Coverdell Partners: Georgia Department of Public Health (DPH) Emory University School of Medicine Georgia Medical Care Foundation (GMCF) American Stroke Association (ASA) Georgia Hospital Association (GHA) If you have anything you would like included in an upcoming newsletter or have achieved recent recognition in the area of stroke, contact: Kerrie Krompf kkrompf@emory.edu or 404-616-8741 Georgia Coverdell Acute Stroke Registry Quarterly Newsletter FALL 2012 EXCITING NEW COLLABORATION FORMED BETWEEN GCASR AND GEORGIA'S EMERGENCY MEDICAL SERVICE (EMS) COMMUNITY The exciting collaboration between the Georgia Coverdell Acute Stroke Registry (GCASR) and Georgia's Emergency Medical Services Community is continuing to solidify and spread across Georgia's ten EMS Regions. This statewide effort actually began over a year ago with several initiatives identified as critical to positive outcomes for patients transported to facilities by ambulance. The primary goals established at that time were: To smooth the transition of care between EMS and hospitals; To improve patients' quality of care and short and long term outcomes; and, to enhance data collection and evaluation, specifically of prehospital data. One of the first efforts of a hospital to reach out to EMS providers occurred in the spring of 2011 when Southern Regional Health Services gave a presentation to EMS providers introducing Target Stroke and discussing ways EMS could assist in lowering door-to-needle (DTN) time. That was quickly followed by educational offerings across the state including a series of one-day seminars named "Link by Link: Focusing on Stroke Care in Georgia." Although the meetings were open to anyone with an interest in stroke care, they particularly targeted EMS providers. Dr. Nojan Valadi, Medical Director of the Cerebrovascular Disease and Stroke Program and Chief of the Department of Neurology at Columbus Regional Healthcare System, was the keynote speaker at many of these events. According to Georgia's Coverdell Murphy Act (SB 549) as passed by the General Assembly, "The department shall adopt or develop a sample stroke triage assessment tool. The department shall post this sample assessment tool on its website and distribute a copy of the sample assessment tool to each licensed emergency medical services provider no later than December 31, 2008. Each licensed emergency medical services provider shall use a stroke triage assessment tool that is substantially similar to the sample stroke triage assessment tool provided by the department." The State Office of EMS (SOEMS) and the EMS Medical Directors Advisory Council (EMSMDAC) moved quickly to adopt the Cincinnati Stroke Scale. Once that was done, Dr. Valadi, working in concert with the SOEMS and EMSMDAC, proposed some slight modifications to the document which would provide the destination hospital with more accurate patient information. In July 2012, the Georgia Coverdell Steering Committee announced "The Next Phase of Coverdell: Collaboration with EMS." Words cannot express how thrilled and honored the EMS community was to learn this news and to be a part of this collaboration. Keith Wages, State EMS Director, remarked at a recent EMS gathering, "The decision by the Coverdell team to focus on collaboration with EMS represents one of the most significant opportunities in the history of our EMS system. For many years, Georgia's hospitals and physicians have worked tirelessly to improve stroke care throughout the state, and now EMS has an opportunity to be a valuable contributor to that effort. I extend my sincere appreciation to Lydia Clarkson, Kerrie Krompf, and the entire committee for their dedication to improving stroke systems of care and for their support and inclusion of EMS in this wonderful opportunity. We are also very proud of the EMS community for the enthusiasm with which they have responded, and we look forward to great accomplishments in the future. " As an initial phase of the collaboration, the Office of EMS provided the Coverdell Team with a list of EMS agencies that are designated as 9-1-1 Zone Providers in Georgia. Over the past few weeks, a team, led by Kerrie Krompf, has been contacting those agencies to discuss in detail the work they are doing, and the EMS community has responded very positively to the proposed initiatives. While there is much work to be done and many challenges ahead, the EMS community welcomes the opportunity to work with our hospital partners to make Georgia's Stroke System the best in the nation. Submitted by: Sam Cunningham, Regional EMS Director for West Central Georgia, and Keith Wages, Director of the Office of EMS and Trauma, Division of Health Protection, Georgia Department of Public Health EMS: Our Community Partners We are all looking for new and better ways to work with our EMS partners. There are some great opportunities for education and collaboration, and here are just a couple of things that we are working on