New initiative to improve in-hospital management of stroke across VA medical system

Researcher-clinicians from the Regenstrief Institute, the Department of Veterans Affairs and Indiana University School of Medicine are leading a national effort to coordinate and organize acute stroke care across the entire VA medical system. This initiative to improve in-hospital management of stroke with the goal of reducing disability and death was implemented by the VA this summer and may serve as a model for public and private hospital systems around the country.

"This undertaking grew out of our research into evidence-practice gaps in care, where we showed that the VA had high quality of post-acute and discharge care for stroke, but some room for improvement in very early stroke care," said Regenstrief Institute investigator Dawn Bravata, M.D., clinical coordinator of the VA's Stroke Quality Enhancement Research Initiative, or QUERI. She is a research scientist with the Center of Excellence on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis and associate professor of medicine at the IU School of Medicine.

All VA facilities that treat stroke patients, no matter the size of the unit or the number of hours per week when stroke care is available, are affected. Coordination and organization of care doesn't mean stroke care will be practiced identically at every facility. It does, however, encourage more uniform quality according to Dr. Bravata. Stroke care quality will initially be measured in three areas: administration of thrombolytic clot dissolving drugs; screening for swallowing difficulties; and use of the National Institutes of Health Stroke Scale to determine critical information about the severity of the stroke.

The specifics of the national quality initiative are tailored to the type of facility and what works in each locality -- from major medical center to small facility. For example, screening for swallowing difficulty will become part of standard care, but it is up to each hospital to determine how that evaluation is done -- perhaps by a nurse in the emergency room or a speech pathologist on an inpatient hospital unit.

"Improving stroke care and outcomes is a challenge as the population ages and hospital systems expand. The VA's experience in stroke care improvement can potentially be adapted to any health care system as a model of how care improvements can be provided in a coordinated, integrated fashion across different types of hospitals," said Regenstrief Institute investigator Linda Williams, M.D., research coordinator of the VA's Stroke QUERI. She is a research scientist with the Center of Excellence on Implementing Evidence-Based Practice at the Roudebush VAMC and associate professor of neurology at the IU School of Medicine. "The VA has been doing a good job using research to better inform how and where care improvements can be made. As health care is increasingly provided by networks of multiple hospitals, this VA example can be used to show how care improvements can be translated throughout the system for the benefit of all patients."