Background and Purpose A large community hospital implemented an acute stroke program to respond to stroke patients in a consistent, systematic, and efficient manner. The primary objectives were to monitor the care delivered, improve the quality of care, and move the patients through their initial hospital stay in a timely manner.
Methods Acute stroke standing orders were developed, with a critical path developed on the basis of these orders and an expected length of stay. A multidisciplinary team began the rehabilitation process early in the hospital stay, monitored patient progress and length of stay, and provided appropriate discharge placement. Retrospective chart reviews were performed over a 4-year period, and the data were collated on a yearly basis.
Results Over a 4-year period, 414 Medicare patients demonstrated a steady decline of initial hospital length of stay from 7.0 to 4.6 days. During this same period of time, there was a decline in total hospital charges from $14 076 to $10 740 per patient. This represented a total dollar savings in charges of $1 621 296 (≈$453 000 per year). The mortality rate for 1994 was 4.6%, with 46.5% of survivors discharged to home, 16.9% to acute rehabilitation, and 32.6% to nursing homes.
Conclusions The implementation of a multidisciplinary acute stroke program decreased length of stay and hospitalization costs of Medicare patients.
Each year, approximately 350 000 people suffer a first stroke and another 100 000 will have a recurrent attack. One third of these patients will remain disabled, which results in enormous social and financial costs. Care of stroke patients, from initial hospitalization through rehabilitation and long-term care, requires expenditures of more than $17 billion annually.1 As the population of the United States continues to age, an increased demand for stroke therapy services is expected. The cost of initial hospitalization for stroke represents a significant proportion of the total cost of stroke care; initial hospitalization and doctor fees total 57% of the costs associated with the first 90 days of ischemic stroke.1 Although immediate therapies to reverse damage from stroke are on the horizon (eg, TPA), it remains to be seen whether these therapies will reduce the cost of short-term care or length of stay. In the increasingly cost-conscious environment of hospital care, provision of efficient and appropriate care for the acute stroke patient is a challenge. Programs to help achieve this goal should result in significant savings to hospitals and payers and at the same time should potentially improve patient care. Such a project is described in this article.
Mercy General Hospital is a 250-bed community hospital in the metropolitan Sacramento, Calif, area. Cardiac services had been highly developed at this hospital, but in 1988, there was no organized approach to neurological services. Introduction of a stroke service appeared to be timely because stroke-care delivery could be specialized and potential research projects loomed in the near future. The project proposal consisted of three parts: (1) recruitment of a Medical Director to help educate physicians and nurses about new approaches to stroke therapy; (2) identification of a designated unit to provide care for all stroke admissions; and (3) development of research projects to improve the level of care of the stroke patient as well as provide Mercy General Hospital with an exclusive service line for marketing purposes.
A “stroke team” was identified to provide support to the Emergency Department (ED) for rapid evaluation of all acute stroke patients. The team’s purpose was to speed the evaluation and treatment of the stroke patient, reduce the time spent in the emergency area, and evaluate the patient for eligibility to enroll in an experimental study protocol. This team included an emergency medicine physician, neurologist, stroke nurse, pharmacist, CT scan staff, laboratory phlebotomists, and IV therapists. When a patient with a probable stroke arrived or was en route to the ED, a pager dedicated to acute stroke, carried by the stroke nurse, was called by the ED staff. An evaluation over the phone or in person was completed quickly, and members of the stroke team were contacted as needed.
A multidisciplinary team was developed to monitor patient care and the progress of the patient and to help move the patient through the hospital stay in an efficient manner. This team comprised nurses; physical, occupational, and speech therapists; a social worker; a discharge coordinator; and a rehabilitation admission coordinator. Weekly multidisciplinary team conferences were held in the stroke unit. Daily consultations with individuals on the team were held as needed. Early involvement of the patient and family in discharge planning was a key component.
Development of Critical Path and Standing Orders for Stroke
To encourage a more consistent approach to the diagnosis and care of the acute stroke patient, the Medical Director developed acute stroke standing orders (Fig 1⇓). These orders were first approved by the Neurology Section and Department of Medicine at the hospital and then introduced to the ED and the stroke unit. The orders were designed to aid the admitting physician to order all likely tests, procedures, and therapies for the acute stroke patient on the first day of hospitalization. It was recognized that specific recommendations regarding blood pressure management, anticoagulation therapy, and diagnostic studies would be difficult (and likely controversial) given the state of scientific knowledge regarding the care of acute stroke. The American Heart Association has subsequently published guidelines for the care of the acute stroke patient2 with recommendations regarding management. Our acute stroke standing orders preceded these guidelines but gave the admitting physician an opportunity to consider such issues as diet consistency, temperature treatment, and blood pressure management without explicit recommendations. A newer version of our acute stroke standing orders is presented in Fig 2⇓. We have again avoided explicit recommendations due to the resistance of the medical staff (primarily neurologists).
