Stroke benchmarks during COVID: HFAP releases latest report
By Matt Phillion, PSQH
While COVID-19 took over much of the healthcare world’s attention for the past year, programs addressing other conditions continued to work hard to keep patients safe—addressing both existing challenges and new ones brought on by the pandemic.
HFAP, a brand of the Accreditation Commission for Health Care (ACHC), issued its annual benchmarking report on stroke programs recently, which demonstrated COVID-19’s impact on these programs. HFAP collected data to help healthcare professionals expand their knowledge of the risks, triggers, and variations of stroke, with findings that took a year of pandemic challenges into account.
“What we’re doing in our annual performance report is metrics—we ask hospitals to submit their compliance with performance metrics for nationally recognized standards for stroke care,” says Carol Roesch, certification advisor for HFAP. “We take their performance and compare it against peers at the four levels of HFAP stroke certification—Stroke Ready, Primary Stroke, Thrombectomy, and Comprehensive Stroke—which allows them to compare their metrics with hospitals certified at the same level.” The report also includes a hospital size component for additional comparison opportunities.
“Our goal in doing this is to support improvement in individual stroke centers, so they can say, ‘Look, we’re doing great in this benchmark or falling behind in another,’ and what can we learn from that,” says Roesch.
COVID-19 had a major effect on this year’s results, as challenges arose due to factors that impacted healthcare across the board. “It’s been a crazy year,” says Roesch. “Anecdotally, I’ve observed that it was harder to maintain benchmarks for a number of reasons.”
COVID-19’s effect on staffing was one of them. Because facilities were running shorthanded, many stroke coordinators, even full-time ones, were called back to the staff nurse level. The reasons for those staff shortages should be no surprise for anyone following the pandemic’s impact: Many nurses couldn’t work for any number of reasons or had to care for their families; staff were afraid to come to work due to COVID-19 or were sick themselves; and of course, many facilities saw patient surges, requiring more staff on the floor to provide care.
“There was something else we observed—hospitals had to struggle more or push harder on some benchmarks that were time-limited,” says Roesch. “Delays were built in because hospitals were full, and also because of additional screening of patients. They had to screen for COVID before those patients would go in for the first test, and those things added time.”
Also anecdotally, the report authors observed that bed shortages in some units made meeting time-related stroke benchmarks harder; patients who needed to be transferred to a higher level of care, for example, might run into a lack of beds in those units. Yet through creativity, organizations found ways to overcome their challenges.
“It’s interesting how creative hospitals were in how they faced these dilemmas,” says Roesch. “Turning a recovery room into a COVID unit—we even heard reports of turning a gift shop into a COVID unit.”
And to meet staffing shortages, hospitals turned to cross-training, such as training surgical staff to the med floor.
Stroke programs faced the same lack of PPE as other healthcare sectors, and used similar creativity to make the resources at hand work.
“The shortages in PPE were something I never thought I’d see in my career,” says Roesch. “Hospitals have been so adaptive. It’s amazing, with almost daily updating of policies at times, and getting the word out to staff for reeducation and safety.”
Fear of going to the hospital
Healthcare in general saw fewer patients venturing into the hospital during the height of the pandemic. While the report doesn’t drill down into hard numbers, anecdotally HFAP observed that, as in other areas of healthcare, there was a noticeable decrease in non-COVID-19 stroke patients going to the hospital.
“They attribute it to a fear of catching COVID by coming into the hospital,” says Roesch. “The worry for the future is, what becomes of those patients who had strokes at home and didn’t come to the hospital?”
No one should brush aside stroke symptoms, which makes this population’s hesitancy to seek care even more worrying.
“You absolutely need to get to the ED as soon as possible,” says Roesch. “If you think about a heart attack versus a stroke, a heart attack has chest pain and the patient realizes: ‘I’ve got to go to the hospital.’ But a stroke may involve weakness on the left side, and the patient may write it off as, ‘Maybe it’ll go away. Dizziness, headache—do I have time to go to the ED for that?’ ”
Stroke care professionals have long pushed for a better understanding of the signs of stroke, working to educate patients about taking symptoms seriously.
“Even during non-COVID times, that’s part of the education we do every year,” says Roesch. “For stroke centers, it’s a requirement: telling the community to call 911 if they have any symptoms, and knowing that getting to the hospital is imperative. We want to make sure we can get the right treatment to them, or if they need an intervention, a thrombectomy, there’s a limited time on that as well.”
Statistically, the field observed an increase in the number of strokes among COVID-19 patients as well.
“There’s a lot of reasons for that,” says Roesch. “COVID patients have an increased risk of developing clots, inflammation, and hypercoagulation, which makes a COVID-positive patient a higher risk.”
The benchmarking report did not observe that any one type of stroke center struggled with or succeeded against pandemic challenges more than other types, though any given center’s success was impacted by how its geographic area was doing with COVID-19.
“I did see that regionally, if COVID was red hot in a community, the hospitals, regardless of stroke center level, were more impacted than others,” says Roesch. “They were still trying to provide the same level of care, the same modalities, but now with all the additional patients and testing.”
Add to this the challenge of family members not being able to stay with the patient, and organizations saw new difficulties for assessing incoming patients.
“What if a patient comes in with stroke and they can’t talk? How do you find out their last known-well data? COVID brought a lot of complicating factors,” says Roesch.
Best practices observed
HFAP hosts quarterly teleconferences for stroke centers to share best practices and ideas for improvement. This year, some of those sessions included discussion about improving times for stroke patients.
“Some presenters discussed ways to get a stroke patient to a CT scan as quickly as possible, for example,” says Roesch. “Time from door to CT is so important. One suggestion that came up: Let’s not even take the patient to a room in the ED. Do a quick triage while they’re on the EMS cart, get a physician and nurse bedside. Make sure [the patient’s] airway, breathing, and circulation are OK, and get them to the CT right now.”
Looking forward, Roesch brings up the impact of COVID-19 on stroke risks. “I think it’s part of the disease process with COVID. When they are that sick—everything going on in their bodies, the inflammation, the hypercoagulability—[it] made them so much more susceptible. It’s not just respiratory. It attacks the whole body,” says Roesch.
Many of the COVID-19 patients who also had strokes were younger, and patients who have experienced a stroke are more likely to have one in the future.
“That’s one takeaway: There’s a population of younger stroke patients who are at a higher risk because they’ve had one,” she says. “There’s always a need for education, and that’s something that is stressed at the time to the patient—if they’ve had a stroke, that puts them at a higher risk for another.”
Despite the pandemic’s unprecedented challenges, the report shows that stroke centers across the country worked hard to keep pace.
“They’ve done an exceptional job to meet the benchmarks,” says Roesch. “I know they’ve struggled because of all the things we’ve discussed. But still, when hospitals are reporting, I’ve seen very little change—very little decrease, in some cases no decrease—in meeting their performance measures in the benchmarking report.”
That success shows how important stroke center quality is to those who work there.
“That quality is shining through, which is part of why we do this benchmarking report,” says Roesch. “It’s a driver of quality, and then they can share that with their colleagues.”