at Grady. Communication and Handoff in the Emergency Room Advanced notification is so important to hospitals, but do our EMS partners know why? Studies have recently shown that advanced notification leads to "improved evaluation, timelier stroke treatment, and more eligible patients treated with tPA," but EMS is currently calling ahead on only 2/3 of patients nationally (Lin et al, 2012). If we work with our EMS partners on the "why", and help them to create protocols to include advanced notification, we can benefit the remaining 1/3 of patients. In turn, we have to give them the courtesy of being ready and waiting to treat their patients when they do call ahead. At Grady we are changing our workflow to include a medic who will answer the EMS radio at the triage desk 24/7. We have also implemented a triage form that will prompt the medic to ask incoming EMS a specific set of questions for stroke patients. That form will stay with the patient, with the goal of enhancing communication. Offering to review your EMS partners' protocols provides a great opportunity for education and collaboration. It allows for clarification of each provider's abilities and limitations with regard to patient transport and treatment. It also gives us the chance to educate EMS partners on our own ED protocols, and solicit feedback on how those processes are working. Coverdell is working with hospitals and the State Office of EMS to create an interfacility transport protocol so that we can all work with our EMS partners to transport our post tPA patients safely. Patient feedback Patient feedback is critically important to our EMS partners but the challenge is figuring out how best to do that. The review and feedback is not only useful to our EMS partners, but can be very useful to us as well. By tracking the patients that come in as a stroke, and more importantly those who do not come in as a stroke, we can identify opportunities for education that we might not otherwise recognize. At Grady our goal is to provide feedback on every patient who comes in as a stroke, and we work toward that goal daily. Realizing that is not feasible in many places, here are some suggested ways to provide feedback. Identify a point person at each of your EMS providers so that you can send a quick update. This can be accomplished with a brief phone call, or the use of a standardized template. Coverdell also recognizes how important the feedback loop is, and is working to create a template for statewide use. Try to utilize your current resources in a way that matches your objectives with EMS. For example, there may be other service lines in your organization that already have a collaborative relationship with EMS, and you can make it a joint effort. If your stroke volume is too overwhelming, perhaps send updates only on tPA or interventional patients. Another consideration is to provide feedback on patients who came in with a stroke mimic and use that as an educational opportunity. Scheduling a once monthly meeting to review all patients face to face might be the best way to accomplish your objective. GWTG data is at your fingertips! Create a report that will download all of the relevant data points and use that to work off of. It will take some time up front, but can save a lot of time on the back end. In closing, we have great momentum going right now across Georgia. Working together to achieve some level of standardization with our EMS providers throughout the state has potential implications for improved patient care that will ultimately be reflected in our patient outcomes. References: Lin C, et al. Emergency Medical Service Hospital Prenotification Is Associated With Improved Evaluation and Treatment of Acute Ischemic Stroke. Circulation: Cardiovascular Quality and Outcomes. 2012 Jul 1;5(4):514-22. Submitted by: Amy Perez, Stroke Coordinator, and Kerrin Connelly Outreach Manager, Grady Health System Georgia Stroke Professional Alliance Pictured above from left to right: Liz Peters, Nancy Mitchell, Tessie Saethang, Debbie Camp, Kerrin Connelly, Catherine Whitworth and Amy Perez "Strike Out Stroke" was a huge success at the Braves last home game of the 2012 season on September 30rd. Because of the genuine commitment of the GA-SPA members to support education and community outreach, many members and their families came out to support the effort. There were baseball fans that were told for the very first time about how to recognize the signs and symptoms of stroke along with how to prevent one. There were those who shared with us the impact of stroke from their own personal experiences. FAST cards, magnets, and t-shirts, along with AHA/ASA stroke educational facts were distributed. Amy Perez provided an awesome interview with the Braves media that was featured on the Jumbotron prior to the game telling everyone in the stadium the importance of recognizing a stroke and calling 911; Kerrin Connelly's son, Patrick, told the fans it was