As noted in the recent Patient Care Services (PCS) National Task Force report to the Undersecretary for Health, led by Dr. Gary Tyndall, the director of Emergency Service within PCS, Veterans need to be able to obtain emergency care that meets a single standard of care for similar VHA facilities nationally. Prompt access to high-quality care is crucial to limiting damage done by a stroke. Current VHA policy does not adequately address standardization of care for stroke victims leading to differences in care and treatment from one facility to the next, and between VA and non-VA facilities, some of which are Joint Commission certified stroke centers.
The Early Management of Acute Stroke PCS Task Force report serves as a critical blueprint for acute stroke service delivery for VA facilities and is a novel effort to standardize services across VHA and stimulate organizational change. The report was a forerunner to the recently released Emergency Department Acute Ischemic Stroke (ED AIS) Directive that mandates the declaration of level of stroke care by VA facilities and implementation of new local policies within 180 days of publication (June 2012). Moreover, the report and Directive is timely as several states (e.g., Florida, Texas) across the US are passing laws that require emergency medical technicians to take acute stroke patients to the nearest stroke certified center, thus potentially bypassing uncertified VA facilities.
In 2011, the Veterans Health Administration (VHA) released the Acute Ischemic Stroke (AIS) Directive developed by the VA Early Management of Acute Stroke Patient Care Services (PCS) Task Force led by Dr. Gary Tyndall, the Director of Emergency Service within PCS, which mandated the reorganization of acute stroke care, including self-designation as Primary (P), Limited Hours (LH), or Supporting (S) stroke center. In partnership with the VHA Offices of Emergency and Specialty Care Services, the VA Stroke QUERI conducted a formative evaluation of a national sample of three levels of stroke centers to understand barriers and facilitators VA facilities faced in response to the Directive as well as organizational factors and resources associated with a facility's designation level.
Armed with this knowledge, the Stroke QUERI will be well-positioned to inform VA policy makers about field needs related to acute stroke and to design a program to help facilities improve their ability to offer acute stroke therapy to veterans with ischemic stroke.
The primary aims of this project are:
(1) To identify VISN and VA facility administrative and clinical perceived barriers and facilitators to implementing the ED AIS Directive and modifying its acute stroke care services; and
(2) To identify the organizational factors and external resources and patterns of acute stroke care associated with a VISN and VA facility's designation of level of stroke emergency services.
We invited a national representative sample of 45 VHA facilities to participate and of these, 38 (84%) participated. In addition, leaders from 10 VISNs from which the facilities were located were interviewed. The final sample included 9 Primary, 24 Limited Hours, and 5 Supporting facilities; and 10 VISN leadership personnel. Among this sample, all VISN personnel and 16 of the Facility interviews were conducted by telephone. The remaining 22 Facilities completed on-site interviews. In total, 117 persons were interviewed including ED Chiefs (22%), Chiefs of Neurology (16%), Neurologists (15%), ED Nurse Managers/Nurses (8%) and others. The semi-structured interviews were based on the AIS Directive and included barriers and facilitators to implementing acute stroke services, reasons for choice of level, and decisions to collaborate with external stroke centers. Completed interviews were transcribed and qualitatively analyzed. In addition, stroke aggregate data from VA facility reports to the VA Inpatient Evaluation Center (IPEC) were included.
Across all three levels of stroke centers, stroke teams identified the specific need for systematic and sustainable nurse training on acute stroke care processes. The most frequent barriers reported were a lack of personnel assigned to coordinate the facility response and conduct quality data collection. For thrombolysis measures, a low number of eligible Veterans was another major barrier. The LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competencies, and a lack of stroke clinical champions. Some solutions applied included cross training X-ray technicians to provide head CT coverage, developing stroke order sets and templates, and staff training. Larger facilities added a stroke code pager system and improved upon its use, and established ED nurses to become first alerts for an acute stroke patient. LH and S facilities attempted to secure additional services and establish formal transfer agreements to improve Veteran tPA access. Evaluation of IPEC stroke data demonstrated neither the level of stroke center self-designation by facility nor the mean number of stroke admissions varied significantly by IPEC reporting status of stroke quality data. However, categorizing site volume did indicate a lower likelihood of reporting among VAMCs with 25-49 admissions per year. VISN leadership discussed the geographic distribution of facilities and resources within their VISN and how the VISN operated alongside community resources and within State laws regarding the EMS delivery of acute stroke Veteran patients.
Conclusions. The AIS Directive brought focused attention to reorganizing and improving stroke care across a wide range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique addition of the LH designation presented some challenges. The collection and reporting of acute stroke quality data by facilities presented additional challenges. LH and S centers coordinated their resources and services within community affiliated stroke centers. The presence and absence of a stroke clinical champion to drive the implementation of the AIS Directive was perceived as instrumental by the field. Therefore, strategies to identify and develop effective clinical champions would be fruitful for the implementation of coordinated care processes within healthcare organizations.
We have informed VHA Office of Emergency Medicine and the Office of Specialty Care Services of our aggregated results based on input from 38 VHA facilities and 10 VISN leadership including the barriers facilities faced in response to the AIS Directive and have made a cyberseminar presentation on September 3, 2013 to the VA SQUINT, a stroke quality network consisting of VA staff/clinicians interested in stroke care. Moreover, VA sites included in this evaluation tended to report their data after participating in this project.
- Damush TM, Miller KK, Plue L, Schmid AA, Myers L, Graham G, Williams LS. National implementation of acute stroke care centers in the Veterans Health Administration (VHA): formative evaluation of the field response. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:845-52.
- Damush TM, Yu Z, Slaven J, Daggett VS, Sager D, Plue LD, Matthias M, Miech EJ, Williams LS. Stroke Care Team Associations with Acute Stroke Quality Improvement in Veterans Healthcare Administration. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):ATP351.
- Damush TM, Miller KK, Plue LD, Schmid AA, Myers L, Graham GD, Williams LS. VA Healthcare System Responses to National Stroke Care Reorganization. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2014 Feb 1; 45(Suppl 1):AWP334.
- Damush TM, Yu Z, Slaven J, Daggett VS, Sager D, Plue LD, Matthias M, Miech EJ, Williams LS. Stroke Care Team Associations with Acute Stroke Quality Improvement with Veterans Health Administration. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2015 Feb 12; Nashville, TN.
- Damush TM, Miller KK, Plue LD, Schmid AA, Myers L, Graham GD, Williams LS. VA Healthcare System Responses to National Stroke Care Reorganization. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2014 Feb 12; San Diego, CA.