Stroke Coordinator: ROI
Author:
Debbie Roper, RN, MSN (d.r. Stroke)
Vice President of Roper Resources, Inc.
debbie@roper-resources.com
214-864-8993
Disclosure
Debbie Roper is a speaker for:
Genentech – Activase
Chiesi - Nicardipine
Debbie has no actual or potential conflict of interest in relation to this presentation.
Stroke Consulting Services
 Stroke Program Development Course
(Six Month Recipe)
 Mock Stroke Surveys
 Certification Consulting Services
Red Gate Inn, McKinney, TX
Redgateinn.com
Objectives
1. Discuss the role of stroke coordinator on increasing inpatient stroke volumes
2. Discuss impact of decreasing length of stay on ROI
3. Understand the value of increasing Activase treatment rates
4. Rationalize the direct cost incurred for the role of a full time
stroke coordinator.
• Cost increase predictions from 2012-2030
• Total direct annual stroke related medical costs expected to
increase from $71.55 billion to $183.13 billion
• Real indirect annual costs projected to rise from $33.65 billion
to $56.54 billion
• Overall annual costs of stroke projected to increase to
$240.67 billion by 2030 (129% increase)
Stroke 2013; 44: 2361-2375
• Aging population =
• Increase in prevalence of stroke
• Additional 3.4 million people with stroke in
2030
• By 2030 nearly 4% of the US population is
projected to have had a stroke
Stroke 2013; 44: 2361-2375
Revised & Updated Recommendations for the Establishment of PSCs
A Summary Statement From the Brain Attack Coalition
• Less disability associated with use of rt-PA
• Use of rt-PA increased in PSCs
• Less disability = less lifetime cost
• Stroke units (Class I, Level A)
•
•
•
•
17-28% reduction in death
7% increase in being able to live at home
8% reduction in length of stay
19% increase in good outcomes
Stroke. 2011;(42): 2651-2665
Stroke Coordinator Role











Commander
Chief
Educator
Motivator
Data Abstractor
Data Analyzer
Speaker
Organizer
Facilitator
Detective
Data Analyst
Stroke Coordinator Qualifications
Registered Nurse
Critical Care Experience (ED/ICU)
Performance Improvement Experience
BCLS + ACLS (per job description)
8 hrs stroke CNE annually
Neurology Experience
Public Speaking Experience
Educating Experience
NIHSS
What does a SUCCESSFUL Stroke Coordinator look Like?
 Achieved/Maintained Stroke Certification?
 No Recommendations for improvement on stroke survey?
 Longevity in stroke coordinator position?
 Stroke Core Measures are 100%
Four Elements of a Successful
Stroke Coordinator
• Stroke Volumes
• Stroke Treatments
• Stroke Outcomes
• Stroke Length of Stays
Increase Stroke Volume
What does success look like?
Volume of In-Patient Strokes
70
76
80
81
68
60
50
40
20
37
42
25
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 Stroke Volume
Ischemic and Hemorrhagic
Yahoo! a steady increase in stroke volume
What About?




Mode of Arrival (EMS vs Pvt Vehicle)
Arrival within time window for stroke treatments
Inter-facility Transfers
Denials – Potential leakage to the competition
Stroke Patient Mode of Arrival
Total
Percent
EMS Volumes by Provider ?
Ambulance
Automobile
What does Success Look Like?
Main EMS Providers
•
•
•
•
•
•
EMS volume increases
EMS is a participant on stroke committee
EMS stroke protocols are reviewed annually
EMS stroke protocols follow current CPGs
EMS run sheets are provided on every patient
Care provided by EMS is assessed to ensure
protocol adherence
• EMS Feedback is provided by stroke center
• EMS attends stroke survey
EMS 1
EMS 2
EMS 3
EMS 4
Time of Arrival from LKN
Acute vs Subacute
140
What does Success Look Like?
120
Total
• Community education events increase (> 2/yr) 100
80
 Largest Employer
 Zip code origin
60
Stroke Volume
• Acute stroke volume increases
 < 3 hours from LKN
 3 - 4.5 hours from LKN
 < 6/8 hours from LKN
40
20
0
Jan Feb Mar Apr May Jun
Acute Strokes 6
8
15 16 22 21
Total Strokes 20 25 40 37 50 42
Jul
28
60
Aug Sep Oct Nov Dec
35 31 32 35 40
70 68 76 80 81
Increase Stroke Treatments
Increase Stroke Treatments
What does Success Look Like?
• ED Physicians find a reason to treat with IV Activase
• Every acute stroke patient is screened
for stroke treatments
 IV/IA Activase
 Thrombectomy Devices
 Clipping/Coiling
 Carotid Stents
 Intracranial Stents
• Percent of all Ischemic stroke patients who receive IV Activase increases (not just acute)
Are Your ED Physicians Finding a Reason to TREAT or NOT TO TREAT?
What does Success Look Like?
•
•
•
•
•
No missed opportunities
ED Physicians discuss their concerns r/t Activase
ED Physicians prescribe Activase without Neurologist
Individual ED Physician Report Cards
Increase number of patients receiving IV Activase
Created by Genesis Lewis RN, BSN
Dallas, Texas
Are You Screening Every Acute Stroke Patient for Eligibility for
Endovascular Treatments?
What does Success Look Like?
• Transfer agreement with CSC
• CSC provides all PSC and ASR facilities with screening criteria
LKN is < 6hrs
NIHSS > 8/10 or higher
NIHSS < 4 with aphasia
CTA = large vessel infarct
• Every Activase patient is screened for Thrombectomy prior to admission to ICU
• All ED Practitioners are knowledgeable about CSC screening criteria
Collaborate with EMS – PSC vs CSC – for Stroke Treatments
What does Success Look Like?
• State EMS transfer protocols - CSC vs PSC
• EMS screen from scene for PSC vs CSC
• EMS participate in IRB studies to validate screening
Improve Stroke Outcomes
How Do You Measures Stroke Outcomes?
What does Success Look Like?
• Patient Disposition – increase of patient discharged
to home and/or rehab
• Compare Initial and Discharge NIHSS – decrease in
NIHSS or return to baseline at discharge
• mRS at 90 days – able to perform activities of daily
living
• No Stroke readmissions within 30 days
Don’t forget the financial impact of
improved outcomes
• Calculate complication rates (pneumonia 3%)
• Calculate cost/case of complication rates
– Pneumonia, DVT, PE (Increase of $33,155)
• Effective dysphagia screening at bedside can reduce aspiration
pneumonia by 50% (Hinchey, et al. Stroke 2005;36)
3% of 340= 10.2 patients with pneumonia ($338,181)
50% reduction = $169,090 in “cost avoidance”
Decrease Length of Stay
• The DRG system is in place to incentivize hospital
efficiency
• Strategies for decreasing cost revolve largely
around the formation of stroke units
• Savings of ~$55 million per 1000 patients
Stroke 2012; 43: 1131-1133
Decrease Length of Stay (Ischemic, Hemorrhagic, TIA)
What does Success Look Like?
• Ischemic stroke LOS =
• Hemorrhagic stroke LOS
• TIA LOS
A Successful Stroke Coordinator’s
ROI Using Four Elements
•Stroke Volumes Increase Year over Year
•Stroke Treatments Increase
•Stroke Outcomes Improve
•Stroke Length of Stays Decrease
Questions