Neurovascular Services: Evaluating the Possibilities

Growth trends over the past decade reveal that many hospitals across the United States have expanded upon their existing services — whether from a diagnostic cardiac center to offering therapeutic cardiac catheterizations or PCI; from general vascular surgery to peripheral and/or endovascular care; from basic electrophysiology (such as device implants) to offering ablative treatments; or even expanding from an established open heart surgery program to offering a less-invasive approach to valve repair. Through these service advances, many key components must be considered, analyzed and implemented seamlessly, which takes diligent effort and clear focus. But, in most cases, a state regulatory board defines the level of service to which a hospital can advance. Such regulations can delay, or even completely derail, a planned expansion, regardless of its clinical, financial, or strategic merit. Corazon has worked with hospitals in many highly regulated states on both the planning and implementation of expanded services, which includes a strategic component to help hospital leadership understand the next level of expansion — the many options available and the rationale for making the right choice. Over the last year, we have increasingly been involved with hospitals pursuing a neuroscience expansion, be it a primary stroke center or a more comprehensive approach to neuro care within their communities. We find that, in many cases, hospitals are willing to explore innovative collaborations between existing programs in an effort to gain efficiencies, manage new technology acquisitions and capital upgrades, and most importantly, to improve patient care. One such collaboration is that between the cardiovascular service line and a new or existing stroke program. Several vendors are now showcasing dual-use equipment that allows full cardiac and vascular imaging with full run-off capabilities, along with very detailed 3D images required for testing intracranial vessels. In hospitals with under-utilized cath labs — either due to low volume or the luxury of multiple labs — such a partnership, with particular attention to patient flow issues, can serve to increase both space utilization and efficiency across both services.

Primary Stroke Certification: The First Step

A stroke, also known as a “brain attack,” occurs when either a blood clot forms and disturbs normal blood flow (ischemic stroke), or when a blood vessel within the brain bursts or ruptures, causing a hemorrhage (hemorrhagic stroke). Approximately 80% of the 700,000 strokes that occur yearly in the United States are ischemic in nature, with hemorrhagic strokes comprising the remaining 20%. According to the American Stroke Association, stroke remains the third-leading cause of death in our country, and is identified as the leading cause of long-term disability among Americans. Although a slightly greater incidence rate with respect to stroke is noted in the African-American population, no one is spared. Nearly one-third of those patients who suffer a stroke each year are under the age of 65. The economic cost of caring for these patients is staggering and estimated to be nearly $70 billion annually. The map in Figure 1 illustrates the nationwide impact of stroke at a state-by-state level. The statistics are inclusive of the number of patients, ages 35 and up, per 100,000 of population who have died as a result of stroke for calendar years 2000-2006. The areas in dark purple experience the highest death rates in the country attributable to stroke, which in many cases are twice the national average. Perhaps most striking is the cluster of states located in the southeastern portion of the United States, often referred to as the “stroke belt.” Much focus has been directed to identifying the reason for the dramatically increased rates in this area when compared to the remainder of the country. Although many ideas circulate among clinicians, no definitive reason has been named for this area of concentrated stroke mortality. One would think that those states most affected by stroke would mirror exactly those states most affected by heart disease, given that both are truly diseases of the vascular bed; however, given that the contributing factors for both heart disease and stroke are remarkably similar, it may indeed be that limited access to care and a poorly organized delivery system could account for the disparity in volumes seen.

So, what do these statistics mean to you?

We believe that stroke care must be an integral component of any hospital. In many cases, care is fragmented and disorganized, with no clear organization of space, staff, resources, or delivery processes…despite the fact that the majority of hospitals receive stroke patients into their emergency departments every day! In organizations that introduce coordinated care of the stroke patient, or for those that pursue certification as a primary stroke center, an engaged and experienced cath lab staff can do much to ensure program success. Care of the emergent neurovascular patient and care of the ST-elevation myocardial infarction (STEMI) patient are remarkably similar. Both are based on the need for rapid triage and assessment, as well as aggressive intervention within a very limited time frame. The organization, patient flow, and established processes used for STEMI patients can serve as a road map to the development of the program-specific processes that need to be in place for a successful stroke (or full neurovascular) program. In this scenario, the expertise and leadership of the cath lab staff is invaluable in developing a program that makes sense — AND one that delivers best-practice, quality care. More and more, hospitals across the United States are aggressively pursuing certification as a Primary Stroke Center (PSC). Driven largely by the incidence rates described above, organizational leaders have become more willing to invest the necessary time and resources in developing formalized stroke services. Further, the increased focus at the national level, with respect to the need for improved and coordinated systems of care, has also proven to be a powerful motivator. In fact, many states currently mandate transfer of a patient who is suspected of having a stroke only to a PSC. Savvy administrators understand the risk of bypass by pre-hospital providers and its resulting impact on an organization’s ED volume. We find that the infrastructure improvements that must occur in order to be successful in stroke program development serve as a strong foundation for any further neurovascular expansion. Imaging upgrades, process and patient flow improvements, and a commitment to staff education as pertaining to the neuroscience patient will all be integral to the success of a broader expansion effort. Corazon experience proves that that lessons learned in developing and running a vibrant cardiac interventional program will not go to waste when properly applied to this new, but very similar, population. In fact, such lessons can assist with more rapid implementation of a stroke program, and help program administrators and clinicians avoid common pitfalls.

