Georgia Coverdell Acute Stroke Registry quarterly newsletter, 2015 Summer

Coverdell Partners:
Georgia Department of Public Health (DPH)
Emory University School of Medicine
Alliant Health Solutions-Georgia Medical Care Foundation (GMCF)
American Stroke Association (ASA)
Georgia Hospital Association (GHA)

Georgia Coverdell Acute Stroke
Registry Quarterly Newsletter
SUMMER 2015
Champion Hospital of the Year" Award Winners

Putnam General Hospital

Habersham Medical Center

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
770-380-8998

Eastside Medical Center

Emory University Hospital

St. Mary's 2015 Star Award Hospital Recipient

Coverdell Awards for Dedication and Leadership to the Georgia Stroke Professional Community

Georgia Coverdell Stroke Champion
Moges Ido, MD

Georgia Coverdell Stroke Physician Champion Michael Frankel, MD

Stroke Champion Mary Robichaux American Stroke Association
Our 2015 Individual Star Recipient has retired. Congratulations to Carol SmithPeters for receiving this prestigious recognition.
We would like to take this opportunity to thank our photographer, Nancy Mitchell. Each and every year, Nancy takes time out to capture all the Coverdell award winners. Many thanks to her.

Thank You Good Samaritan Hospital
St. Mary's Good Samaritan Hospital hosted more than 20 Georgia hospitals on May 14 at a first-ever conference to enhance stroke care across the state, especially in rural communities, by showing attending hospital leaders how their facilities can become designated Remote Treatment Stroke Centers.
Good Samaritan Hospital, the first designated Remote Treatment Stroke Center in Georgia, held the conference in conjunction with the Georgia Hospital Association, The Georgia Coverdell Acute Stroke Registry, the Georgia Department of Public Health Office of EMS and other co-presenters. Meeting at Greensboro First United Methodist Church to accommodate more than 60 attendees, the conference provided nuts-and-bolts overview of how even small hospitals can use high-tech diagnostics, telehealth systems, and other innovations to provide life-saving stroke care fast.
Since Good Samaritan achieved designation in October 2013, two more Georgia hospitals also have been designated by the Georgia Department of Public Health: Piedmont Newnan Hospital in Newnan and University Hospital McDuffie in Thomson.
"We applaud St. Mary's Good Samaritan Hospital for their commitment not only to providing excellent care to stroke victims in its own region, but to equipping other hospitals in the state with the tools to become Remote Treatment Stroke Centers," said Georgia Hospital Association President and CEO Earl Rogers. "The end result of this effort is that thousands of additional stroke victims in Georgia will receive life-saving care at the right time."
"It's a very exciting time for stroke care in Georgia and throughout the country," said Michael Frankel, M.D., chief of neurology and Director of the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital, speaking by video. "We've learned that time is absolutely critical. The longer the brain is deprived of blood flow, the greater the likelihood there will be permanent damage and, therefore, long-term disability. The quicker we can treat patients, the less likely that they will have permanent damage and the greater likelihood that they will have a good recovery."
In urban centers like Atlanta, Athens and Augusta, hospitals have transformed their stroke programs to provide care fast. The driving force is a clot-busting drug called tPA. When administered by IV, optimally within three hours of the onset of stroke symptoms, tPA can stop certain strokes in their tracks and even reverse damage.
But, according to H. McCord Smith, M.D., vascular neurologist and neuro-hospitalist with St. Mary's Health Care System, far fewer patients are receiving tPA than could potentially qualify for it. Studies show up to 30 percent of stroke patients could benefit from tPA, but nationwide, only 5 percent receive it. Even at stroke centers like St. Mary's, where stroke is treated very aggressively, tPA is given in only about 13 percent of cases.
"That's due to three issues primarily," Dr. Smith told the group. "First, patients arrive at the emergency department too late. We have a limited window of time in which tPA is effective about 3 to 4.5 hours and it takes time to stabilize the patient and complete the diagnostics needed to make sure we can give tPA safely. So if patients delay coming to the hospital, they may get to us too late for tPA to help.
"Second, many patients live too far from a primary stroke center and don't have access to tPA at their local hospital, so their transport time puts them outside the time window. And third, there just aren't enough neurologists to go around."
Georgia's Remote Treatment Stroke Center program works to address all three of these issues, Dr. Smith said.
The program has a strong educational component to teach stroke symptoms to
people in the community and urge them to call 911 immediately when symptoms appear.
To become a Remote Treatment Stroke Center, rural hospitals like St. Mary's Good
Samaritan invest in diagnostic equipment, training for staff and doctors and enhanced communications with EMS and major stroke centers. The capability means it is often possible to start tPA much earlier than if patients had to be transported to a distant primary stroke center.
To cope with the scarcity of neurologists, especially in rural areas, Remote
Treatment Stroke Centers use telehealth systems to connect in real time with neurologists in primary stroke centers. These experts use live video, audio and data links to examine patients, consult with doctors, view CT imagery and see other test results. With their consultation and collaboration, local emergency room doctors can have confidence that it is safe to administer tPA, even if there is no neurologist in their community.

