Framing the Issue
• Every year, more than 795,000 people in the United States have a stroke.
• Stroke kills almost 130,000 Americans each year — that’s one out of every 20 deaths.
• About 87% of strokes are ischemic strokes, which block blood flow to the brain.
• Each year, stroke costs the United States an estimated $34 billion, including the cost of health care services, medications and missed days of work.
• Only 38% of respondents to a 2005 survey were aware of all major stroke symptoms and knew to call 9-1-1 when someone was having a stroke.
• Patients who arrive at the emergency department within three hours of their first symptoms tend to have less disability three months after a stroke than those who received delayed care.
When a man in his 30s suddenly went numb on one side while working out, the folks at his gym worried he was having a stroke and called 9-1-1. The emergency medical technicians rushed him to nearby Taylorville Memorial Hospital, a 25-bed critical access facility in rural central Illinois.
In the emergency department, his wife questioned whether paramedics had erred by taking him to Taylorville instead of a larger hospital in Springfield, about 25 miles away. “Our physician assured her this is the best stop,” says Gayle Hoock, R.N., the hospital’s ED manager.
The EMTs had sent a stroke alert before arrival, so the hospital staff already had activated its stat stroke protocol, cleared the CT scanner and lab, and met the patient at the door.
The staff immediately ran labs, an EKG and a CT scan. Because the stroke was ischemic — caused by a blood clot in the brain — they administered the clot-busting drug tPA. They then transferred the patient to Springfield’s Memorial Medical Center which, like Taylorville, is an affiliate in the Memorial Health System.
“By the time his wife got to the ED in Springfield, he threw both his arms in the air and said he thought she was going to take him home,” Hoock says. “The side that he was not moving at all was saved.”
The stroke preparedness exhibited by the paramedics and Taylorville Memorial is part and parcel of an effort in Illinois to create a stroke system of care. Several other states are establishing similar systems. The Centers for Disease Control and Prevention provides funding to get stroke systems off the ground through its Paul Coverdell National Acute Stroke Program. Eleven states receive funding from the program, named after a U.S. senator from Georgia who died in 2000 of a massive hemorrhagic stroke. The American Stroke Association also advocates for states to develop coordinated, comprehensive stroke systems — systems that facilitate patient access to the full range of stroke services and improve care quality.
Effective collaboration among hospitals and others
The stroke system of care concept has evolved over the past 15 years because of advances in treatment. Before federal approval of tPA in 1996, no treatment existed to reverse or limit a stroke’s damage to the brain, says Michael Frankel, M.D., chief of neurology and director of the Marcus Stroke & Neuroscience Center at Grady Memorial Hospital, Atlanta.
“Stroke was not considered a neurological emergency,” Frankel says. “It sounds stupid to even say that today, but there was no proof that anything we did helped people. We didn’t have the sense of urgency to bring people in quickly, to assess them quickly, to save the brain and, therefore, improve outcomes.”
Approval of tPA was the very beginning of the stroke system of care story, Frankel says. The CDC’s creation of the Coverdell program in 2001 helped to move things along.
Georgia was one of the first states to receive federal funding and, from the outset, its stroke registry was more than a disease surveillance program. It harnessed stroke data to drive change.
“The really neat thing about the registry is that it provides a framework for hospitals and EMS providers to come together to develop and implement practices that lead to improvement,” says Jean O’Connor, chronic disease prevention director for the Georgia Department of Public Health.
“By having all these data about these patients, we’re able to see what the outcomes look like and to understand where small changes in care can really improve the long-term outcomes for these patients,” she says.
Initially, the registry was focused on hospital treatment for acute stroke. The first priority was persuading providers to use tPA for ischemic strokes, says Frankel, lead neurologist for Georgia’s registry. “There was reluctance to change treatment paradigms.”
The second piece was to make speed a priority. Processes were changed in participating hospitals’ EDs, labs and radiology departments so that tPA could be given as quickly as possible, says Frankel, also a professor of neurology at Emory University School of Medicine.
Now the 67 participating hospitals report on 13 quality indicators, from administering tPA within 60 minutes of the patient’s hospital arrival to preventing deep vein thrombosis. Each indicator necessitates a plan to improve.
“The thing I’m most proud of in the Coverdell registry is that we’ve got 67 hospitals that openly collaborate,” Frankel says. “They share best practices, protocols and experiences. That trust and collaboration, which has taken years to develop, is because of really great people at multiple hospitals who have themselves become experts in how to improve care.”
