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 770-380-8998 Georgia Coverdell Acute Stroke Registry Quarterly Newsletter WINTER 2015 Georgia Coverdell 2015 Awards "Georgia Coverdell Champion Hospital of the Year" Award Winners CONGRATULATIONS TO THE FOLLOWING 4 HOSPITALS: Putnam General Hospital (very small hospital, 25 beds or less) Habersham County Medical Center (small hospital, 26100 beds) Eastside Medical Center (medium hospital, 101350 beds) Emory University Hospital (large hospital, over 350 beds) All Georgia Coverdell hospitals have the opportunity to receive next year's award, which is based on a point system. A total of four hospitals receiving the most points during the period from January 1, 2015 through December 31, 2015 will be next year's recipients. The award is a certificate to share with your hospital and hospital administration. The point system is based on the following criteria: Participation Hospital attendance on GA Monthly Coverdell Call Hospital presenting on GA Monthly Coverdell Call Physician Champion presenting on GA Monthly Coverdell Call Published Q-Tip in Coverdell Quarterly Newsletter Published Article in Coverdell Quarterly Newsletter Published "Blurb" (250 words) in Coverdell Quarterly Newsletter Published Stroke Survivor Story in Coverdell Quarterly Newsletter Workshop attendance (per hospital) Points Allotted 1 5 10 5 10 2 10 5 In the event that multiple articles, blurbs, stroke survivor stories, Q-tips, etc. are submitted for publication and space is not available, the Coverdell Steering Committee will review all submissions and decide what is published. All submissions will be eligible to appear in future publications. 25 points will also be awarded to one hospital in each bed size category achieving: Highest percentage increase in defect free care For defect free care we will compare the period of April 1, 2014 September 30, 2014 to April 1, 2015 September 30, 2015. If a hospital has six consecutive months from April 1, 2015 September 30, 2015 of meeting 85% performance or higher on defect free care they will automatically receive the allotted points. Georgia Coverdell Announces the 2015 "Door to Needle Time" Hospital Award Winners and is Raising the Bar for 2016 to < 45 minutes Door to Needle Time (DTN) is the Golden Hour (60 minutes). This award is given to all hospitals that have shown a 20% decrease in door to needle time, comparing 2013 data to 2014 data based on data entered by the time of analysis. In addition, the award is given to any hospital having entered a minimum of 5 patients in 2014 with an average door to needle time of less than 60 minutes. For next year we are raising the bar: This award will be given to all hospitals that have shown a 20% decrease in door to needle time, comparing 2014 data to 2015 data based on data entered by the time of analysis. In addition, the award will be given to any hospital having entered a minimum of 5 patients in 2015 with an average door to needle time of less than 45 minutes. Hospitals improving door to needle time by 20% AND with an average door to needle time of < 60 minutes Hamilton Medical Center - Dalton Redmond Regional Medical Center Rome St. Joseph's Hospital Savannah Wellstar Kennestone Hospital Marietta Hospitals with an average door to needle time of < 60 minutes Athens Regional Medical Center Athens Atlanta Medical Center Atlanta Emory Saint Joseph's Hospital - Atlanta Emory University Hospital-Atlanta Floyd Medical Center - Rome Grady Memorial Hospital-Atlanta Gwinnett Medical Center - Lawrenceville Midtown Medical Center Columbus Navicent Health - Macon Piedmont Henry Hospital Stockbridge South Georgia Medical Center- Valdosta Southern Regional Medical Center - Riverdale Hospitals improving door to needle time by 20% Piedmont Hospital-Atlanta Piedmont Fayette Hospital - Fayetteville St. Francis Hospital - Columbus Once again, congratulations to all of the above hospitals for showing great improvement in reducing Door to Needle time. Georgia Coverdell Announces the 2015 "Star Award" Recipients Congratulations! The "Star Awards" recognize an individual and a hospital for leadership in the GCASR. The award recipients were nominated by their colleagues. We want to recognize people and facilities that have changed and continue to change stroke care in the state of Georgia. The awards are in appreciation for the mentoring, support, and passion that our Coverdell hospitals and staff provide to the registry. We received an overwhelming number of submissions and we want you to know that the voting process took place by an independent team of reviewers not affiliated with the Georgia Coverdell Acute Stroke Registry. We will continue to offer these awards again next year. Individual recipient: Carol Smithpeters RN "is the Stroke Program Manager at Piedmont Fayette Hospital (PFH). Carol