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Stroke Program at Northwestern Medicine Central DuPage Hospital

Winston Wong: Welcome to the Journal of Clinical Pathways. My name is Winston Wong, editor‑in‑chief of the journal, and I will be moderating today's discussion.

I am joined today by Anne Lindstrom, Director of the Stroke Program, and Hillary Crumlett, Clinical Director of Clinical Care Services and the Mobile Stroke Program at Northwestern Medicine Central DuPage Hospital, located in Winfield, Illinois.

Anne and Hillary will be sharing with us the story of the development and benefits of their stroke program. Anne and Hillary, can you please tell us a bit about your background and how you became part of the stroke program at Northwestern?

Anne Lindstrom: Sure. Thank you for having us, first of all. I'm Anne Lindstrom. I am the director of the program currently at Northwestern Medicine Central DuPage Hospital. I started in this program about 10 years ago as a nurse practitioner, and prior to that, was involved in stroke care, both in critical care and the emergency department as a staff nurse.

Over the last 10 years, I have continued clinical practice as a nurse practitioner within the stroke program and now also provide leadership as part of that program.

Hillary Crumlett: Great. Thanks, Anne. I'm Hillary Crumlett. I'm the Director for Critical Care Services in our Mobile Stroke Unit Program. I've been with the organization for about 18 years, but really started getting interested in stroke probably about 10 years ago, when I made the transition into adult critical care, and had the great privilege of working with Anne in her NP role.

Really started to dive into what our current stroke program looked like at that time. My focus has been in a leadership role overseeing critical care and neurocritical care and the integration of the stroke program into those spaces. Most recently, helping to build, implement, and then execute the state's first mobile stroke program here in Illinois.

Winston: Wow. Given your tenure, there's no doubt, you definitely have experience and knowledge within the stroke area. Let's start with an overview of the stroke program. How does your program fit into the care continuum?

Hillary: I think we're really fortunate, because we get to see the patient across the continuum of care. With the addition of the Mobile Stroke Program, or the MSU vehicle, we start seeing our stroke patients in the field. That MSU program is integrated with EMS, so we start delivering care at the patient's home or the sites where the stroke may be initially recognized.

Then we're able to bring them into our hospital, either through the emergency department or up directly into our ICU space and treat them immediately as they're coming through from that MSU or EMS perspective. From an acute care hospital program, we're really fortunate that we have that service to be delivered to our patients.

It certainly does integrate well into the pathway that we've developed and has helped to improve our times. I'm going to flip it over to Anne, so she can talk a little bit more about the comprehensive approach to the stroke program.

Anne: We are certified as a Joint Commission comprehensive stroke center. We can provide that highest level of care to our stroke patients. As Hillary mentioned, we're unique in that we have the Mobile Stroke Unit.

Also, as we've thought about these pathways and what we wanted them to be, it was really looking at from the second we made contact with that patient to their post‑acute care, and helping provide a seamless transition through that.

As a health care system, we also do have an acute rehab hospital as part of our organization. We were also able to partner with them to make sure that we were providing that post‑acute support to our patients also.

Winston: Wow. it sounds like you actually, you really do cover the entire spectrum of care for these stroke patients. In terms of the mobile program, where you're seeing the patients, let's say, in their home, do you actually initiate treatment in the home, or do you bring them into the hospital first before you treat them?

Hillary: That's a great question. As we brought this program, there's been a lot of questions of how does that program work to effectively deliver care? The Mobile Stroke Unit is an ambulance. On the ambulance, we have a highly specialized crew of critical care staff and paramedics.

They respond in tandem with our EMS providers. That ambulance is also outfitted with a CT scanner, and then specific stroke drugs, like TPA, which most people will be familiar with. We also have Kcentra onboard. When we get that call, the ambulance is deployed. We go to the site where the patient is experiencing those stroke symptoms.

The crew assesses the patient, and then if we do feel that that patient is, in fact, a stroke, we bring them into the MSU, and we do a CT scan. We have the ability to connect virtually with a neurologist. that neurologist works with the crew to assess the patient.

Then, from there, we will hopefully have had that CT scan completed. A radiologist reads it and gives the report to the neurologist, who then updates the crew. Once the crew receives that notification, we decide what the next level of intervention is. We certainly can deliver either that TPA or Kcentra on the ambulance as needed to support the patient.

Getting those time‑sensitive drugs to the patient, it really does improve their outcomes. There is a lot of literature out there supporting the importance of that golden hour, that initial response to treatment. The program really, really does help us from the acute care standpoint in terms of improving patient outcomes.

