4 Telling Questions That Reveal the Integrity of Your Stroke Care Systems

Last week, I talked about the root of all evil in STEMI care (variability) and then about some sources of variability in STEMI care and how to identify and reduce them in your facility. When it comes to variability, stroke programs have their challenges too. Today I will share with you the top four questions I ask that reveal when the "V word" has snuck into your stroke systems.

1. Who responds when a Code Stroke is called at your hospital?

"Sometimes the Neurologist responds and performs the NIHSS, but when they don't, it's the ED physician. Oh wait, sometimes it's the Stroke Coordinator." I can't make this stuff up - often when I show up and ask the Stroke Coordinator who does the NIHSS, she tells me that the ED Charge Nurse does it ... most of the time. Sometimes the Neurologist does it if she is in-house. And while it's understandable that the same person isn't responsible for performing NIHSS every single time (that would hardly be fair), the real problem is that there is no rhyme nor reason for who does it when. With no clear expectation of who will be performing the NIHSS, it's often delayed simply because Person A is thinking that Person B is going to do it and vice versa. This also makes it difficult to have consistent NIHSS assessments that are accurate and dependable.

2. What Pre-hospital Stroke Score do you use?

Even with all of the major changes in the stroke world, I am still met with blank stares when I ask this question. Other times three people confidently shout out different scores. The most common answer is "It depends on which EMS agency it is." All stroke systems should be moving toward using the latest and greatest scores to better identify emergent large vessel occlusions (ELVOs) in the field. With consistency comes confidence, and unfortunately, confidence isn't something that I regularly see when it comes to stroke code activations.

3. Do you bypass the ED and go straight to CT?

The answer has improved over the past year, but there's still much room for improvement. The most popular answer is "We do when possible." My follow-up question is always the same: "Well, when is that?" What allows you to bypass the ED and go straight to CT? What makes it possible? "Well if we think it's really a stroke we go to CT." It's easy to see how variability feels right at home with practices like that. Different staff on call, different presentation of symptoms, different time of day, different levels of chaos in the ED ... all things that can change whether or not you "think it's really a stroke." The process needs to be clearly defined and followed every time if we want to do what's best for the patient.

4. What is the standard order set for stroke?

You guessed it, "It depends." Some ED Physicians are good about following the Stroke Protocol, and others like to shoot from the hip. When it comes to lab tests, the only one required is glucose, unless the patient is on anticoagulants. Again, consistency is key when it comes to protocols. If the nurses know what to expect, they can move forward with precision and speed. If things change from one physician to another, speed is the last thing you can expect. A stroke program like this will struggle to meet the expected benchmarks.

Creating a system that has both speed and accuracy can be challenging, but achieving consistency in your protocols is my number one secret to reaching that sweet spot. And remember, even the best teams can always get better. Whether you need a complete system overhaul, or just want to tweak a few things, Pulsara automates and streamlines your stroke care processes for you, helping you achieve beloved consistency every time.