has been a Stroke Program Manager for 5 years and has been diligently working on obtaining Stroke Certification for her hospital which was recently obtained in May 2014. Since the certification PFH has doubled in volume the number of stroke patients that they are now seeing and she continues to work enthusiastically to assure they receive quality care. She has been instrumental in stroke education for the hospital staff, community and EMS Partners. She has supported PTC EMS in obtaining ASLS for their Fire and Paramedics. Recently Piedmont Healthcare added 3 new Stroke Managers at the different Piedmont facilities and she has been instrumental in mentoring them for success in their respective positions. She has maintained the stability for the system, updating stroke guidelines and best practices. Her passion for the patients to receive the right care at the right time is always evident as she responds to stroke alerts and evaluates processes. These are only a few reasons she is a candidate as a Star Award nominee." "Carol Smithpeters has given her all over the last few years to stroke at Piedmont Fayette Hospital". In addition, to working with the hospital and stroke team on Primary Stroke Center Certification, she has been one of a handful of Georgia ASLS instructors and is always willing to teach the ASLS Instructor Class" It's Carol's commitment to stroke and the community that makes her deserving of the Georgia Coverdell Individual Star Award." Hospital recipient: St Mary's in Athens "is a community hospital who has always been a beacon in the night, a faith based facility with a mission of being a healing presence in the community. They have been providing exceptional stroke care for many years. They became a certified Joint Commission Primary Stroke Center in 2004 and the first in the state to sponsor a Remote Stroke Treatment Center. In 2009 St. Mary's developed a Neuro Hospitalist/Telestroke model with their Stroke Champion physicians, Dr. McCord Smith and Dr. Van Morris along with Reach to assure 24/7 neurology coverage. They demonstrate their commitment to quality as a Gold Plus, Target Stroke Honor Roll facility and offer the full continuum of care with Acute Rehab and Palliative Care services. They are noted for their exceptional relationship with their community EMS partners and the education they have done with ASLS across the State. St. Mary's have brought national speakers and experts to Georgia to share the latest and greatest best practices with the stroke community. They have presented their best practices at ISC and collaborate closely with the Marcus Stroke Comprehensive Center to assure that their patients are offered the most up to date interventional services. They are a role model for other hospitals in Georgia and across the country in how to provide the best care for patients utilizing the resources they have at hand. This is just a short synopsis of St. Mary's but it is evident they are a Star Award Facility! "St. Mary's Healthcare was the first hospital in Georgia to work with one of their smaller affiliates on becoming a Georgia state designated Remote Stroke Treatment Center. The hospital has set a precedent for the rest of Georgia encouraging other hospitals to take their lead. In addition, their former stroke coordinator, Shelley Nichols, was one of only a handful of people in Georgia recognized by the University of Miami to teach the ASLS Instructor class. St. Mary's has worked diligently to maintain a close relationship with National EMS. This strong relationship has encouraged other hospitals and EMS companies to work closer with one another. St. Mary's definitely deserves the Hospital Star Award from Coverdell". Administrative Data Linkage to Evaluate a Quality Improvement Program in Acute Stroke Care, Georgia, 20062009 The Institute of Medicine outlined principles including active collaboration and communication between clinicians and institutions and provision of care based on the best available scientific knowledge to redesign the healthcare system to improve the quality of care patients receive.1 Hospitals participating in the Georgia Coverdell Acute Stroke Registry embody these principles; they share expertise and best practices, and they are striving to provide the best possible evidence-based care to their stroke patients. Several hospitals participated in this collaborative effort since its inception and have demonstrated that the quality of care can be improved through continuous monitoring of performance and targeted quality improvement activities. However, how much patients have benefitted from these improvements in the process of care delivery has not been examined. We present you the summary of results from a data analysis answering this question. Below are the links for the full article. html version http://www.cdc.gov/pcd/issues/2015/14_0238.htm pdf version http://www.cdc.gov/pcd/issues/2015/pdf/14_0238.pdf 1. Committee on Quality Health Care in America (Institute of Medicine). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C: National Academy Press; 2001. Introduction Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients. Methods Multistage probabilistic matching using a fine-grained record integration and linkage software program and combinations of key variables were used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared. Results Age Average of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.031.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry. Conclusion Hospital discharge data can be linked with death data to assess the impact of clinical-level or community level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome. Submitted by Moges Ido, MD, MPH, - Georgia Coverdell Acute Stroke Registry Epidemiologist Georgia Department of Public Health Legislative Report and Data Summary The Georgia Department of Public Health produces an annual report for the legislature on specific types of stroke data as stipulated in the Senate Bill 549, the Georgia CoverdellMurphy Act. For the latest report you can click on the uniform resource locater: http://dph.georgia.gov/sites/dph.georgia.gov/files/2014%20Legislature%20Stroke%20Rep ort.pdf The Georgia Coverdell Acute Stroke Registry (GCASR) serves as a primary data source for the legislative report, and more information on the progress attained by GCASR is available at the following link: http://dph.georgia.gov/sites/dph.georgia.gov/files/2014%20Coverdell%20Data%20Summa ry.pdf Be One in a Million and Pledge to Support the Million Hearts Initiative Million Hearts is a national initiative to prevent One million heart attacks and strokes in the U.S. by 2017. Launched by the U.S. Department of Health and Human Services (HHS) in September 2011, it aligns existing efforts, as well as creates new programs, to improve health across communities and help Americans live longer, more productive lives. The Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS), co-leaders of Million Hearts within HHS, are working alongside other federal agencies and private sector organizations to make a long-lasting impact against cardiovascular disease. The Georgia Department of Public Health (DPH) is joining in on the efforts as a Million Hearts Partner by targeting improvements in clinical preventive practice and community prevention through the following goals: Improving care for people who do need treatment by encouraging a targeted focus on the "ABCS"-Aspirin when appropriate for people at risk, Blood pressure control, Cholesterol management and Smoking cessation-which address the major risk factors for cardiovascular disease and can help to prevent heart attacks and strokes. Empowering Georgians to make healthy choices such as preventing tobacco use and reducing sodium and trans fat consumption. This can help reduce the number of people who need medical treatment such as blood pressure or cholesterol medications to prevent heart attacks and strokes. Million Hearts Partners are organizations that make a formal commitment to the initiative to help prevent one million heart attacks and strokes by 2017. This formal commitment includes concise and specific action steps that an organization proposes to conduct in support of the Million Hearts initiative, with explicit timelines for completion, measurable results, and rationale for how it will help support the goal. Interested organizations can make their pledge by going to http://millionhearts.hhs.gov. Submitted by: State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health Grant Georgia Tobacco Quitline Collaborates with the Georgia Coverdell Acute Stroke Registry The Georgia Tobacco Quitline is a public health service funded by the Georgia Department of Public Health through the Georgia Tobacco Use Prevention Program (GTUPP). GTUPP partners with a national tobacco cessation vendor to provide telephone and web-based counseling services in accordance with the United States Public Health Service Treating Tobacco Use and Dependence Clinical Practice Guidelines. The counseling services are available at no-cost to Georgia adults, pregnant and postpartum women, and teens (ages 13 and older). The quitline is excited to begin a collaboration with the Georgia Coverdell Acute Stroke Registry (GCASR). Available 24 hours a day and 7 days a week, the Quitline is accessible and efficient by eliminating barriers of traditional cessation classes (e.g. waiting for classes to form) and offering services to Georgians who reside in rural or remote areas. The Quitline is particularly popular among underrepresented populations, who actively seek help using the Quitline. The Georgia Tobacco Quitline appeals to tobacco users reluctant to seek help