With the stroke standing orders used as a guideline, a critical path care plan was designed (Fig 3⇓). The nursing staff served as coordinators of the care plan, which was reviewed with the multidisciplinary team. The critical path is a tool to monitor and document the progress of patients as they move through the short-term-care setting and are discharged to home, short-term rehabilitation, or subacute levels of care.
Our acute stroke unit opened in September 1990. The next 6 months were devoted to the establishment of the multidisciplinary team, standing orders, care plans, and experimental protocols.
We conducted a retrospective cost analysis of all Medicare patients from December 1990 to December 1994 whose diagnosis fell into diagnosis-related group (DRG) 14 (Specific Cerebrovascular Disorders Except Transient Ischemic Attack). We included an analysis of length of stay (LOS) and patient destination after discharge from the acute stroke unit. The total number of patients with this DRG was 414. Fig 4⇓ shows the hospital charges and LOS for these patients from December 1990 to December 1994.
At the beginning of the project, the average LOS for a Medicare stroke patient in the immediate care setting was 7 days and total hospital charges per patient were $14 076. Over the next 4 years, the LOS and hospital charges consistently declined. Our most recent data for January 1994 to June 1994 show an LOS of 4.6 days and per patient charges of $10 740. This compares with a national mean LOS estimated by Dobkin3 of 7 to 8 days in 1994. We are currently shifting our analysis from hospital charges to true costs of care.
The mortality rate during the short-term stay for our stroke patients from January 1994 to December 1994 was 4.6%. The discharge destination was 46.5% to home, 16.9% to acute rehabilitation, and 32.6% to nursing homes. The PORT Study estimates 15% to 30% of surviving stroke patients are discharged to nursing homes, 5% to 20% to rehabilitation units, and 35% to 60% to home.3
There are many ingredients in our stroke project, including a stroke neurologist medical director, stroke nurse, multidisciplinary team, dedicated stroke unit, standing orders, stroke care plan, and experimental stroke protocols. Application of this entire format to other community or academic hospitals may not be feasible, but portions of it could be used at any hospital. Despite the cost and effort required, the dramatic decline in LOS, hospital charges, and apparent costs of short-term stroke care will result in savings to the hospital. At Mercy General Hospital, our charges to Medicare for stroke patients declined $1 621 296 over 3.5 years. More recently, we monitored cost per patient rather than charges and have found lower costs and shorter LOS for patients with stroke standing orders and critical path plans than for those without such plans (unpublished data, 1995).
Other authors have examined the impact of stroke projects on hospital costs. Bowen and Yaste4 reported a 6-month study of patient outcomes after institution of stroke pathways and orders (which were not described). Using hospital charges, they found the main change was a decreased LOS, with no change in complications. Gorelick5 advocates a “time-zero” plan, which utilizes an approach similar to ours. He points out that LOS is the major variable in short-term stroke cost, and our experience supports that view.
The next step in our project is to determine the outcomes at 3 or 6 months for our acute stroke patients in terms of their level of function, where they are living, and their satisfaction with the care they received at our hospital. We will be unable to compare this with historical data before institution of the stroke project because we have no outcome data for that period. Current evaluation of outcomes will serve as a benchmark for future projects.
We gratefully acknowledge the efforts of all the staff at Mercy General Hospital who helped to develop and implement this program. We recognize the staff of the Emergency Department, NeuroCare Unit, Clinical Laboratory, Radiology, Pharmacy, Rehabilitation Services, Social Services, and Discharge Coordinators. A special thanks to the Administration of Mercy Healthcare Sacramento for the support that was so greatly needed in the development of the Acute Stroke Program.
Reprint requests to Deidre Wentworth, RN, MSN, c/o Mercy General Hospital, 4001 J St, Sacramento, CA 95819.
- Received November 28, 1995.
- Accepted February 28, 1996.
- Copyright © 1996 by American Heart Association
Matchar DB, Duncan PW. Cost of stroke. Stroke Clin Update. 1994;5:9-12.
Guidelines for the management of patients with acute ischemic stroke: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Adams HP Jr, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA, Feinberg W, Mayberg M. Stroke. 1994;25:1901-1914.
Dobkin B. The economic impact of stroke. Neurology. 1995;45:6-9.
Bowen J, Yaste C. Effect of a stroke protocol on hospital costs of stroke patients. Neurology. 1994;44:1961-1964.
Gorelick PB. Acute ischemic stroke and transient ischemic attack: a costly business and a strategy to reduce costs. J Stroke Cerebrovasc Dis. 1995;5:1-5.