Delivering Comprehensive

Stroke Care:

Hub and Spoke Model

James R. West

President and Chief Executive Officer

Disclosures

I have no actual or potential conflict of

interest in relation to this

presentation.

“It’s more than what we do—

it’s who we are.”

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• 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.

PIH Health Hospital - Whittier

• Non-profit

• 547 General Acute Care Beds

• Serving more than 2 million residents in

Los Angeles and Orange Counties

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

Service Area Map

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

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

LA County EMS-Approved

Stroke Centers

Stroke Death Rate per 100,000

Time is Brain

Saver, J. “Time is brain – quantified” Stroke 2006:37:263-6

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

Leading Cause of Death,

Age-Adjusted Death Rate

Stroke Certification

Three Types of Certification:

1. Stroke Ready

2. Primary Stroke Center

3. Comprehensive Stroke Center

Stroke Certification

PIH Health Hospital - Whittier

Comprehensive Stroke Program

Standards

Practice

Guidelines

Performance Measures

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.

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

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

“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

“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

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

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”

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

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

Process Improvement

• Stroke care should be consistent

• Transfer procedures should be clear

• Benchmarks should be set and reviewed continuously

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

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

Neuroendovascular Outcome Report

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.

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

Collaboration

• Be Present

- Attend ED Section meetings and staff meetings

- Community outreach

• Education

- Spoke hospital staff education

- EMS education

- Community education

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

Thank you

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/