provided in a group setting. The Quitline provides free & confidential, professional tobacco cessation telephone & web-based counseling services to all tobacco users with many different chronic conditions including stroke. Through proactive calls, the Georgia Tobacco Quitline can offer hospitals great assistance with helping their patients (e.g. stroke recovery patients who smoke or use other tobacco products) make a successful quit attempt. The proactive calls are a part of the Quitline's healthcare fax referral process, where a healthcare provider or other hospital staff member obtains consent from his or her patient during routine visits or other encounters to have the Quitline call him or her to begin the quit process. The Quitline personally works with each patient to best assist him or her with their tobacco use cessation needs. Details regarding the intervention are sent back to referring healthcare providers via fax or electronically (i.e. electronic medical records or EMRs). The quit process begins with the patient providing basic information to the registration specialist who then transfers him or her to a Quit Coach. Quit Coaches provide participantfocused behavior change coaching services via phone or the web using established, evidence-based strategies and protocols. These services are provided to patients ready to make a quit attempt within 30 days of initial contact with the Quitline via a single call intervention or a multi-call (4 call) intervention. Lastly, cessation services address the use of all tobacco products, including smokeless tobacco products (e.g. dip or SNUS). Submitted by: DPH Tobacco Use Prevention Program What about Remote Stroke Treatment Centers (RSTC)? A message from our PI and QI Director James Lugtu In 1991, a movie starring Richard Dreyfuss and Bill Murray was released. The movie was entitled, What About Bob? Bill Murray played "Bob" a psychiatric patient of a vacationing psychiatrist Dr. Leo Marvin played by Richard Dreyfuss. During the movie one of Dr. Marvin's therapies recommended to Bob was to take "Baby Steps", to live life one step at a time. The recommendation was to "set reasonable goals for yourself one step at a time, one day at a time. With the problems of today seeming insurmountable, we must take everything bit by bit take baby steps". Though this is fictitious counsel from a movie it does have some ring of truth. The pursuit of Primary Stroke Certification has been viewed by many as an unsurmountable task. Many are not sure where to start and if that goal is even achievable at their facility. Why not take Dr. Leo Martin's advice and start taking "Baby Steps", small steps towards your goal of PSC certification? Unlike Bob who took the counsel literally and started walking throughout the movie taking baby steps, we can start making small progressive steps in reaching the goal of PSC certification. Regardless if your facility is pursing certification from DNV, TJC or HFAP one common "Baby Step" in the State of Georgia is Remote Stroke Treatment Center designation or RSTC. Achieving the step goal of RSTC certification can be crucial first step in achieving your goal of becoming a PSC. The RSTC process is very easy to follow and is achievable for most of our non-PSC Coverdell Facilities. There are only three basic requirements that must be met prior to applying: 1. Participating in Coverdell, 2. Currently entering data into the GWTG Outcomes tool and 3. A letter of agreement preferably from a Coverdell PSC (HUB) Hospital stating they will work with your facility to establish stroke care transfers and communication protocols. Your facility may already meet these requirements. If your facility is not yet a PSC why not take the "Baby Step" of becoming a RSTC? Some facilities may not desire to become a PSC due to their unique circumstances and limitations. Despite their limitations, many of these facilities are doing a lot of great work and are providing excellent stroke care. These ones can gain public validation their achievements by pursuing RSTC designation. If you would like to learn more about RSTC designation, please review the documents at the end of this newsletter. Further details are also available for the State Office of EMS and Coverdell. As you consider your future goals for 2015 ask yourself, What About RSTC? Update on State Designated PSC Re-Certification Some have asked if it is possible to have an updated letter acknowledging your facility as a State Recognized Stroke Center. After discussion with leaders from the Department of Public Health, Coverdell and the Georgia State Department of EMS, it was decided that an updated letter can be provided. The letter will state that your facilities' designation will not expire as long as you remain a designated PSC from a nationally recognized accrediting agency. If you would like an