time to "Play Ball." We wore our "Strike Out Stroke" shirts proudly and educated many people while having a lot of fun with family and friends. If you didn't have an opportunity to be there this year we hope this is the start of a tradition to make this an annual event so you can come and join us next year! GO BRAVES, let's all do our part to "Strike Out Stroke"! Submitted by Debbie Camp, Stroke Coordinator, Atlanta Medical Center; on behalf of the Georgia Stroke Professional Alliance National EMS Recognized by Patient's Family The following letter was sent to National EMS by a stroke patient's daughter. Thanks to all the EMS providers in Georgia for helping to make a difference in a patient's life. This letter has not been edited. Hi Benny, It's Brooke. I am not sure if you remember me but my daughter (Erin Eskew) cheered and played softball with Abbey when they were 4 and 5 years old. This past Friday, my dad (Bob Callaway) had a major stroke at his home in Conyers and luckily my mom was home at the time. The EMT's arrived shortly after calling 911 and they were awesome. I was so very impressed with the professionalism and the decision that they made to have my father flown by helicopter to Grady so that he could get the best possible stroke care available. My dad was in very bad shape (paralysis on left side of body) when he arrived to the Grady E.R. Grady was able to administer the tPA drug immediately and the neurology team was available to perform a cerebral angiogram to break up and extract the blood clot in his brain. The results were amazing and my dad regained use of that side of his body right after the procedure. The doctors at Grady's Marcus Stroke Center were very clear in making sure that we understood that it was the EMT's that saved his life and/or prevented major disabilities. My dad is now home and it looks like he appears to be on his way to a full recovery with no limitations or disabilities. I can't say enough how thankful I am for all the efforts of the EMT's. I would like to do something for the team that helped my dad. Would you be able to help me figure out when they would be working so that I could do something for them. The call was this past Friday (9/28) around 4:00pm. I think one of the guy's name was Josh. Please let them all know what an excellent job they did and that Grady Hospital acknowledged that it was their efforts that saved my dad's life. Thank you for your service and commitment to our community. You all are amazing! Brooke National EMS has always been committed to getting all patients to the right place at the right time, and we are confident that the partnership between Coverdell and the EMS community will significantly enhance the system of stroke care statewide. We work very closely with the hospitals in our service area and recognize the importance of responding in the same manner as a 911 call to transfer the stroke patient from one hospital to a Primary Stroke Center. National EMS is proud to work with the State Office of EMS and help the Georgia Coverdell Program continue to be so successful. Submitted by: Benny Atkins, Chief Operating Officer, National EMS Medical Center of Central Georgia On 8/13/12 at approximately 8:11 am, a patient presented to MCCG's ER with slurred speech and right-sided weakness that initially began at 5:45 am when he woke up. While preparing to shower, he felt "a little weak" but nothing out of the ordinary. It was at the table while eating breakfast that he began to "feel funny" on his right side. However, he was still able to get ready for work and leave his home. While driving to work, the patient began experiencing more severe weakness and decided to pull over and call an ambulance. He had an initial National Institute for Health Stroke Scale (NIHSS) of 9 (slight facial droop, right arm flaccid, right leg weak, moderate dysarthria and upper extremity ataxia) on arrival to the ER. The goal of administering thrombolytics is within 60 minutes of the patient's arrival to the ER in order to "save the brain" and limit the amount of permanent loss of function as much as possible. When the patient arrived in the ER, a "code stroke" was called and many disciplines responded to ensure the patient got the tests, scans, and physician evaluation needed in order to make a decision about how best to save his brain. The staff was able to administer tPA and the patient left MCCG 3 days later with no complications, no significant cognitive or physical deficits, and requiring no rehabilitation. Without the expertly trained stroke team of nurses, doctors, radiologists, speech and physical therapists, rehab consults, discharge planners, and an in-house stroke coordinator, the patient could have easily been left without use of his arms and legs and brain. This highly trained team quickly assesses the patient, rushes to have a CT scan of the brain and lab work and an evaluation for stroke protocols. As soon as it is determined that the