My name is Vishal Jani. I am a vascular and interventional neurologist who completed a residency and fellowship training from Michigan State University. In 2016, the standard of care for stroke treatment was changing throughout the globe because of the American Heart Association’s level 1 data. Most institutions were looking to establish a new stroke and neuro-endovascular program. During my interview at Creighton School of Medicine/CHI Health Hospitals, I was introduced to the their vision for the state of Nebraska. The CHI Health in Nebraska consists of 14 hospitals of various sizes predominantly focused on primary care with an academic teaching tertiary care center. Despite being one of the largest health systems in the nation, the stroke care protocol was limited to 24 hours of CT brain scan with less than 0.1% of rtPA administration rate and almost 0% thrombectomy or any endovascular aneurysm coiling. This was the care provided in the total 2100 stroke cases a year in our health system.
Dr. Vishal Jani
Creighton University School of Medicine / CHI Health
I accepted this challenge and my first task was to initiate a conversation with Nebraska’s Department of Health and Human Services (DHHS) for establishing a stroke system of care. The Nebraska legislative bill LB722 for a stroke system of care was introduced and passed, focusing on triage, transfer, and treatment.
Next, there was work with the State Emergency Medicine Board to prepare transfer and triage protocols to serve the 4000-plus stroke patients at every level of care throughout the state.
A third task was to align the “5A’s” needed for any successful physician’s practice. My chairman, Dr. David Kaufman, taught me those 5As during training: available, affable, ability, affordable and accountable. This was a part of the 24/7 TeleStroke/Telephonic Stroke coverage in every emergency department throughout the state and involved setting up a transfer center staffed by ICU nurses with a single hotline number and synchronized air transport; stroke and neuro-endovascular feedback loop and educational videos for all health care providers; utilizing a financial and length of stay dashboard for administrative leaders; and creating a system stroke committee and system stroke matrix maintained by statewide stroke navigators who are our best ICU stroke champion nurses.
The last task was surveillance. My health system, CHI Health, was one of the early adopters of AI technology at its beginning. Artificial Intelligence software to detect large vessel occlusion and cerebral hemorrhage was installed in every CT scanner in our state’s health system to allow for automated identification of suspected large vessel occlusion strokes on CT angiogram imaging and CT perfusion with real-time activation.
This was the beginning for statewide stroke care that matched the national standard. I was committed to creating a cohesive clinical team with a commitment of a higher standard of clinical services. The mentorship of department chair and neuroscience director, Dr. Sanjay Singh, taught me how to navigate through this process. The program excellence was recognized by the Joint Commission when it was certified as the country’s fourth thrombectomy-capable stroke center in April 2018.
In the last 24 months, our total stroke volume has grown by 150%, and transfer rates have increased by 200%. At the present, IV rtPA administration has increased from 0.1% to 21%, and the treatment rate for emergent large vessel occlusion from 0% to 4%. This has occurred among the total 2100 stroke patients in the health system.