updated letter noting these changes please notify James Lugtu (James.Lugtu@dph.ga.gov) or Kerrie Krompf (kkrompf@emory.edu). Acute Ischemic Stroke and Postpartum Phase After giving birth, most families are focused on going home to begin their new lives as a family. New fathers are preparing the house for their wife and new baby's homecoming. The last thing anyone would expect to hear is "Your wife had a stroke". This article is about a 29 year old new mother with no past medical history and one day postpartum, who had sudden onset of dense left hemiplegia, right gaze, and hemi-neglect. Rates of stroke in women during pregnancy or soon after giving birth have jumped 54 percent in the last decade. The elevated risk of thrombotic events previously seen in mothers in the 6 weeks after childbirth now appears to last about twice as long, though the absolute risk remains very low. The rate of stroke has climbed about 47 percent in women before giving birth and about 83 percent in new moms in the postpartum period (0-12 weeks after giving birth). The risk of stroke rises in pregnancy in part because of high blood pressure, higher volume of blood, risk for clots, inherited primary hypercoagulable state, and migraine headaches. Fluctuations in hormones and blood pressure in the weeks after giving birth may increase risk during that time including the fact one in five women is obese when she becomes pregnant. Though relatively rare, thrombotic events associated with pregnancy can have serious consequences. Postpartum stroke carries a mortality rate of 5% to 30% even though the occurrence is low.1 The Northside hospital staff caring for this patient had been recently educated on the new 2014 stroke clinical practice guidelines for women2 with a special focus on the signs and symptoms possible during the postpartum phase. As a result of that training, there was an immediate activation of the in-patient stroke alert and rapid response team arrival within 5 minutes of the onset of symptoms. She was taken to CT without delay and the results were called in to the Neurologist (Dr. Silverboard). The patient was not a candidate for IV tPA given the recent delivery and was transferred to Grady Hospital for possible endovascular rescue. The quick response of all those involved in her care was the most significant factor in ensuring a good outcome for this postpartum patient. Upon arrival to Grady, she was showing improvement in her left-sided weakness with some antigravity movement. However, her hemi-neglect persisted, and she had an NIHSS of 9. CT perfusion demonstrated a small area of infarct with a very large area of penumbra. Angiogram revealed complete occlusion of the M1 segment of the right MCA. She underwent a thrombectomy with full reperfusion. Less than 1 day after the procedure she progressed to a near complete recovery with an NIHSS of 1. Further workup showed an atrial septal aneurysm and PFO. She was discharged to home with decreased sensation to light touch on her left face and arm, and slightly asymmetric nasolabial folds. PRETREATMENT ANGIOGRAM AP VIEW FINAL ANGIOGRAM AP VIEW PRETREATMENT ANGIOGRAM LATERAL VIEW FINAL ANGIOGRAM LATERAL VIEW CLOT REMOVED!! In summary, increased awareness and rapid response times are essential to reducing maternal complications related to stroke. Our next step should be to validate recent research findings in a larger cohort clinical trial and try to identify risk factors. References 1. Hooman Kamel., (et al) Thrombotic Risk after 6-Week Postpartum Period N Engl J Med 370;14 NEJM.Org April 3, 2014 2. Bushnell C, (et al) Guidelines For The Prevention Of Stroke In Women: A Statement For Healthcare Professionals From The American Heart Association/American Stroke Association. Stroke. 2014 May;45(5):1545-88. 449 references on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council for High Blood Pressure Research. Submitted by: Jean Pruitt Jean Pruitt, Neuroscience Clinical Nurse Specialist, Tri-Campus Northside Hospital,Stroke Certified Registered Nurse, Stroke Coordinator, Northside Hospital Atlanta Coverdell Highlights December Conference Call Thank you Dr. Brian Dawson, Director of the Stroke Program at South Georgia Medical Center, Jeremy Norman, Assistant Chief of EMS at South Georgia Medical Center and Mandy Yarbrough RN, ED Representative for the Neuro Care Team for South Georgia Medical Center for their presentation on the December Coverdell Call. They gave a very informative presentation on "Essential Components of Decreasing Door-to Needle Time (DTN) March 18th Abstraction Training Workshop and Advance Reports Workshop The Coverdell Stroke Registry will be offering two workshops on March 18th at Piedmont Newnan Hospital. If you have not received an invitation or for more information, please contact Kerrie Krompf at: kkrompf@emory.edu or 770-380-8998