Beyond Stroke Care: Further Neuro Expansion

As with any proposed expansion, hospitals must fully understand their current capabilities and limitations, and then plan accordingly. It is only through a comprehensive understanding of the opportunity, the resources, and most importantly, the “level of commitment” from both the hospital, and the physicians and clinicians alike, that a reasonable plan including expected results can be developed. Beyond stroke certification, a wide range of possibilities exists as related to neurovascular service expansion. Established cardiac programs that make the decision to consider expansion into neurovascular services may have difficulty identifying the services or initiatives to be included in such an expansion effort. After all, cardiac and vascular services are easily defined, and when stated, clinicians universally understand at once what services are included. Neuro, however, is somewhat amorphous; services included in a community hospital setting, for example, will look very different from those in an academic or tertiary center. Inclusion of services “outside” of those considered to be neurovascular, but under the umbrella of neuroscience, will serve to further expansion efforts and assist in the achievement of necessary approvals of the dollars required to be successful. The neuro subspecialty is one of the fastest growing, and organizations may indeed have difficulty keeping up with cutting-edge treatments that have become available only within the past several years. Catheter-based and minimally-invasive treatment techniques for neurovascular conditions offer the greatest hope for patients, while at the same time present some of the greatest challenges for organizations in terms of securing the necessary physician expertise and technology upgrades. The graph in Figure 2 reflects the number of patients who benefit from inpatient neurovascular care across the US. As discussed earlier, the decision-making and planning around any expansion of neurovascular services is complex, and as such, must be approached systematically. Corazon experience demonstrates that there are several key components that should be considered critical to program success. Programs committed to offering a higher-level quality of care to their community must have a clear understanding of:

• Current state regulations • Facility design • Patient flow • Patient, family, and clinical staff education • And MUCH more!

Perhaps the most crucial component of any expansion effort is that of securing and retaining physicians with the necessary training and expertise — practicing physicians who also demonstrate a willingness to aggressively participate in an ambitious growth initiative from a strategic and operational perspective.

The Neuro-Interventionalist

At the forefront of any neuroscience program is the neuro-interventionalist, who will need to be integrated into the existing medical staff and be willing to work collaboratively with other subspecialty physicians. Competition among in-hospital programs can be fierce in terms of securing the necessary access to imaging equipment, for example, or in determining the allocation of available capital. Neurovascular services is no exception. A complex and capital-intensive program like neuro can be a divisive force, rather than a unifying one, if existing programs feel that their need for staff, resources, or even public and administrative attentions are being undermined by the new program under consideration. It is essential that throughout any proposed expansion of neuroscience capabilities, the hospital ignite collaboration from other interventionalists and physician specialists already practicing at an organization (e.g., radiologists, cardiologists, vascular surgeons, etc.). The expansion of one service at the expense of another is a no-win situation. The goal of attracting and retaining physician talent must be paramount across all services, both new and existing. Many programs which have the benefit of existing sub-specialist physician expertise may assume that if the specialist currently practices or is employed at the hospital, then program expansion would be a natural progression, with the established physician as the de facto program champion. The physician(s) must never be taken for granted. It is important, through careful analysis and collaboration, that a physician champion be identified or appointed. In Corazon’s experience, programs that take the time to establish a multi-disciplinary approach and a defined organizational structure among the specialists will achieve the greatest success. Through the various committees that arise from this collaborative approach, consensus can be achieved at the outset, instead of through a contentious process at a future date, as related to clinical protocols, technology needs, a structured quality program, credentialing, and peer review, with special emphasis on stroke, as well as cardiac and vascular. Not only will improved outcomes result, but also a robust and sustainable program that will be successful well into the future. It is essential that physicians from all areas of practice be included in this effort, as any expansion of neurosciences will impact every member of the medical staff, either directly or indirectly. Although in many hospitals the stroke or neuro program will be outside the purview of cardiovascular services, all of the physician specialists must feel a personal investment in the success of the expansion effort, which can only come from a sense of ownership. We recommend that an advisory committee be created, as the value of such a committee, regardless of the level of program expansion, cannot be overstated.