One example is the recent collaboration on discharge instructions.
“We discovered through some of our conversations that not all the hospitals were giving stroke patients the same kind of information about tobacco cessation when those patients were discharged,” O’Connor says. “Now the stroke registry hospitals have agreed voluntarily to add that to their discharge protocols.”
Paramedic training pays off
The urgency of stroke care meant that the registry had to branch out beyond hospitals to involve the EMS community. Thanks to the collaboration among the registry hospitals, emergency medical services and the state, all Georgia EMS responders have been trained using the Advanced Stroke Life Support curriculum. EMTs know how to screen patients for stroke symptoms and determine the last time they were known to be well. The specialized training helps paramedics determine what the patient may be facing and what level of care they need.
To transport patients to the hospitals best able to care for them, paramedics need to know which hospitals are stroke-ready. That’s where stroke certification comes in.
In 2003, the Joint Commission, with the American Stroke Association, launched its Primary Stroke Center Certification program. The organizations in 2012 created Comprehensive Stroke Center certification for hospitals that offer more advanced stroke care. And in July 2015, they plan to launch an acute stroke-ready hospital certification program for small hospitals that are able to administer tPA and then transfer patients to primary or comprehensive stroke hospitals.
Typically paramedics take stroke patients to the nearest stroke-ready hospital because time is of the essence. In Georgia, the choice of hospital remains with the patient or family. “Sometimes patients want to go to the hospital where they had their gallbladder removed, but that might not be the right hospital to deal with their stroke,” Frankel says. In such cases, EMTs use their knowledge of hospital stroke readiness to offer advice.
Georgia’s work has paid off in care improvements. A 2014 Georgia Department of Public Health data summary shows that the median door-to-needle time for tPA administration in registry hospitals went from 72 minutes in 2009 to 59 minutes in 2013. The American Stroke Association guideline’s target door-to-needle time for ischemic stroke is 60 minutes. The percentage of acute stroke patients who received defect-free care jumped from 50 percent to 76.3 percent in the same period.
Hospitals step up, no matter how large or how small
State systems of care typically require supporting state legislation. In Georgia, that legislation was the Coverdell-Murphy Act, enacted in 2008. It established a two-tiered stroke system for the state — primary stroke centers and remote stroke-treatment centers, equivalent of the Joint Commission’s upcoming acute stroke-ready certification. The law also tasked EMS with administering the designation process.
In Illinois, the first law paving the way toward today’s stroke system of care passed in 2009. It created a system to identify hospitals capable of providing stroke care, and directed EMS providers to transport possible acute stroke patients to those hospitals. In August 2014, the state updated the law to formally recognize all three Joint Commission levels of stroke care certification.
The state has formed 11 EMS regions, and each was required to organize a stroke committee to develop protocols for how to handle stroke calls. The EMS is responsible for knowing which hospitals in their area have stroke designation. They are allowed to bypass non-designated hospitals, says Peggy Jones, stroke and ST-Elevation Myocardial Infarction consultant for the Illinois Critical Access Hospital Network.
Today, 122 Illinois hospitals have stroke designation, according to the Illinois Department of Public Health. Half are certified as primary stroke centers, and half are designated as emergent stroke-ready, equivalent of the Joint Commission’s acute stroke-ready.
The state has had particular success among critical access hospitals. Before the laws passed, no rural hospitals were designated to treat stroke, Jones says. Now, of the state’s 53 critical access hospitals, 51 will qualify as acute stroke-ready when the Joint Commission’s program launches, she says. Only two won’t meet the standards because they don’t have 24/7 access to stroke services.
The CAHs’ success “is very important, not only to the patient, but also to the community because it means that our rural hospitals continue to serve a great need,” Jones says. “Without serving that need, the rural hospitals could disappear, and then you’d have nowhere to go even for smaller problems than strokes.” Illinois CAHs are achieving a median door-to-needle time of 47 minutes, she adds.
The process change necessary to become stroke-ready was difficult work. “It took a lot of time and effort because people in these little hospitals do more than one job,” Jones says. And that commitment doesn’t end once the designation is awarded. Each hospital is required to maintain a stroke care quality improvement group.
At Taylorville Memorial, earning its emergent stroke-ready designation in 2014 didn’t require a lot of change because most of the required policies already were in place. Hoock had to begin keeping a log of all strokes.
The facility typically sees from one to six acute strokes a month. Hoock conducts quality audits on each case. With its stat stroke protocol, Taylorville is able to reach the goal of administering tPA within 60 minutes, she says.
