Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Abstract

Background: In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified. Methods: The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care. Results: This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters. Conclusion: In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.