The Facility

Hospitals expanding into offering interventional capabilities or a more comprehensive neuroscience program must clearly identify and understand where within the existing facility the interventions will be performed. Is there room to support a new procedural suite as well post-procedure care? Where will the technology fit best? Is it within radiology, the operating room, or perhaps even in the cardiac catheterization laboratory? In many cases, the cardiac cath lab may seem to be an obvious choice; however, if existing space is limited or unavailable, then other options will need to be considered. Considerations related to the types of cases performed must be paramount — both currently and in the future. For instance, hospitals with an active STEMI program that are regularly at cath lab capacity shouldn’t consider integrating neurovascular services into an existing lab. Using a busy cath lab for a neuro case that could last in excess of eight hours could severely compromise the management of both scheduled and emergent cardiac volume. Further, Corazon recommends that hospitals carefully consider the geography of a neuro suite. If new facility design or updates are required, what are the costs associated with this expansion, and what additional ancillary services will be impacted? Volume is often complemented by coronary and peripheral vascular intervention as well. The above considerations must be made regarding the “intra” procedural. Programs will also need to define where the patient will recover. Programs that carefully map out patient flow will often find opportunity from within existing patient care units, or will need to plan for a higher level of patient acuity. Our experience reveals that programs that have expanded into a more comprehensive neuroscience service line will most likely complement a post-care unit by adding additional beds, or by building a specialized pre- and post- neuro unit.

Education

While the space component is important, launching a specialized neuro unit will take more than just paint and plaster. Specially trained neuro clinicians are vital to a unit’s success, especially in terms of patient satisfaction. Failure to address the educational needs of the staff, in addition to the patients and their families, during any neurovascular service expansion would constitute a fatal flaw in any expansion plan. Front-line caregivers, even experienced ones, are often intimidated by the introduction of the neuroscience patient into an organization. Additionally, these patients are extraordinarily complex and require a significantly elevated level of care in order to realize the best outcomes. Assessment skills must be superb, and are completely dependent on the clinician. For example, there is no monitor to alert a nurse to a patient’s deteriorating neuro status; rather, only through a detailed and comprehensive neurologic examination performed by a well-trained and experienced neuroscience nurse, can subtle changes in condition be realized early enough to allow for intervention prior to a permanent decline in neurologic function. Education is critical on every level, especially as programs define the pre- and post-care unit for this patient population. In conclusion, understanding a few key elements of a neuroscience program expansion will assist in understanding what it takes to get started. If programs decide to utilize existing cardiac catheterization laboratories, it must be understood that existing volumes could be impacted. It is important to understand the level of education that needs to be provided to staff in order to assure the highest level quality of care is provided. Integration of all efforts is essential in order to ensure that the nuances of need in each patient population are recognized and integrated into any plan. Whether staff education, IT integration, or quality reporting, all must be individualized, but with an eye toward building on past successes rather than a completely new program building effort. Beyond the “basics,” it is critical to build a solid foundation with the key stakeholders — the clinicians, the physicians, and executive leadership. Knowing where you stand currently, and understanding the vision for where you want to be in both the short- and long-term future are two critical components that every hospital must know before taking on such an endeavor. Hospitals that have decided to raise the bar and offer the community a higher level of care will no doubt contribute to providing better access to care, a higher patient satisfaction rating, and most importantly, a better quality of life. In the case of a successful “marriage” of cardiovascular services and neurovascular services, both subspecialties will enjoy the added benefit of long-term viability via sustained growth and solid financial performance that can serve as an example of well-executed plan across any organization. Amy and Stacey are Directors at Corazon, offering consulting, recruitment, and interim management for the heart, vascular, and neuro specialties. For more information, visit www.corazoninc.com or call (412) 364-8200. To reach Amy, email anewell@corazoninc.com To reach Stacey, email slang@corazoninc.com