1. Author: Debbie Roper, RN, MSN (d.r. Stroke) Vice President of Roper Resources, Inc. debbie@roper-resources.com 214-864-8993 Stroke Coordinator: ROI

2. Disclosure Debbie Roper is a speaker for: Genentech – Activase Chiesi - Nicardipine Debbie has no actual or potential conflict of interest in relation to this presentation.

3.  Stroke Program Development Course (Six Month Recipe)  Mock Stroke Surveys  Certification Consulting Services Stroke Consulting Services Red Gate Inn, McKinney, TX Redgateinn.com

4. Objectives 1.Discuss the role of stroke coordinator on increasing in- patient stroke volumes 2.Discuss impact of decreasing length of stay on ROI 3.Understand the value of increasing Activase treatment rates 4.Rationalize the direct cost incurred for the role of a full time stroke coordinator.

5. Cost increase predictions from 2012-2030 Total direct annual stroke related medical costs expected to increase from $71.55 billion to $183.13 billion Real indirect annual costs projected to rise from $33.65 billion to $56.54 billion Overall annual costs of stroke projected to increase to $240.67 billion by 2030 (129% increase) Stroke 2013; 44: 2361-2375

6. Aging population = Increase in prevalence of stroke Additional 3.4 million people with stroke in 2030 By 2030 nearly 4% of the US population is projected to have had a stroke Stroke 2013; 44: 2361-2375

7. Revised & Updated Recommendations for the Establishment of PSCs A Summary Statement From the Brain Attack Coalition Less disability associated with use of rt-PA Use of rt-PA increased in PSCs Less disability = less lifetime cost Stroke units (Class I, Level A) 17-28% reduction in death 7% increase in being able to live at home 8% reduction in length of stay 19% increase in good outcomes Stroke. 2011;(42): 2651-2665

8. Stroke Coordinator Role  Commander  Chief  Educator  Motivator  Data Abstractor  Data Analyzer  Speaker  Organizer  Facilitator  Detective  Data Analyst

9. Registered Nurse Neurology Experience Critical Care Experience (ED/ICU) Public Speaking Experience Performance Improvement Experience Educating Experience BCLS + ACLS (per job description) NIHSS 8 hrs stroke CNE annually Stroke Coordinator Qualifications

10. What does a SUCCESSFUL Stroke Coordinator look Like?  Achieved/Maintained Stroke Certification?  No Recommendations for improvement on stroke survey?  Longevity in stroke coordinator position?  Stroke Core Measures are 100%

11. Four Elements of a Successful Stroke Coordinator Stroke Volumes Stroke Treatments Stroke Outcomes Stroke Length of Stays

12. Increase Stroke Volume

13. What does success look like? Volume of In-Patient Strokes Yahoo! a steady increase in stroke volume What About?  Mode of Arrival (EMS vs Pvt Vehicle)  Arrival within time window for stroke treatments  Inter-facility Transfers  Denials – Potential leakage to the competition

14. Stroke Patient Mode of Arrival Ambulance Automobile Total Percent EMS Volumes by Provider ?

15. EMS 1 EMS 2 EMS 3EMS 4 Main EMS Providers What does Success Look Like? EMS volume increases EMS is a participant on stroke committee EMS stroke protocols are reviewed annually EMS stroke protocols follow current CPGs EMS run sheets are provided on every patient Care provided by EMS is assessed to ensure protocol adherence EMS Feedback is provided by stroke center EMS attends stroke survey

16. Time of Arrival from LKN Acute vs Subacute What does Success Look Like? Community education events increase (> 2/yr)  Largest Employer  Zip code origin Acute stroke volume increases  < 3 hours from LKN  3 - 4.5 hours from LKN  < 6/8 hours from LKN

17. Increase Stroke Treatments

18. What does Success Look Like? ED Physicians find a reason to treat with IV Activase Every acute stroke patient is screened for stroke treatments  IV/IA Activase  Thrombectomy Devices  Clipping/Coiling  Carotid Stents  Intracranial Stents Percent of all Ischemic stroke patients who receive IV Activase increases (not just acute)

19. Are Your ED Physicians Finding a Reason to TREAT or NOT TO TREAT? What does Success Look Like? No missed opportunities ED Physicians discuss their concerns r/t Activase ED Physicians prescribe Activase without Neurologist Individual ED Physician Report Cards Increase number of patients receiving IV Activase Created by Genesis Lewis RN, BSN Dallas, Texas

20. Are You Screening Every Acute Stroke Patient for Eligibility for Endovascular Treatments? What does Success Look Like? Transfer agreement with CSC CSC provides all PSC and ASR facilities with screening criteria LKN is < 6hrs NIHSS > 8/10 or higher NIHSS < 4 with aphasia CTA = large vessel infarct Every Activase patient is screened for Thrombectomy prior to admission to ICU All ED Practitioners are knowledgeable about CSC screening criteria

21. Collaborate with EMS – PSC vs CSC – for Stroke Treatments What does Success Look Like? State EMS transfer protocols - CSC vs PSC EMS screen from scene for PSC vs CSC EMS participate in IRB studies to validate screening

22. Improve Stroke Outcomes

23. How Do You Measures Stroke Outcomes? What does Success Look Like? Patient Disposition – increase of patient discharged to home and/or rehab Compare Initial and Discharge NIHSS – decrease in NIHSS or return to baseline at discharge mRS at 90 days – able to perform activities of daily living No Stroke readmissions within 30 days

24. Don’t forget the financial impact of improved outcomes Calculate complication rates (pneumonia 3%) Calculate cost/case of complication rates –Pneumonia, DVT, PE (Increase of $33,155) Effective dysphagia screening at bedside can reduce aspiration pneumonia by 50% (Hinchey, et al. Stroke 2005;36) 3% of 340= 10.2 patients with pneumonia ($338,181) 50% reduction = $169,090 in “cost avoidance”

25. Decrease Length of Stay

26. The DRG system is in place to incentivize hospital efficiency Strategies for decreasing cost revolve largely around the formation of stroke units Savings of ~$55 million per 1000 patients Stroke 2012; 43: 1131-1133

27. Decrease Length of Stay (Ischemic, Hemorrhagic, TIA) What does Success Look Like? Ischemic stroke LOS = Hemorrhagic stroke LOS TIA LOS

28. A Successful Stroke Coordinator’s ROI Using Four Elements Stroke Volumes Increase Year over Year Stroke Treatments Increase Stroke Outcomes Improve Stroke Length of Stays Decrease

29. Questions