Leading Your Stroke Team

February 7, 2009

John R. Belden, MDMedical Director, Stroke Program

Neuroscience Institute, Maine Medical Center

Financial Disclosures: none

Overview

How MMC built its’ Stroke Team Concept of a “hospital neurologist” How 30 years of practicing medicine maybe

prepared me to do this job What I do What the future holds Accomplishments and Challenges Conclusions

MMC Stroke Objectives

Provide evidenced based care in a Center of Excellence for Stroke More efficient organization of stroke care,

from the ED to discharge

Achieve JCAHO “Primary Stroke Center” certification

Role of Evidence- Based Medicine

Acute stroke Thrombolysis BP DVT

Secondary prevention BP Anti-platelet drugs Warfarin

Application to Joint Commission standards

Necessary Ingredients (2004-2006)

Multidisciplinary Stroke Operations Team Clinical Guidelines and Pathways Balanced Scorecard Tools to support evidence-based care (i.e. Order Sets) Standard Data Collection Tool: AHA/ASA “Get With The Guidelines” Co-horting of stroke patients Dedicated Staff

Stroke Program Team

Core Stroke Team: .2 Medical Director (now .3) .5 Nurse Practitioner .5 Program Manager .5 Data Analyst

Extended Team:Emergency Department Physicians and Nursing, Stroke Unit Nursing Directors, Chief of Medicine, Neurologists, Neuro-radiologists, Physiatry, Rehab and other Clinical Staff and Administration

2007: Incorporated into Neuroscience Institute

BRAIN INJURY

PEDIATRICS

MEMORY DISORDERS

NEURO ONCOLOGY

EPILEPSYDEGENERATIVE

NERVOUS SYSTEM

DISORDERS

SPINE

STROKE

NEUROTRAUMA

How is it Working?

Efficient tracking of quality measures Investigate and track mortality, LOS, “outliers”

to optimize care Staff, resident, and attending physician

medical education- this is a big job! Improved “flow” with New England Rehab

Hospital Research- tough to find time to do this!

Accomplishments

Opportunities for Clinical Integration of Stroke Care at System Level

Transfer and referral issues Telestroke Consistent care pathways across system Community outreach

Ingredients for Success

Hire people with an interest in stroke Financial commitment from the hospital Set realistic goals, which can evolve, and keep

working at it 99% perspiration, 1% inspiration

Monthly meetings to discuss data and old/new ideas

Organizational structure- “all politics is local” Small hospitals- you do not need a neurologist

Concept of a “Hospital Neurologist”

Economic and stress factors have led neurologists to focus on outpatient work and resign from hospital medical staffs

Creation of “neurohospitalist” role to focus on inpatient care

MMC coverage provided by Maine Neurology and one private physician

Call coverage rotated job in 3 to 4 day shifts; consultative work only

Continuing education on a wide range of neurological disorders affecting sick hospitalized patients provided

Medical Director: Ingredients for Success

Solid training and experience in stroke care Familiarity with primary care doctors and

pertinent specialists in the region Business skills not really needed, but handy “Collaborative” personality

What do I do at MMC?

Three weekly 2 hour sessions Many other meetings, lectures, etc. 2-3 hrs. per week on e-mail Many hours a week of lecture

preparation, writing guidelines, etc. Evolving “Telestroke Program” Small amount of research

What does the future hold at MMC?

Telestroke network development

More work with MMC Research Institute

Selected clinical trials Transition to medical

school relationship with Tufts

Challenges at MMC

Organization of stroke beds Dysphagia screening Lipid screening Patient education Use of common orders sets Transfer of patients to MMC when “the

inn is full” (new beds April 09!)

Lessons Learned

Vision Leadership Team Work Homework Patience Persistence Assistance

Questions and Answers