We've been really, really excited and fortunate that our organization has supported. We've been able to expand the services from the initial 6 towns that we were working with now to the 24 surrounding towns. We've been able to increase that program over the last 3 years in service to our community.

Winston: The 24 surrounding towns, is that all, how many ambulances do you have?

Hillary: We have one.

Anne: One.

[laughter]

Winston: Wow.

Hillary: They can have some pretty busy days. All in total, it takes about 90 minutes from the time we're deployed to the time we get to where we're going to be on scene, work with the EMS providers that are on the scene already, deliver the care, get them into the hospital, settled into their bed, and then get that ambulance cleaned and back in service.

We are operational 12 hours a day, 7 days a week, for right now. As we continue to learn more about the program, we hope that we get additional support to continue to expand those services.

Winston: These 24 cities, how wide is that area? Curiosity.

[laughter]

Hillary: I would have to think about mile‑wise, how wide that is, but it serves a fair number of towns from market share. We really are in portions of what I'm going to call several counties in the area. We serve our main county and then portions of the northeastern county and then far western counties. We've gotten a pretty significant reach.

Anne has been pretty instrumental in setting up some of those pathways in terms of being able to move what we call from one EMS region to another. Her work with the state has really been instrumental. Anne, I don't know if you want to talk a little bit about you were able to increase the footprint of the MSU.

Anne: Yeah, as part of a comprehensive center, we serve as a network for hospitals to transfer to us. We have strong partnerships with those hospitals, with the stroke programs in those transferring. Also, with their emergency department and their EMS services. Through that work, we were able to share some data around our initial cities that we started with.

As Hillary mentioned, share that impact that we were making on patients. That treating patients within that golden hour, so within 60 minutes of when their symptoms really first start is where we see the biggest benefit for those patients. As we've been able to share that data, more and more cities actually have been interested in wanting access to that for their residents.

Thankfully, this is a team who is innovative and always wanting to do more for patients. Every time a city says, "Could we consider serving our residents?" this team is always willing to jump in and look at how we can make an impact. We don't go directly to the scene for every one of these patients. In some cases where they're a little bit further out, local EMS will meet and bring the patient.

We will intercept and assume care for that patient. The benefit of that, in addition to the TPA, has really been being able to streamline access for those patients who qualify for mechanical thrombectomy. Patients who need to be transferred to a comprehensive center are now able to bypass that initial stop at a hospital that would be transferring them, anyway.

We're able to move a little faster and get that patient straight into the angio suite and the mechanical thrombectomy performed.

Winston: Interesting. How long has the program been in existence? What actually factored into looking to create the program?

Hillary: I think the program has been in existence now, is it 4 years?

Anne: Mm‑hmm.

Hillary: Four years, my gosh. Time flies when you're having fun. As we were really thinking about putting the program into place, there were a few programs that were popping up across the world.

One of the foundational programs established in Germany, then we saw our fellow colleagues down at University of Texas and Cleveland Clinic, and then over at University of Tennessee starting to have these programs.

As we were learning more, I think the innovation and the possibility of being able to impact care in an innovative way while improving outcomes for the patient certainly sparked everybody's interest. Using the clinical pathways that we had developed over time; we had already started to see significant gains in our patient outcomes.

This just, as we were working through that work, the addition of the MSU program really felt like the next natural step in order to continue to push the boundaries of what outcomes were possible, and really, the efficiencies that could be gained when you have those partnerships with EMS. Anne, I don't know if you have anything else to add to that.

Anne: I would just add, I think the development of these pathways helped us set the structure as we looked at the MSU. Stroke care can be so complex. Being able to lay it out in a way that the bedside nurse, the clinician providing care can really look at this and say, "This is what I know I need to be thinking about, considering for my patient," that has made a significant impact in our outcomes.

Winston: When you created the pathway, was it totally home‑grown, where you did your own research, looked at the national guidelines, talked to consultants, or was it modeled after one of the other programs that you mentioned?

Anne: There are a few programs that have pathways that are out there. We looked at what was out in the community and used the American Stroke Association guidelines as a framework for that. Looked at, when a patient comes into the emergency department, I'm the staff caring for that patient, at day zero, as they walk in, what do I need to think about for that patient today?

Now, the patient's in the ICU. Day two, day one, what do I need to think about for that patient? We took the guidelines and really modeled it against that. In essence, to answer your question, I think we were influenced by what is out there in the community, but to some degree, still home‑grown.

I can't tell you how many hours I think of Hillary and I, at our work group, just sitting there, going through, saying, "This is what the guidelines say." As a clinician, as a nurse, as a rehab therapist caring for this patient, what do I need to know on this day?