Across the system
Its relationship with Springfield’s Memorial Medical Center helps. Because the hospitals are in the same system, doctors at Taylorville can teleconnect with neurologists or neurosurgeons at Memorial. They’re on the same electronic network, so the Memorial specialists can look at the patient’s CT scan while they discuss the case with the Taylorville physician.
Hoock says she benefits from the networks of hospital stroke coordinators that have emerged as part of the state’s system of care. In Central Illinois, that group is called Stroke INC. (Interweaving Network Consortium). It offers professional education, gives stroke coordinators opportunities to learn from one another, and undertakes projects.
One initiative is educating fifth-graders about stroke prevention, how to identify stroke and the importance of calling 9-1-1. “We want them to recognize the signs of stroke because so many kids live with their grandparents today that they may well be witness to their guardian having a stroke,” Jones says.
Expansion is a priority
Georgia and Illinois are working to strengthen their stroke systems of care. One priority in Georgia, located in the nation’s so-called stroke belt, is to encourage more hospitals to participate. The 67 hospitals in the registry represent about half of Georgia hospitals, and cover 80 percent of acute stroke admissions. Still, only three are remote stroke-treatment centers.
Some hospitals may be reluctant to join because of the resources necessary to meet data entry requirements and national stroke guidelines, O’Connor says, adding that many hospitals face multiple challenges in their communities and may have different priorities.
A goal for Georgia and Illinois is to expand their stroke systems of care to include post-stroke care. The task is particularly difficult because patients are discharged to a variety of settings — from home to a skilled nursing facility or rehabilitation hospital — so data can be hard to collect.
Although recovery and rehab services are available, those need to be looped into the whole stroke system, Jones says. Forging partnerships with national rehabilitation organizations, similar to how stroke systems work with the American Stroke Association, would help states move toward that aim.
“We need to work with them to find those solutions [as to] how we can make all of this fit together and work better for the patient,” she says. — Geri Aston is a contributing writer for H&HN.
What is a stroke system of care?
Many Americans don’t know the signs and systems of stroke, and some people, especially the elderly, are reluctant to call 911. To get the word out, the Illinois Critical Access Hospital Network created a community educational project, Pact to Act FAST (Face-Arms-Speech-Time). The acronym is short for facial droop/uneven smile, arm numbness/weakness, speech difficulty, and time to call 911.
The goals is for each ICAHN hospital to partner with its community to provide four stroke educational opportunities in 2015. “We talk about how time is brain,” Jones says. “We talk about how your family has a plan for a tornado or a fire, but what’s your plan if someone has a stroke?” After the session, people sign the pact.
Ten states have expressed interest in the program, developed by Jones. ICAHN is working with the Arkansas Department of Health to launch Pact to Act FAST there and, with a Chicago partner, is determining how to spread the message to the African-American and Latino communities, which have higher risk of stroke, Jones says.
Hospitals don’t respond as quickly to patients having strokes in the hospital as they do to patients with community-onset strokes, found a Canadian study published May 4, 2105, by JAMA Neurology. “It’s a bit of a paradox,” says Michael Frankel, M.D., chief of neurology and director of the Marcus Stroke & Neuroscience Center at Grady Memorial Hospital, Atlanta. It can be hard to identify stroke in patients coming out of anesthesia and in patients under sedation, he notes.
Findings: Patients with in-hospital strokes experienced a longer time from symptom recognition to initial neuroimaging, were less likely to receive clot-busting drugs, experienced longer door-to-needle times, had longer hospital stays and were more likely to be disabled at discharge. However, adjusted stroke fatality among in-hospital stroke patients was lower at seven days and not significantly different at 30 days or one year than those with community-onset stroke.
Characteristics: Patients with in-hospital stroke had higher rates of comorbid illness and experienced more severe strokes.
Location: In-hospital stroke occurred during angiography (15 percent), or during an admission for cardiac surgery (25 percent), for noncardiac surgery (22 percent), or to a medical service (32 percent). Patient location at the time of stroke was undetermined in 6 percent of cases.
Conclusion: Those with in-hospital stroke represent a distinct subgroup of patients who may require specific care pathways and whose outcomes may differ from those with community-onset stroke, regardless of care received.
Recommendations: Hospitals should develop targeted code stroke protocols for the in-hospital stroke population, similar to those used in the emergency department. Front-line staff education and step-by-step algorithm for diagnosis and treatment might facilitate rapid access to best-practice investigations and timely initiation of therapy, with a view toward improving outcomes.