delivering comprehensive stroke care€¦ · hub and spoke model the hub-and-spoke model arranges...
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Delivering Comprehensive
Stroke Care:
Hub and Spoke Model
James R. West
President and Chief Executive Officer
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Disclosures
I have no actual or potential conflict of
interest in relation to this
presentation.
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“It’s more than what we do—
it’s who we are.”
0
• PIH Health has been dedicated to serving the community for nearly 100 years.
• Today, amidst a dynamic healthcare landscape, our mission spans across two hospitals, 20+ medical offices, and countless community programs in partnership with those who share our vision to improve health and wellness, and our generous donors.
• Collaboration runs deep within our organization, and we are proud to be an integral part of so many thriving partnerships in our local communities.
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PIH Health Hospital - Whittier
• Non-profit
• 547 General Acute Care Beds
• Serving more than 2 million residents in
Los Angeles and Orange Counties
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PIH Health Hospital - Downey
• Non-profit hospital with a rich history of serving
the community nearly 100 years
• 199 general acute care beds
• Serving the residents in Los Angeles County,
Orange County, and the San Gabriel Valley
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Service Area Map
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PIH Health Hospital - Whittier
Comprehensive Stroke Program
• PIH Health Hospital - Whittier treats over 500 strokes per year
• 2009 – Designated a Primary Stroke Center
• 2017 – Comprehensive Stroke Designation
• Get With The Guidelines – Stroke Gold Plus with Target Stroke Honor
Roll Elite Plus; recipient since 2014
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LA County-Approved
Comprehensive Stroke Centers
(CSC)
• Cedars-Sinai Medical Center
• Northridge Hospital Medical Center
• Glendale Adventist Medical Center
• Good Samaritan Hospital
• Huntington Hospital
• Kaiser Foundation Hospital – Sunset
• Long Beach Memorial Medical Center
• Los Alamitos Medical Center
• Los Robles Hospital and Medical Center
• Methodist Hospital of Southern California
• PIH Health Hospital - Whittier • Pomona Valley Hospital Medical Center
• Providence Little Company of Mary – Torrance
• Providence Saint John’s Health Center
• Providence Saint Joseph Medical Center
• Ronald Reagan UCLA Medical Center
• UCLA Medical Center – Santa Monica
• Saint Jude Medical Center
• Torrance Memorial Medical Center
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LA County EMS-Approved
Stroke Centers
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Stroke Death Rate per 100,000
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Time is Brain
Saver, J. “Time is brain – quantified” Stroke 2006:37:263-6
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Time is Brain
Every 30 min delay
results in 15% decrease
in likelihood of a good
clinical outcome
Khatri et al, “Time to angiographic reperfusion and clinical outcome after acute ischaemic
stroke, an analysis of data from the IMS phase 3 trial”. Lancet Neurology 2014:13:567-74
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Leading Cause of Death,
Age-Adjusted Death Rate
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Stroke Certification
Three Types of Certification:
1. Stroke Ready
2. Primary Stroke Center
3. Comprehensive Stroke Center
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Stroke Certification
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PIH Health Hospital - Whittier
Comprehensive Stroke Program
Standards
Practice
Guidelines
Performance Measures
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PIH Health Hospital - Whittier
Comprehensive Stroke Program
Program Concept CSC
Program Medical Director Has extensive expertise; Available 24/7; 8 hours of stroke
education annually
Acute Stroke Team Available 24/7 at bedside within 15 minutes; at least 8
hours of stroke education annually
Emergency Medical Services Collaboration Designated by the county as a Comprehensive Stroke
Center. Access to protocols used by EMS, routing plans
Stroke Unit Availability of dedicated neuro intensive beds for complex
stroke patients; 24/7 on-site LIP’s with neurovascular
training
Initial Assessment of Patient ED Physicians responds to bedside upon arrival
Diagnostic Testing Capability Availability of Advanced Imaging- Carotid Duplex
Ultrasonography. Transcranial Doppler, CT, CTA, CTP,
MRI, MRA
Neurology and Neurosurgical Services Neurologists, interventional radiologists, and
neurosurgeons available 24/7. IR and neurosurgery are not
on call at any other hospitals.
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PIH Health Hospital - Whittier
Comprehensive Stroke Program
Program Concept CSC
Treatment Capabilities IV thrombolytics; Microsurgical clipping of aneurysms;
Neuroendovascular coiling of aneurysms; Carotid endarterectomy;
Neurovascular stenting and other endovascular therapies
Transfer Protocols and Agreement Transfer agreement with spoke hospitals; 24/7 stroke hotline fully
prepared to facilitate interfacility transfers
Staff education requirement ED nurses-2 hours stroke education; other nursing staff- 8 hours of
stroke education
Provision of educational opportunities Minimum of 2 public education; Quarterly stroke education; Stroke
Conference
Clinical Performance Measures STK and CSTK measures
Research ARAMIS and Strong Study
Clinical Practice Guidelines Stroke protocols are based on recommendation from Brain Attack
Coalition, AHA/ASA
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Hub and Spoke Model
The hub-and-spoke model arranges service delivery assets into a network consisting of an anchor
establishment (hub), which offers a full array of services, complemented by secondary establishments
(spokes), which offer more limited service arrays, routing patients needing more intensive services to the hub
for treatment.