We wanted this to be a document that the team could look at and reference as they're going through so that we were sure every day we were providing that true evidence‑based care for our patients.

Winston: In terms of the guidelines and the pathway that you have, I'm assuming they are frequently updated. What would trigger an update or some type of a practice‑changing change?

Anne: Just that. Any kind of practice change, so if the American Stroke Association updates the guidelines, we then, in turn, update the pathways. We are in an every‑2‑year cycle review. If there is no guideline update, we review the pathways every 2 years, and we put that on the same cycle as our Joint Commission certification.

As we're starting to prep for that, we also pull these pathways and review as a team. Minimum, every two years, we look at them. Things have been changing so quickly in stroke over the last few years that we've looked at them more frequently. As we see a guideline update, but a minimum of that 2 years.

Winston: One of the problems that we have found as a barrier to pathway utilization within the oncology practices is the ability of that treating oncologist at the bedside or at the table side being able to access those pathways and talk to their patient about treatment options.

With your pathways and the programs starting out in the field, potentially in the patient's home, and going all the way through the acute care phase and into rehab, are the guidelines of the program treatment pathways readily assessable so that they can be checked off, so to speak?

Or that each caregiver can go and check off exactly what they've done to make sure they're consistent with the guidelines that are in place?

Hillary: I think that's an interesting question, because that has been a little bit of a journey that I know Anne and I have really enjoyed being on. Initially, we really looked at the development of a paper tool. We were newer on our EMR at that point in time, and we were actually meeting a little bit of resistance around innovating how do you integrate a clinical pathway into the EMR.

We started the first phase of the project by putting these on‑paper tools and using them pretty conventionally in terms of having them available for the nurses to document. Then that document travels with the patient as they move through the continuum. Starting on paper was a benefit, because it helped us realize maybe where we had some gaps in the pathway that we created.

It allowed us to quickly re‑calibrate or tweak. We did use the DMAIC process improvement methodology as we rolled out this phase one of the process. Then, I think, as we started to learn more about the EMR, there was opportunity for us to really optimize the use of the clinical pathway.

I'm going to turn it over to Anne to talk about that, because she did a ton of work in terms of helping to integrate the clinical pathway into the EMR.

Anne: Thank you, Hillary. I think the work continues, I'll say that. We're still a work in progress. We have linked, actually, that paper tool within the EMR so staff really always have that full picture view. As a clinician, it's important to be able to go in and say, "I'm here now, but where are we trying to get to?" so they can see that entire document. We also have built pieces of it into the EMR.

The education pieces for staff, the patient goals, all of that are currently built into the EMR. What I will call phase three for my dream, and I think Hillary's dream also, was to have this pathway be a separate tab or area within the EMR where that paper version really becomes live. What I would love to see is best practice alerts and prompts for staff as we go through.

We've been able to build some of that in. For instance, every stroke patient who comes in needs a screening for dysphagia. We have a best practice alert built in for our staff. When a head CT is ordered, staff automatically get an alert to say, "The head CT was ordered. This patient might be an acute stroke patient. Please do your dysphagia screen."

The nurse is then able to chart against that within that alert. We have an opportunity to optimize some more of that, using those alerts to help guide the clinicians through as care progresses.

Hillary: I just wanted to add a little bit onto that, because I think, to your point about the inter‑professional collaboration that needs to occur for these patients, I think leveraging the EMR helped really drive that collaboration across the disciplines.

With the paper tool, what we learned about it is really works with nursing when we were using that paper tool. By getting it integrated into the EMR, it made it alive for the physicians, respiratory therapy, occupational therapy, physical therapy, and also our rehab partners who can see that record.

There's a lot of communication that's happening across the disciplines into different spaces to notify them that a patient is in need of something. From that clinical pathway standpoint, we almost leveraged it like artificial intelligence in terms of integrating it into the EMR, so that we're not having to remember to do anything.

The computer and the EMR is actually driving the work based on how that pathway was created, which I think is pretty amazing that we have come that far in terms of technology that we can start to use the EMR for AI capabilities.

Winston: I would dare to say, at the risk of getting some tomatoes thrown at me, that some of the oncology practices could probably learn from what some of the benefits that you've already learned. [laughs]

In terms of your rehab partners, I understand you said they can what's going on with the patient, what the needs are. Do they themselves, as rehab caregivers, are they able to go and chart into that as well?

Anne: They can chart therapies, yep. Each discipline, from providers, respiratory therapy, rehab services, everyone can access their piece and document against it.

Winston: With all that charting you have over a 4‑year time period, what have been the results of your program? Was it worth the effort to put the program in?