patient has had a stroke and is a candidate for tPA, it is given under the supervision of this specially trained team. Afterwards, the patient is monitored and assessed for complications and the need for therapy. Specialized education and support is given to the patient and family in order to make the transitions and decisions easier for all involved. The important thing to know when anyone experiences the signs of a stroke is to get to the hospital or call 911 ASAP. Delaying doing this can result in the possibility of not receiving the clot busting drug to save the brain function. There are only a few hours from the time the symptoms start until the drug can be given. Even if you are unsure if it is a stroke, let the experts make the determination. Submitted by Jeremy Mills, Stroke Coordinator, Medical Center of Central Georgia South Georgia Medical Center South Georgia Medical Center in Valdosta, Georgia received the Get With The GuidelinesStroke Bronze Achievement Award. SGMC's receipt of this bronze-level award signifies the achievement of 90 consecutive days of high quality stroke care based on the guidelines of the American Heart Association/American Stroke Association. Within the period from December 1, 2011 to February 29, 2012, SGMC achieved an average of 98.3% against seven different achievement measures set out by the AHA/ASA. SGMC is the only hospital in South Georgia to receive this award. Since SGMC Stroke Program began in July 2011, 380 stroke patients have been treated and 38 public education programs have been presented in Valdosta and surrounding areas by Dr. Brian Dawson, Stroke Program director. SGMC will be eligible for the Silver award, which recognizes guideline achievement for 12 consecutive months, at the end of this year. Submitted by: Judy Warren, Stroke Coordinator, South Georgia Medical Center Augusta Area Hospitals and EMS Providers Join Forces to "Strike Out Stroke" On September 1st volunteers from Augusta area hospitals and EMS agencies came together to "Strike out Stroke" at the Augusta Green Jackets baseball game. Magnets and stroke educational materials were passed out to all who entered the gates of the baseball game. Free blood pressure measurements were offered at several stations during the game. Augusta Mayor Deke Copenhaver declared September 1st Augusta Stroke Awareness Day to commemorate the importance of the occasion. Mary Morrison, a morning news anchor for ABC- News 6 is a stroke survivor who received care from a local hospital two years ago. She threw out the first pitch of the baseball game surrounded by the group of volunteers. Mary also completed a special news report that was aired on Sunday. In the special report on stroke she interviewed a local flight nurse who discussed the signs and symptoms of stroke and the importance of calling 911. She also interviewed a game attendee who was receiving a blood pressure screen about the importance of knowing your personal risk factors for stroke. The event was a huge success and plans are in the works to repeat next season! Submitted by: Holly Hula, Stroke Program Coordinator, Georgia Health Sciences Medical Center Coverdell Highlight October Conference Call We would like to thank Dr. Michael Frankel, Lead Neurologist for the Georgia Coverdell Acute Stroke Registry, for facilitating the October 1st call on "Transfer of Protocols." Lots of great discussion resulted from the call and since that time a "Transfer of Protocol" subcommittee has been established and they are meeting regularly to discuss the protocol. Thank you to Dr. Frankel and all those that agreed to be on the subcommittee. Coverdell Q-Tip (Quality Tip) In Japanese it is called Kaizen, in English it is called "improvement" or to "change for the better." Over the last few months I have had the privilege to visit many of our Coverdell facilities' stroke programs. I am very proud at how well our facilities are doing in quality improvement (QI) and process improvement (PI), and this is evident in the patient outcomes and satisfaction. Despite our great strides as a whole, quality improvement is a never-ending process. No matter how well we are doing, we can always improve; it is the nature of QI. With that in mind, I encourage each and every one of our Coverdell facilities to review their current QI and PI plans. Have you updated recently? Have you successfully accomplished your QI goals? Do your goals need to be revamped, perhaps by trying new interventions? Remember that QI is a cycle: the more you "cycle," the closer you will get to your QI goals. As our environmental friends like to say, "Recycle, make it part of your every day cycle." If you have specific QI issues you'd like to discuss, please contact the GCASR team! Submitted By : James Lugtu, QI Director for the Georgia Coverdell Acute Stroke Registry For more information about the Georgia Coverdell Acute Stroke Registry, contact Kerrie Krompf at: kkrompf@emory.edu or 770-380-8998.