- Elrod, J. 2017
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“Hub Hospital” Components
• Advanced diagnostic
capability
• Additional treatment
options
- IV tPA
- Surgical and
Endovascular Options
- Clinical Research
• Personnel
- Highly trained in stroke
care across the continuum
• Plan
- Protocols and guidelines
• Partnership
- Transfer agreement
- EMS
- Telemedicine
• Availability
- 24/7, 365 days
• Education
- Community Outreach
- Stroke Conference
- Stroke Education to Spoke Hospitals
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“Spoke Hospital” Components
• Stabilize and treat acute stroke patients
• Provide initial acute care - Provision of neuroimaging studies – non-contrast CT Head
- Initiate thrombolytic therapy “drip and ship”
- Stabilization of vital functions
- Management of blood pressures
• Ability to transfer to comprehensive stroke center
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Benefits of Hub and Spoke
Model in Stroke Care
• Extend quality acute stroke care to spoke hospitals
• Access to stroke specialist to provide consultation before
initiating t-PA
• Ability to transfer stroke patients requiring complex care
to the hub
• Reduce unnecessary transfers
- Wagner, J. 2016
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Systems
Each hub and spoke partnership is unique
• Each partnership should address specific goals
• Goals will be different for each partnership
“The ultimate goal is to improve the
overall neurological care in the region”
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System
Establish clear goals and benchmarks from each
hub/spoke hospital partnership:
• Reduce patients’ neurological sequelae
• Improve functional recovery
• Reduce lifetime cost of stroke care thru timely
referral and access to comprehensive stroke
care
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System Improvement
• Solidify relationships with existing
referral hospitals
• Increase access to comprehensive
stroke center for other facilities
• Educate surrounding hospitals, and
facilitate transfer of patients who need
higher level of care (i.e. Endovascular,
neurosurgical, etc.)
• It will ultimately benefit patients,
patients’ families, and community
hospitals
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Process Improvement
• Stroke care should be consistent
• Transfer procedures should be clear
• Benchmarks should be set and reviewed continuously
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Transfer Coordination
Stroke Patient Requiring Higher Level of Care
Identified from Spoke Hospital
Call PIH Health Stroke Hotline at (562) 967-2000
Access Coordinator will facilitate communication between referring
physician and on call neurologist
Access coordinator will stay on the call to anticipate transfer
Patient
accepted for
transfer
No
• Admit to hospital
• Proceed with further work up
and evaluation
Yes
Access Coordinator will
coordinate transfer and
ambulance pick up
Upon discharge provide
outcome information to
spoke hospital
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Outcomes
• Metrics: Door-to-Needle for all “Drip and Ship”
• Referral Base Hospital
• Metrics: timeliness of response, door to puncture, timeliness of reperfusion
Provider
• Functional outcome
• Satisfaction with care Patient
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Neuroendovascular Outcome Report
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Course of Treatment
• Stroke recognized at PIH Heath Hospital - Downey, with mild
symptoms but very significant arterial blockage.
• Patient transferred to PIH Health Hospital - Whittier due to concern for
worsening of symptoms.
• The following morning, the patient suddenly lost his ability to speak,
understand, and move his right side.
• Mechanical thrombectomy was done by Dr. Shao-Pow Lin.
• After the procedure, patient transferred to ICU where he stayed for
three days.
• He went home a week later with minimal disability.
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Life Without Comprehensive
Stroke Intervention
This 31-year-old husband, father of two children would:
• Continue to have slurred speech and right hand numbness
• Not be able to continue his present employment as a carpet installer
• Not be able to provide for his family
• Have an altered quality of life due to his long-term disability
• Have difficulty enjoying social outings with his family
• Because of his young age and his less-severe stroke disabilities, it would be
challenging to obtain financial aid and social service support
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Collaboration
• Be Present
- Attend ED Section meetings and staff meetings
- Community outreach
• Education
- Spoke hospital staff education
- EMS education
- Community education
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Challenges
• Which patients should be transferred to the Hub?
Stroke patients vs non-stroke neuro cases
• Data Collection
Adopting open data sharing will improve patient care
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Thank you
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References
Cramer, S., Stradling, D., Brown, D., Carrilo-Nunez, I., Ciabarra, A., Cummings, M., Stratton, J. (2012).
Organization of a United States for comprehensive acute care. Retrieved March 16, 2018 from
http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.111.635334/-/DC1
DeHavenon, A., Sultan-Qurraie, A., Hannon, P., Tirschwell, D. (2015). Development of regional stroke
programs. Current Neurology and Neuroscience Report. 15(5). 1-8.
Elrod, J. & Fortenberry, J. (2017). The hub-and-spoke organization design: An avenue for serving patients
well. BMC Health Services Research. Retrieved March 16, 2018 from
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2341-x
Wagner, J. (2016). Building the ideal stroke network with telemedicine. Retrieved May 2, 2018 from
https://evtoday.com/2016/02/buildingtheidealstrokenetworkwithtelemedicine/