Collaboration with EMS is vital, too, several presenters noted. Paramedics and EMTs can conduct tests and relay vital information, both from the scene and while in route. Their efforts allow the receiving hospital to activate its emergency department, radiology staff, laboratory staff and stroke telehealth system before the patient arrives. "Learning about our patients and how they enter our system, and how quickly they get a CT scan and how quickly we can institute thrombolytic therapy is very important," Dr. Frankel said. "A 5-minute or 10-minute reduction or certainly a 20-minute reduction in the time to treatment can make the difference between a good recovery and not a good recovery." Speaking about the experience of St. Mary's Good Samaritan Hospital, President Montez Carter noted that becoming the state's first Remote Treatment Stroke Center improved quality across the entire emergency department and related areas of the hospital. "The process brought us closer together as a team," he said. "We invested in staff training, diagnostic equipment, the REACH telehealth system from Georgia's Regents University, and collaborative processes across departments. That investment has already paid off. Now, we can not only administer tPA safely, we have built closer working ties with EMS and internally across departments, and that's good for all our patients." Expanding that collaborative spirit was the key focus of the conference itself, said presenters Shelley Nichols, Grady's stroke coordinator, and Joyce Reid of the Georgia Hospital Association. They stressed that the conference brought together the GHA, the Coverdell Acute Stroke Registry, the Department of Public Health Office of EMS, American Heart/Stroke Association and the Georgia Stroke Professional Alliance, as well as representatives from Grady Memorial Hospital, Piedmont Newnan Hospital, St. Mary's Health Care System and St. Mary's Good Samaritan Hospital. "All of these entities help to make the Remote Treatment Stroke Center possible across Georgia, not just the entities themselves but all the people who are committed to blanketing the state with excellent stroke care," Nichols said. "The Remote Treatment Stroke Center designation is very possible because there are so many willing helpers."
Presenters included, L-R: Joyce Reid, Vice President, Georgia Hospital Association Community Health Connections; Montez Carter, President St. Mary's Good Samaritan Hospital; Kerrie Krompf, Hospital and EMS Coordinator, Georgia Coverdell Acute Stroke Registry; Shelley Nichols, Stroke Coordinator, Grady Memorial Hospital; H. McCord Smith, MD, neurohospitalist, St. Mary's Health Care System; and R. Keith Wages, Director, Georgia Office of EMS and Trauma
Submitted by: Mark Ralston, Public Relations Manager - St. Mary's Health Care System

