Cryptogenic Stroke Quality Improvement Project (CSQIP)
One third of ischemic strokes are deemed cryptogenic (undetermined mechanism), and have historically had inadequate clinical attention given a lack of data and tools with which to diagnose and treat. However, that dynamic has changed and will continue to do so. Despite this fact, many patients are not clearly identified as having had a cryptogenic stroke and do not undergo a rigorous evaluation which may put them at risk for a recurrent stroke. There are limited to no published recommendations on what pathways hospitals should operationalize in order to work up a patient deemed to have a cryptogenic stroke that include these newer data and technologies. Several practice gaps can be identified in the care of these patients:
Care transitions have become an increasing focus in the realm of hospital medicine, and appropriately so. The Centers for Medicare and Medicaid Services (CMS) has made this a priority, largely focusing on readmissions. By introducing a financial penalty, hospital administrators have needed to view this as more than just a patient safety and quality initiative. 1Beyond readmissions, many if not most hospitals have focused on throughput as well. Throughput refers to the efficiency with which a patient moves through the hospital system – transitioning from the Emergency Department to inpatient status and on through discharge.
High-performing neurohospitalist programs will be integrally involved in the management of care transitions given their applicability to their population of patients in general, but to stroke patients in particular. The timeliness of these transitions is of significant import for patients being treated with thrombolytics or with endovascular intervention. The quality of these transitions is of paramount importance for patients with cryptogenic stroke.
Given the complexity of cryptogenic stroke, the Neurohospitalist needs to create a system of care for these patients. There are a number of ways to develop a system of care. Cryptogenic stroke needs to be identified as a diagnosis in order for the system to be established and recognized by other providers and by Internal Medicine Hospitalists and Cardiologists in particular. Once the diagnosis is made, a clear algorithmic approach is needed. Each hospital or hospital system may have a different methodology, but order sets, pathways and protocols are typically facilitated in an electronic health record (EHR).
Management of cryptogenic stroke is complex and spans both the inpatient and outpatient world. Tests may take time to process and only become available after discharge, and others may need to be done on an outpatient basis. Frequently, the inpatient providers do not have outpatient practices, and there may be limited access to neurologists or other providers in the outpatient realm or patients may not followup consistently. Consideration should be given, in those cases in particular, to performing studies that can be done appropriately during an inpatient stay, or during the transition from inpatient to outpatient. The latter may include performing a test or applying/implanting cardiac monitoring after discharge, but before a patient has left the hospital campus – such as being discharged and going directly to a cardiology clinic.
No matter the process, a clear plan needs to be established at the time of discharge. A physician contact is necessary who will be the primary point person for assuring that results are reviewed and subsequent evaluations/testing performed as needed. Involving patients and their families is ideal so that they are clear on the diagnosis and tests that are planned or pending. Written materials may be helpful in this regard. High performing neurohospitalists will make direct communication by phone with the provider who will be seeing the patient after discharge to assure there is no “voltage drop” in information after discharge from the hospital.
- Large external focus on care transitions and readmissions
- Care transitions need to be actively managed
- Identify a clear system of care
- Expedite and assure that appropriate testing is done
- Written materials for discharge
- Identify and communicate with outpatient provider(s)
- Assure that tests pending at discharge are followed up
- Cryptogenic stroke/ESUS clearly identifed in discharge diagnosis/diagnoses
- Readmission within 7 and 30 days
- Time to follow up with outpatient neurologist, cardiologist, primary care provider
- Receipt of written discharge materials
- Appropriate testing performed per protocol/algorithm – inpatient and outpatient
Judd M Jensen, MD
Neurologist Blue Sky Neurosciences
David Likosky, MD, SFHM FAAN FACP FAHA
Director of the Stroke and Neurohospitalist Programs, EvergreenHealth & Overlake Medical Centers
Medical Director, EvergreenHealth Neuroscience Institute
Clinical Assistant Professor of Neurology, University of Washington
Jana Wold, MD
Associate Professor of Neurology Director, Veteran’s Affairs Stroke
Program Director, Adult Neurology Residency
University of UtahClinical Neurosciences Center
Salt Lake City, Utah
Shadi Yaghi, MD
Assistant Professor of Neurology Department of Neurology
The Warren Alpert Medical School of Brown University
Providence, Rhode Island
Atrial Fibrillation 2016 (Management of) ESC Clinical Practice Guidelines
American Heart Association/American Stroke Association 2014 Stroke Prevention Guidelines Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236.
Gladstone DJ, Spring M, Dorian P, et al. Atrial brillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-2477.
Kamel H, Johnson DR, Hegde M, et al. Detection of atrial fibrillation after stroke and the risk of recurrent stroke. J Stroke Cerebrovasc Dis. 2012;21(8):726-731.
Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fi. N Engl J Med. 2014;370:2478-2486.
Yaghi S, Bernstein RA, Passman R, Okin PM, Furie KL. Cryptogenic Stroke: Research and Practice. Circ Res. 2017;120(3):527-540.
American Heart Association/American Stroke Association Cryptogenic Stroke Initiative.