Abstract TP404: Transforming From a Primary Stroke Center to a Comprehensive Stroke Center

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Background: St. Luke’s Baptist Hospital (SLBH) received certification as a Primary Stroke Center (PSC) in 2009. In 2015 a plan to achieve Comprehensive Stroke Center (CSC) certification was developed. This certification establishes SLBH as a Center of Excellence that provides a wide range of interventional treatments for the management of complex stroke patients. The purpose is to describe the transformation process from PSC to CSC.

Methods: Medical Director and APN Stroke Coordinator were appointed to provide program oversight. Gap analysis assessed the requirements for CSC. This led to additional order sets, screening tools, performance measures, staff education and a protocol to manage multiple complex stroke patients. Post hospital follow up was initiated. A dashboard kept the team on task with increased CSC requirements and performance measures. CSC purpose, opportunity, short and long term program goals and CSC team roles were defined. Order sets and forms were revised to include ICH reversal, stroke severity scores and depression screening and were approved by the Stroke Committee, CSC Medical Director, Quality, and Medical Executive Board Committees. A CSC kickoff, highlighting the differences between PSC and CSC, was held to inform all hospital staff of this initiative. To further improve effectiveness and success in this CSC endeavor, rehabilitation, case management, pharmacy, dietary, community outreach and an EMS representation were added to the stroke committee.

Results: Intense coordination of all components and requirements resulted in certification as a CSC. SLBH is the first stroke center to achieve CSC certification in San Antonio, Texas.

Conclusion: With the support and commitment of hospital administration, resources were provided for successful attainment of a CSC Certification. Passionate work, a focused goal and a joint effort enabled SLBH to obtain certification readiness in 6 months. Front line staff involvement, stroke committees, multidisciplinary team collaboration, and administrative support are imperative for successful CSC certification.

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