Gail Burton Fights Back From Two Strokes to Help Others Recover
As a certified nurse assistant and restorative aid for nursing home residents, Gail Burton, age 55 of Cleveland, never thought she might need care herself during her recovery from two strokes.
On May 20, 2013, Gail was at work at The Oaks Assisted Living in Baldwin. She had a small headache that just wouldn't go away. When she approached a coworker at the nurses' station for aspirin, her coworker noticed that Gail's speech was slurred and immediately called 9-1-1.
Within minutes, Gail had no movement on her right side and her headache was much worse. She was having a full-blown stroke. Habersham EMS paramedics quickly transported her to Habersham Medical Center where the emergency department team activated their specialized Primary Stroke Center response team and administered tPA, a medication that dissolves blood clots. Once she was stabilized, she was transferred to the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital in Atlanta where she spent the next two weeks recovering.
After being released from Grady, Gail underwent extensive physical therapy three-daysa-week with a home health service. And she was able to return to her job eight months after the massive stroke almost took her life.
A few weeks ago and almost two years later, Gail suffered another debilitating stroke. A large majority of stroke patients do suffer additional strokes, and fortunately for Gail, her second one was not as severe. This time she knew immediately she was having a stroke. The signs and symptoms were very clear blurred vision, a headache and slurred speech. Gail has had multiple health issues and has a history of blood clots and other risk factors that make her a prime candidate for a stroke like stress and a family history. "I told my family that they didn't have to give me this! A family picture would have been just fine," she laughs. On May 11th, Gail returned back to work part-time after recovering from her second stroke. She is currently working at Gateway Health and Rehab in Cleveland. "I still can't drive, have a small limb, and the right side of my mouth is still drawn a little, but I'm still going and thankful to get up every day. I can't wait to dance down the halls at work and drive everybody crazy!"
Surprisingly, Gail's job is to take care of nursing home residents many of whom have had a stroke themselves. As a restorative aid, she enjoys helping residents regain some of their mobility or range of motion after suffering strokes by helping them do lower and upper extremity exercises to help them be as independent as possible. "Once you have dealt with it yourself, you look at it in a whole different way. I am thrilled when one of my residents is able to walk again even with the assistance of a walker," she says. "It is very gratifying because I know how hard it is and really understand what they are going through. There were many times I wanted to give up. Now, I'm a lot more patient. I thank God I am still here to help others; even if is just holding their hand."
Gail loves working in health care and credits her coworkers and Habersham Medical Center for saving her life not just once but twice. "My coworkers quickly recognized the signs and symptoms I was having as being a possible stroke and got the help I needed immediately. My doctor told me that if I would have been at home, I would not have made it. And, the staff at Habersham Medical Center was very experienced and professional. I was in Cleveland when my second stroke occurred, but I had already told everyone that if anything else ever happened to me to only take me to Habersham."
When asked what helps her get through each day, Gail laughs and says "My stubbornness!" She is a fighter for sure. "Through it all, I'm very blessed and definitely have a new lease on life. I love working in a nursing home, but I don't want to live there! I know they would take great care of me, but I'm way too independent!"
Submitted by: April James, director of business development, Habersham Medical Center

Help Your Patients Quit Smoking Today
This article is a follow up of the June 1, 2015 Coverdell Stroke Registry conference call which focused on the Georgia Tobacco Quit Line (GTQL) and the Georgia cAARds Program (Ask, Advise, Refer with Follow-up) fax referral process. A health care provider's advice to quit tobacco use is an important motivator for tobacco users. In 5 minutes or less, you can execute the Georgia cAARds (Ask, Advise, and Refer with Follow-up form attached on last page of this newsletter) program and ensure your patients receive evidence based, best practice tobacco cessation counseling.
Ask all patients about tobacco use during each visit Advise them about the benefits of tobacco cessation Refer them to the Georgia Tobacco Quit Line for a free "Quit Kit", individualized plan
and behavioral counseling : 1-877-270- STOP Complete the Georgia Tobacco Quit Line fax Referral Form with the patient
GTQL Fax Referral Form can be downloaded from DPH's website https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/GTQL%2 0Fax%20Referral%20Form_Revised%2003-2014ERPCM.pdf
5 Sections to Complete: a. Healthcare Center/ Clinic/ Physician Office/ Hospital Information Ex. Grady/ Stroke Registry b. Select Tobacco Cessation Treatment Given: Ask, Advise , & Refer with Follow-up c. Identify Professional Designation & Contact information Ex. Stroke Coordinator's information d. HIPAA Status & Request for Patient Outcome Report e. Patient/ Client Information & Consent to release participation information
Inform the patient they will be contacted by a Georgia Tobacco Quit Like staff member within 48 hours or less
Submitted by: Kayla Lloyd, MPH, CHES, Tobacco Cessation Coordinator, GA DPH

