Abstract TP394: Inpatient Onset Stroke Protocols in the Era of Value Based Medicine: Can We Remove Effectively Process Inefficiencies?

Abstract

Introduction: The American Stroke Association guidelines (2018) extension of the window for stroke interventions created an opportunity for quality improvement (QI) efforts in a sub-population designated as In-hospital (Inpatient) strokes (IHS). The new focus on salvageable tissue allows qualified IHS to receive effective reperfusion interventions. To improve outcomes in this population, hospitals are designing protocols and QI initiatives specific to IHS. Methods: An analysis of the implementation of a Code Stroke Rapid Response Team (RRT) process in a Primary (PSC) and a Comprehensive Stroke Center (CSC) was performed. We utilized descriptive statistics and cost estimation of centralizing the care of IHS on dedicated units. Results: CSC patients had a lower treatment -OR=0.17 CI 95%, and a higher mimics rate -OR= 3.03 95% CI compared to PSC. Cost of intra-hospital transfers was estimated at $5,000 to $8,000. Most of IHS occurred in cardiothoracic and trauma patients. While overall quality metrics improved -symptom discovery to CT 47% under 25 min, discovery to assessment 90% under 10 min, in the CSC the intra-hospital transfers contributed to added expenditures. The false-positive calls documented multiple contraindications to acute interventions. Conclusions: When implementing QI programs, hospitals should balance available resources, patients population specifics, and desired outcomes. Creating one-size-fits-all protocols can lead to multiple wastes in complex organizations. In the era of Value-Based Medicine and declining reimbursements, adopting flexible organization-specific and clinically oriented pathways and aligning treatment goals of multi-specialty teams will address the needs of IHS. Utilization of tools specific to early detection of IHS and further studies with a systematic collection, evaluation, and analysis of data is needed. Fostering efficient and consistent team communication and processes that balance quality metrics and fiscal responsibilities based on hospital structural and functional differences should become the next step in designing Code Stroke protocols. Real-World Evidence from sharing results will lead to an improvement in inpatient stroke care and patients’ outcomes- a mission long overdue.