Treating stroke is a team sport.
Numerous studies show that multidisciplinary teamwork produces better quality of care and reduces mistakes, which is why teamwork is increasingly receiving top priority in research about healthcare delivery systems.
The positive impact of teamwork on performance is manifested in all areas of healthcare, but it is particularly powerful in an emergency such as stroke where every second counts. Every Angels award-winning hospital knows that it is a team effort that delivers the best patient outcomes – and in this Lenmed Ethekwini Hospital and Heart Centre is no exception.
There is however something exceptional about the stroke team at this Durban hospital that recently became the first private facility in South Africa to meet the requirements for a WSO Angels Award. It’s that teamwork in this instance doesn’t only stretch across several medical disciplines and specialisations as it should: it also spans the management hierarchy all the way to the top.
Take a meeting of the stroke committee, for example, that takes place once a month and is chaired by neurologist Dr Zaynah Dangor, with the support of Dr Mohammed Khan, neurologist. It is a multidisciplinary gathering of clinicians including neurologists, neurosurgeons and emergency doctors, the clinical programme coordinator, Samantha Myles, nursing and unit managers, specialists in post-acute care and rehabilitation, practice managers from radiology and pathology, the pharmacy manager, and representatives of the ambulance team.
Also in attendance: the hospital CEO Niresh Bechan as well as, by invitation, the group chief medical officer Dr Nilesh Patel, group clinical governance manager Deena Naidoo and the group quality systems specialist, Samantha Hall.
In stark contrast with hospitals whose stroke teams struggle to secure management support for changes needed to optimise the stroke pathway, at Lenmed Ethekwini Hospital and Heart Centre improving stroke care is already on everyone’s agenda. In fact, Niresh Bechan says, “the stroke programme is our passion”.
Passion at this hospital is ambition turned into action, but there is also a sense in which passion is personal. It springs to mind when Niresh, acknowledging his hospital’s gold award at Angels Day in Johannesburg early December, shares a personal story about the impact of his grandfather’s stroke on his family and himself. And he’s not the only one in the team for whom passion is an energy that comes from the heart.
Clinical programme coordinator Samantha Myles was a first-year nursing student when she heard her grandfather speak for the last time before a stroke robbed him of both speech and mobility. And it wasn’t just the desire to understand how the brain works and unravel its many mysteries that drew Dr Dangor to neurology. Seeing her Parkinsons-stricken grandfather deteriorate in his final decade influenced both her choice of speciality and her drive to “do more and be better”.
Lenmed Ethekwini Hospital and Heart Centre was established in 2008. It is part of the Lenmed Private Hospital Group that traces its history to 1984 when the first Lenmed Clinic, now named Ahmed Kathrada Private Hospital, opened its doors in Lenasia outside Johannesburg. The hospital thrombolysed its first stroke patient in 2010, well ahead of the majority of hospitals in South Africa, and went on to become a landmark in cardiac care. The only hospital in KwaZulu-Natal that offers paediatric cardiac surgery, and the first in Africa to be accredited by the American College of Cardiology, Lenmed Ethekwini Hospital and Heart Centre performed its first heart transplant surgery in 2008
A formal partnership with Angels in 2018 marked the start of a structured programme to improve its stroke care by means of training and protocol revision, and from March 2022 this programme was pursued with fresh vigour. The stroke committee was formed in July. In September, a team comprised of Dr Nilesh Patel, Deena Naidoo, Samantha Hall and Samantha Myles went on a field visit to Steve Biko Academic Hospital in Pretoria, the first hospital in South Africa to win a WSO Angels diamond award largely thanks to the ingenuity of neurologist Dr Louis Kroon.
The real game changers however have been two actions that directly impacted the stroke pathway by identifying opportunities for improvement. One was a recent simulation that delivered consensus around commencing thrombolysis at CT, and the second an earlier decision to capture their patient data in the stroke care quality improvement registry, RES-Q, through which they became eligible for a WSO Angels Award.
As a hospital group that positions itself as a provider of market-leading clinical outcomes, Lenmed’s leaders are fluent in the language of data-driven improvement. Lenmed Group Clinical Governance Manager, Deena Naidoo, recites stroke data for January to October 2022 as if from memory: 198 cases were registered in RES-Q, of which 99 were TIAs, 35 stroke mimics and 39 ischaemic strokes, along with 8 cases of subarachnoid haemorrhage and 3 of cerebral veinous thrombosis. Samantha Myles, the clinical programme coordinator who is responsible for the on-the-ground management of the stroke programme, has performance metrics at her fingertips: since partnering with Angels, her hospital has reduced its median door-to-needle time from 80 minutes to 27, and almost tripled its recanalization rate from 14,3 to 33 percent.
These are numbers far exceeding the requirements for the gold award that put the team on the stage at in Johannesburg this December. They already feel like a diamond hospital and are determined to make it official – an ambition that is supported by the integration of evidence-based guidelines into routine hospital practice and adherence to all but one of the key priority actions identified by Angels.
Pre-notified is standard, following which the team is rallied via a stroke alert Whatsapp group. Although the patient isn’t delivered directly to CT, they spend a maximum of 15 minutes in the emergency department, where point-of-care testing is available for glucose and INR. Once the therapeutic decision is taken, treatment commences at CT.
But the strongest signal yet that this hospital will continue its improvement journey is that it has created a culture and systems that enable it to learn from mistakes.
The stroke committee meeting is an opportunity for feedback and learning, Niresh says.
On the agenda is a case review for which they select a patient with the most gaps in their journey, in order to impact future performance.
The same learning focus determines the agenda of the weekly multidisciplinary meeting attended by neurologists, allied specialists and the nursing team, and coordinated by Samantha Myles. There is nothing punitive about these case reviews. Instead, the foundation is set for future success by creating a safe zone where failure is a teacher.
At Lenmed Ethekwini Hospital and Heart Centre, improvement is the goal and teamwork the key, but it’s the willingness to scrutinise their own performance that truly makes them stand out. As Niresh Bechan says, “Every opportunity is used to learn to be better and do better”.