Performance in Dysphagia Screening
Quality is a construct which is measured indirectly through various observed attributes. This is also true when we describe the quality of a clinical care. The Centers for Disease Control and Prevention adopted ten specific evidence based clinical care elements to define quality in stroke patient care.
The Georgia Coverdell Acute Stroke Registry (GCASR) and its participating hospitals are striving to provide quality care adhering to the guidelines of those ten specific components of patient care. GCASR hospitals are engaged in quality improvement activities in order to provide the best possible care to Georgians suffering from acute stroke. In our previous newsletter GCASR epidemiologist presented analysis showing that GCASR hospitals, on aggregate, reached a plateau in defect-free care.
Defect-free care is a conservative composite measure that helps to monitor the progress of the stroke care quality improvement initiative. A patient who received all the care components he or she needs is said to have had a defect-free care. Though we can't directly and entirely attribute to it, we can deduce from figure 1 that low rates of dysphagia screening contribute more to the low level of defect-free care than other performance measures.
Figure 1. Performance Measures, GCASR 2014
Figure 2 above shows Trend in Dysphagia Screening Among Pts. cared for by GCASR Participating Hospitals
Submitted by: Dr. Moges Ido, GCASR Epidemiologist

Is a follow-up call necessary for every stroke patient or is a random sample adequate?
Patient satisfaction and clinical outcomes can be improved significantly using follow-up phone calls. Follow-up calls are extremely important because stroke patients usually experience intensive care and rehab instantaneously following an event, but unfortunately care frequently fragments later on, leaving patients slightly uncertain about what's next (Darves, 2009). During follow-up calls facilities typically utilize a formal script, inquiring about treatments, symptoms and follow-up appointments. Each facility define their policy as there is currently no regulated standard in place for follow-up calls nor are there sampling requirements. If a facility decides to complete follow-up calls on a sample of the population instead of the global population, sampling specifications can be found on the Joint Commission's website. Once a protocol for follow-up calls is established within a facility, Joint Commission and DNV will evaluate to determine if that protocol is being followed. It is recommended that follow-up calls are completed within 30 days to decrease the incidence of preventable readmissions. Darves, B. (2009, October). ACP Internist, October 2009 - Collaboration key to post-stroke follow-up. Retrieved from http://www.acpinternist.org/archives/2009/10/stroke.htm
Submitted by: Sanita Floyd, GCASR QI consultant
Update on acute stroke therapeutics the future is now!
Dear Coverdell Partners,
I am thrilled to update you on the new consensus guidelines for neuroendovascular intervention in acute ischemic stroke. As you heard on our April Coverdell Conference call on 4/13/2015 from Dr. Raul Nogueira, 2015 came in like a lion, providing a flurry of positive Phase III clinical trials presented and now published. Prior to these reports, the future of thrombectomy appeared bleak. Based on multiple international clinical trials, like the definitive US-based SWIFT PRIME Trial http://www.nejm.org/doi/full/10.1056/NEJMoa1415061 that Dr. Nogueira co-authored, the benefit of thrombectomy in acute ischemic stroke is now well established. And the new AHA consensus guidelines provide a thoughtful approach to the evidence. I encourage all of you to read thru the new recommendations. Here is the link: http://stroke.ahajournals.org/content/early/2015/06/26/STR.0000000000000074.full.pdf+ht ml
From my perspective, this is particularly gratifying. Having spent my entire 23 year academic career on clinical trials in acute stroke, this moment stands out as a major triumph for the field. I was thrilled to be a part of the NINDS t-PA Stroke Trial which led to FDA approval in 1996 and subsequent consensus guidelines, serving as the basis for creating the Coverdell Stroke Registry. And equally thrilled now to have been a part of the recently published SwiftPrime randomized clinical trial of thrombectomy, one of several recent trials providing clear evidence of benefit.
As we celebrate this wonderful breakthrough moment in acute stroke therapeutics we now have the challenge of developing and implementing an effective stroke systems of care strategy to provide access to this new therapy. Timing is perfect for our Coverdell Team. The CDC is supporting the GA Coverdell Acute Stroke Registry for another 5 years. And in close collaboration with the AHA, we will be working closely with the AHA to develop a regional stroke systems strategy called Mission Lifeline-Stroke.
The cardiologists have always been one step ahead of us in coronary reperfusion. We're starting to catch up. Our organ is less forgiving than theirs so the battle is so much more challenging. But that makes the success stories, like the thrombectomy story, so gratifying.
We will continue to be challenged by defining new therapeutic approaches to improve outcomes after stroke. Thrombectomy for acute ischemic stroke is a breakthrough for sure, but there's so much more work to be done to improve the lives of our patients and the public health of our community.
I look forward to working with everyone on our Coverdell Team in this exciting era!
Most sincerely,
Michael
Michael Frankel, MD Lead Neurologist for the GA Coverdell Stroke Registry, mfranke@emory.edu

