Monico Peter Baňez, MD, MBA, FACP, SFHM
CHAPTER CONTENTS
STROKE CENTER
Hospital neurologists are increasingly being asked to treat strokes acutely. Because of this, we are asked to start or participate in Stroke Centers.
There are different levels of stroke center certification, and the key is selecting which is the best fit for each facility. The certifications are designed and granted by The Joint Commission (TJC). Requirements are complex and subject to change, so source documentation from TJC should be consulted (visit https//www.jointcommission.org/facts_about_joint_commission_certification). xThe criteria presented are active at the time of writing.
The types of stroke centers are:
•Acute stroke-ready hospital (ASRH)
•Comprehensive stroke center (CSC)
Many hospitals have the personnel and resources to be a PSC. CSC certification is usually the province of academic hospitals and regional referral medical centers. Smaller hospitals may seek certification as ASRHs.
ACUTE STROKE-READY HOSPITAL
ASRH certification is best suited to hospitals with 24/7 ED service typically without in-house neurology. Basic requirements include:
•Initial evaluation by physician, nurse practitioner, or physician assistant
•Neurologic consultation in person or by telemedicine
•Imaging including computed tomography (CT) and magnetic resonance imaging (MRI) available 24/7
•Ability to administer IV tissue plasminogen (tPA) with subsequent transfer to a stroke center
•Transfer agreement with a PSC or CSC
There are other requirements regarding education, timing of response, record-keeping, and requirement of TJC site visit.
PRIMARY STROKE CENTER
PSC certification is best suited for hospitals with 24/7 neurology coverage, although the criteria do allow for telemedicine to fulfill this requirement. In comparison to the ASRH designation, the PSC must have more extensive access to advanced imaging and neurovascular interventions. Some of the requirements are:
•24/7 provider coverage, but initial evaluation can be by ED physician
•Neurologic input in person or by telemedicine also 24/7
•Imaging access 24/7 not only including CT and MRI but also computed tomography angiography (CTA), magnetic resonance angiography (MRA), and cardiac imaging
•Ability to provide neurovascular procedures including acute endovascular therapy, carotid stenting, carotid endarterectomy, and intervention for aneurysms
•Access to neurosurgical coverage or a transfer agreement for neurosurgery
COMPREHENSIVE STROKE CENTER
CSC certification is usually for established academic medical centers or regional referral centers. Full-service neurological, neurosurgical, and neuroradiological service is needed. Requirements that distinguish CSC from ASRH and PSC include:
•Neurology expertise available on-site 24/7
•Neurosurgeon and neuroradiologist/neurointerventionalist available 24/7
•Imaging availability including transesophageal echocardiogram (TEE) and catheter angiography in addition to carotid duplex sonography (CDS), transthoracic echocardiogram (TTE), and the other imaging modalities required for PSC
•Participation in patient-centered research requiring institutional review board (IRB) approval
•Sponsor for public educational opportunities
CSCs usually partner with regional PSCs and ASRHs to form a network. Ideally, the CSC should guide the local stroke network on best practices, standards of care, and metrics.
TELENEUROLOGY
Teleneurology has been a logical subset for telemedicine since many busy hospitals either do not have neurologists or do not have sufficient numbers of neurologists to cover calls 24/7. Teleneurology can accomplish at least some of the following:
•Reduce the number of transfers
•Improve urgent evaluation of patients especially with suspected stroke and seizures
•Reduce length of stay and unnecessary tests
•Improve cooperation of local providers and remote specialists
Barriers to more extensive use of teleneurology include:
•Unavailability of participating neurologists
•Concerns that the mechanics of teleneurology can sometimes delay acute care
To address the concerns over reimbursement and staffing, carefully negotiated agreements between facilities have to be established. Preferably, the teleneurology service should be provided by the regional referral hospital that can accept the patient in transfer if needed.
BILLING AND CODING
Billing and coding are complex, and a complete discussion is outside of the scope of this text. However, there are some common issues for consideration.
Timely billing: Providers are better about timely delivery of medical care than timely billing. Most modern electronic medical record (EMR) systems provide the ability to designate a level of service at the time of the encounter, providing the documentation has been completed. Hospital documentation should be completed on the day of service.
Accurate coding: Neurologic coding is complicated, and many capable coders are not facile at the fine points of neurologic coding. Specialty coding expertise is helpful especially for neurology and neurosurgery.
Records and audits: Audits are performed routinely by larger clinics and hospitals to determine quality and completeness of documentation and charge management. Feedback to the providers to correct persistent deficiencies in documentation is essential. In addition, the providers should have the ability to see the performance data regarding the billing performed on their behalf.
METRICS
Quality measures and other metrics for hospital neurology practice present a moving target. The American Academy of Neurology has a series of quality measures for various neurologic disorders. These are available online.1
Most of the guidelines pertain to outpatient neurology. However, there are guidelines for some inpatient neurology practice, especially stroke.
In these days of constant push to improve medical care, uneven quality persists. The source of this unevenness is multifaceted and includes:
•Failure to learn new advances in best practices
•Anchoring in the old practice patterns
•Lack of team involvement in practice
•For some providers, high patient volumes
Improved quality and fewer mistakes will help to reduce the casualties that the Institute of Medicine (IOM) reports we are causing in our medical care.
RISK MANAGEMENT
Neurology generally has a relatively low risk of malpractice liability, but this risk can be enhanced with hospital practice.
Case load: Recent changes in hospital practice, including stroke services, have increased the inpatient and ED case load for neurologists. This needs to be controlled. This is accomplished by considering locums, diversion, and telemedicine, in addition to ongoing recruiting.
Shift duration should be controlled. Most medicine hospitalists limit shifts to 12 hours, and, preferably, this should be standard for hospital neurologists.
Continuity of care reduces risk of litigation. As part of hospital practice, where patients are seen on successive days by different providers robust hand-off procedures are essential.
FUTURE DIRECTIONS
Predicting future trends in hospital neurology practice is complicated by uncertainties in the political landscape, regulatory pressures, business pressures from insurers, and evolution in medical education. We expect the trend will continue to have increasing numbers of hospital physicians of all types, including neurology.
An increasing proportion of hospitals are using co-management agreements or call-pay arrangements rather than the traditional obligatory call schedules. This is partly promoted by the need to incentivize providers to meet mandated metrics.
Hospital-at-home has been studied, and there is no evidence that this model is associated with poorer outcomes.2 But there is no evidence that hospital-at-home for early discharges reduces costs or improves outcomes.3