Anne: Yeah, absolutely. We talked a little bit about how important this standardization of the care is, and really standardizing that helps demonstrate the impact. We saw a decrease in our re‑admissions, so when we first started, we were at 8.8%. We're now down to 5.8%, which is well below the benchmark.

Then we actually saw a half‑day decrease in length of stay for these patients, which as you can imagine, we hover about for ischemic stroke patients about 4.3 days length of stay for those patients.

Taking a half‑day off is pretty significant, and allowed us, especially for those patients who are transferring to an acute care center, helped streamline that so that we are taking as much advantage of that time as we can. We're providing the care they need to stabilize them within the hospital.

Then we're quickly getting them to acute rehab, where they can start intensive therapy and start working towards improving outcomes. Hillary, I don't know if you would add.

Hillary: No, I think you did a nice job summarizing it. I think, too, from the compliance standpoint, if I put on that clinical administrator lens, you're constantly driving to compliance, especially when you're talking about Joint Commission coming in, or any of your regulatory agencies coming in to assess your program.

That is, from an administrator standpoint, where you can be most vulnerable when they're reviewing charts. The additional benefits, we clearly want to impact patient care outcomes, but we also see compliance really driving up above 90% on almost every aspect.

I know our last Joint Commission visit, they were very complimentary of the fact that we were so well in compliance with all of our measures. That was a goal, but maybe an unintended consequence of building it into the EMR that drove performance in a different way. Organizationally too, you're going to see a pickup from organizational performance too in addition to the patient care outcomes.

Winston: Wow. One thing we did learn from the oncology arena is oncologists don't like the term compliance. They'd rather hear the term "consistency with the pathway."

[laughter]

Winston: To hear that you have a 90%-plus consistency with your pathways is great. Any thought of, when you first started 4 years ago, what your consistency rate might have been?

Anne: I would say, depending on the measure we're looking at, we've seen anywhere from a 5-10% increase. What I will say is we have decreased that variability, which was the biggest thing. We don't have the highs and lows now, we just have that consistency to the pathway, I'll say, instead of compliance.

We're consistent now with that metric, so we don't see as we look at it month to month that variability we were seeing prior to development of these pathways.

Winston: I wasn't meant to give you that as a trick question, it was more to go...

[laughter]

Anne: ...good information here. Neurologists might feel the same way, so it's...

Winston: It was really more to emphasize the 90%‑plus consistency, so that's great. With the other programs that are out there, would you say that stroke management pathway programs are still in development and up‑and‑coming, or are you the cutting edge that's leading the way? What do you see for the future?

Hillary: From my standpoint, when I think about innovation or cutting edge, I think we're at a distinct advantage, because we have that Mobile Stroke Program, which puts us on the cutting edge of stroke in general. In terms of what it means for the pathways, we now have started to develop pathways for the Mobile Stroke Unit.

What the team will be doing when they're out in the field in order to continue to move the pathway along, it was quite the lift to start to integrate the hospital EMR into that ambulance service, given the logistics of needing to report to the state and our local EMS providers, what that would look like.

We're excited that we're at this place that we can start to integrate the pathways into the Mobile Stroke Unit. What will that mean for the future of stroke? We're still learning quite a bit as we look at that.

Winston: Is the hospital looking at implementing programs like this or pathways in other areas?

Hillary: Yeah. Our good learning from the stroke really did help drive some work, one, in oncology. We were able to really leverage the framework for which this was developed to do some work in the oncology space. Then we did a tremendous amount of work around cardiac surgery patients and what that would mean.

We, again, saw a tremendous lift when we talk about cardiac surgery patients as well. We had a pretty significant number of those patients going to skilled nursing facilities postoperatively. We were able to build some clinical pathways.

We reduced that number significantly, to where only a very, very small percentage of our patients ever see the inside of a skilled nursing facility postoperatively from cardiac surgery. We've been able to leverage what learned in those other service lines.

Winston: Great. Thank you, Anne and Hillary, for a very interesting discussion. It's truly very refreshing to learn about the application of clinical pathways outside of the oncology arena. I can definitely tell you that I'm impressed with what you've done in terms of the extent of the program, the details of the program, as well as the scope of the program.

Especially as we move onto this value‑based care area, I can see where your program's going to be very effective in driving a cost‑effective care. As always, thanks to the "Journal of Clinical Pathways" for the opportunity to have this discussion. Finally, thanks to the audience for taking the time to listen in on this discussion.

For the latest updates on issues related to the development, implementation, and evaluation of clinical pathways, please check out our website, www.journalofclinicalpathways.com. Good day.   

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