The Future of Coverdell
It has been stated that "Time flies when you're having fun." In Georgia, we must have been having a lot of fun. It's hard to believe that the Georgia Coverdell Acute Stroke Registry (GCASR) has received continued funding from the CDC for over 14 years. The GCASR has been funded by the Centers for Disease Control and Prevention (CDC) since 2001, growing in size from 26 to 66 participating Georgia hospitals. Despite the progress achieved in the last 14 years, much work remains to address this public health burden of stroke in Georgia. The foundation for this work has been established through strategic planning, extensive educational programs, strong partnerships, and a cohesive staff. We are pleased to announce that GCASR has received an additional five years of funding from the CDC.
In our next five years of funding, GCASR will address the Georgia stroke burden by continuing its core quality improvement activities with the participating hospitals, while expanding activities related to the pre-hospital and post-hospital periods. Pre-hospital activities will include raising Georgians' knowledge of stroke signs and symptoms and calling medical assistance through 911, maintaining and improving the delivery of evidence-based stroke care by strengthening existing partnerships between EMS and stroke hospitals and training EMS personnel on identifying stroke attack and alerting hospitals when en-route. GCASR will assist in building relationships between stroke hospitals and home health care agencies and rehabilitation facilities. The GCASR staff will make data-driven quality improvement a culture in stroke care. Finally, GCASR plans to expand its reach to geographic areas of Georgia not covered , as well as recruit at least 31 additional EMS agencies, 8 rehabilitation facilities, 8 home health facilities, and 2 primary care practices to provide data on stroke patients.
In order for us to accomplish our goals a strong Stroke System of Care (SSOC) would need to be in place. With the addition of the rehabiliation and post-hospital component to our pre-hospital and hospital model, Georgia would finally have a true SSOC. But in order for this system to work all of us must play our part. The past and future accomplishments of GCASR are due to the strong collaborative partnerships with each and every one of you. We look forward to working hand in hand with all our partners as we continue our fight against stroke. This work could only be done with your continued assistance and support. Thank you for all we have accomplished and will accomplish, you make Georgia a fun place to be.
Submitted by: James Lugtu, QI Director, GCASR
Georgia Stroke Net Clinical Trial-Telerehealth
Dr. Steve Wolf, a physical therapist and internationally renowned expert in neuroscience, is leading a new Georgia StrokeNet clinical trial. The study is NIH funded and testing the effectiveness of a novel home-based telerehealth system designed to improve motor recovery and patient education after stroke (https://clinicaltrials.gov/ct2/show/NCT02360488). Candidates with arm motor deficits 4-20 weeks after an ischemic stroke will be randomized to receive 6 weeks of intensive arm motor therapy (a) in a traditional in-clinic setting or (b) via in-home telerehabilitation (rehabilitation delivered to the participant's home via an internet-connected computer. The intensity, duration and frequency of this therapy will be identical across the two groups, with participants in both treatment arms receiving 36 sessions (18 supervised, 18 unsupervised), 80 minutes each, over 6 weeks. If you are interested in learning more about the study, please contact Aimee Reese at aimee.reiss@emory.edu. For information about the Georgia StrokeNet, please contact Kiva Schindler at kiva.m.schindler@emory.edu or go to https://www.nihstrokenet.org/the-network/about-us/georgia.
Coverdell Highlights
June Conference Call Thank you to Brittany Taylor, Cardiovascular Health Program Manager at the Department of Public Health and Kayla Lloyd, Tobacco Cessation Coordinator at the Department of Public Health for presenting on "A Million Hearts" program and how Coverdell is planning to align with the program. It was an extremely informative presentation and we look forward to collaborating with both of them in the coming years.