department (ED) arrival to tPA
administration to a goal of less than 60 minutes. Dramatic improvement has been made as
57% of patients received intravenous tPA within 60 minutes of ED arrival in FY 2011
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compared to only 7% in FY 2008. In 2011, Baptist Health System’s performance exceeded
that of Texas hospitals (37%) and US hospitals (31%).
2. Dysphagia Screening: Dysphagia is a swallowing disorder that can be a potentially serious
complication of stroke. The BHS Dysphagia Screening Tool was developed collaboratively
by speech-language pathologists and nurse educators. The patient’s ED nurse performs the
initial screening. Upon hospital admission, the patient is rescreened by the primary nurse,
and if needed, then evaluated by a speech-language pathologist. Education on proper
administration of the dysphagia screening is provided to nurses at initial orientation, periodic
educational fairs conducted by nurse educators, and through an annual online training
module requirement.
3. Patient and Family Education Folder: BHS has developed a comprehensive patient
education folder including stroke signs and symptoms, calling 911, types of stroke, risk
factors, smoking cessation, lifestyle modification, medications, recurrent stroke prevention,
follow-up care, and resources and support. This written information is given to the patient
and family at admission and reviewed daily with the patient by the primary nurse.
4. Orientation for Physicians: The BHS Regional Quality Department developed a
comprehensive orientation program for new physicians. It updates the program regularly to
insure currency of information, regulatory compliance, and standardization of message. The
Chief Medical Officer of each hospital conducts physician orientation monthly. The stroke
program is discussed briefly with the mandatory use of Physician Order Sets for Stroke
Admission and Discharge clearly communicated. Failure to use mandatory order sets is
handled by the Medical Quality Committee comprised of physician peers.
5. Coordination with Outside Agencies: BHS Stroke Program leadership participates in the
Governor’s Emergency Medical Services (EMS) and Trauma Advisory Council Stroke
Committee for effective coordination with Emergency Services. BHS educators provide
periodic stroke education to local emergency medical services staff. BHS also contracts with
Specialists-on-Call to provide neurology and neurosurgery consultation via video
teleconference technology.
Other key factors to the successful implementation and continuous improvement of the BHS
stroke care program include strong administrative and clinical leadership, designated stroke units
with trained staff, extensive data analysis of quality and service metrics, multidisciplinary stroke
team meetings for communication, and sufficient resources.
Results: All five BHS hospitals have attained Primary Stroke Center Certification from the Joint
Commission. The American Heart and American Stroke Associations have named the Baptist
Health System to the Target Stroke Honor Roll. The five BHS hospitals are the only healthcare
facilities in San Antonio who have received the Silver PLUS Award from the American Heart
Association, which requires meeting TJC performance measures and additional quality measures.
Patient surveys indicate that 97% of stroke patients at BHS hospitals rate their care as very good
or good.
Conclusion: The BHS Stroke Program meets the best practice criteria. It is outcomes based,
focused on measurable quality, service, efficiency, and financial metrics. The program is
adaptable to other organizations with the evidence-based practice guidelines from the Brain
Attack Coalition and the American Stroke Association. Their innovation is apparent in the use
of telemedicine for neurology consultation and their participation as a clinical trials site. The use
of mandatory stroke order sets, stroke care protocols, and extensive data analysis provides a
strong mechanism for the organization to sustain their results over time.
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References
American Heart Association (AHA). AHA Statistical Update Heart Disease & Stroke Statistics
– 2012 Update: A Report from the American Heart Association. Circulation 2012; 125: 188197.
Fonarow, G. C., Gregory, T., Driskill, M., Stewart, M. D., Beam, C., Butler, J., Jacobs, A. K.,
Meltzer, N. M., Peterson, E. D., Schwamm, L. H., Spertus, J. A., Yancy, C. W., Tomaselli, G. F.,
and Sacco, R. L. Hospital Certification for Optimizing Cardiovascular Disease and Stroke
Quality of Care and Outcomes. Circulation 2010; 122: 2459-2469.
Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al.
Forecasting the future of cardiovascular disease in the United States: a policy statement from the
American Heart Association. Circulation 2011; 123(8): 933–944.
Lattimore, S. U., Chalela, J., Davis, L., DeGraba, T., Ezzeddine, M., Haymore, J., Nyquist, P.,
Baird, A. E., Hallenbeck, J., and Warach, S. Impact of Establishing a Primary Stroke Center at a
Community Hospital on the Use of Thrombolytic Therapy: The NINDS Suburban Hospital
Stroke Center Experience. Stroke 2003; 34:e55-e57.
The National Institute of Neurological Disorders and Stroke (NINDS). NINDS Symposium
Produces National Plan for Rapid Stroke Treatment. (1996, December 13). NINDS Press
release.
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