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)
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
FALL 2016
Georgia Coverdell Acute Stroke Registry 2016 Performance Measures
From July 2015 to end of December 2015, GCASR staff, Steering Committee, and State Office of EMS worked hard on identifying patient-level performance measures of care for Pre-Hospital (EMS), Hospital and Post-Hospital settings.
Pre-Hospital Measures:
1. % of stroke transports where EMS called in a stroke alert pre-notification 2. % of stroke transports with a blood glucose checked and recorded 3. % of stroke transports that had a documented the time last known to be well 4. % of stroke transports that had a stroke screen completed and recorded
Hospital Measures:
1. Administration of tissue plasminogen activator (tPA) 2. Dysphagia screening 3. Administration of antithrombotic medication within 48 hours 4. Deep Vein Thrombosis (DVT) prophylaxis 5. Prescription for lipid lowering medication 6. Delivery of stroke education 7. Rehabilitation assessment 8. Prescription for antithrombotic medication at discharge 9. Prescription for anticoagulant medication for patients with atrial fibrillation 10. NIHSS Score recorded 11. Door to Image time 12. Intravenous tPA within 60 and 45 minutes of hospital arrival 13. Smoking cessation counseling and/or treatment provided
Post-Hospital Measures:
1. % of stroke patients discharged to home who have died by 30 days 2. % of stroke patients who were readmitted to the hospital within 30 days of discharge 3. % of stroke patients who were seen in ED within 30 days of discharge 4. % of stroke patients checking their blood pressure 5. % of stroke patients taking blood pressure medication 6. % of Stroke patients taking lipid lowering medication 7. % of stroke patients that had a follow-up appointment scheduled prior to discharge 8. Smoking cessation counseling and/or treatment provided
GCASR with the support of the Steering Committee agree to make our 2016 State Performance Measure indicator to be:
1. Improve Door to Image time less than 15 minutes from 25% to 100%
2. Reduce the average door to Intravenous tPA time to less than 45 minutes
We will all work together on achieving our goals for calendar year 2016, please let us know how we can all help.
Submitted by: Rana Bayakly, PI for the GCA reprinted from an earlier newsletter

Remote Treatment Stroke Center Update
Congratulations to the following hospitals for achieving Remote Treatment Stroke Center (RTSC) designation through the Georgia Department of Public Health, Office of EMS and Trauma: Appling HealthCare System (2015), Meadows Regional Medical Center (2016), Morgan Memorial Hospital (2016), St. Mary's Good Samaritan Hospital (2013), University Hospital McDuffie (2014), Wellstar Douglas Hospital (2016).
Since 2014, the Georgia Office of EMS and Trauma, The Georgia Coverdell Acute Stroke Registry, the Georgia Hospital Association, American Heart/American Stroke Association and the Georgia Stroke Professional Alliance have been assisting hospitals around the state who are interested in becoming Remote Treatment Stroke Centers. Typically rural, a Remote Treatment Stroke Center is a hospital that is certified as being able to deliver rapid acute stroke care to patients in its emergency department or inpatient facility. Often utilizing telestroke, staff of these hospitals are trained to immediately recognize stroke symptoms, quickly obtain CT; and if indicated, emergently and safely administer Alteplase. Upon receiving Alteplase, the patient will be transferred to either a Primary or Comprehensive Stroke Center for aftercare as well as additional study and treatment. RTSCs partner with their local EMS agencies and together they provide the best care for patients in their respective communities. The Remote Treatment Stroke Center collaborates with their designated Primary and/or Comprehensive Stroke Center for education, maintenance of best practices, and other far reaching support. The Coverdell Murphy Act enacted in 2008, paved the way for the designation of Remote Treatment Stroke Centers in the State of Georgia. Through this legislation a strong Stroke System of Care is being developed across the state. Becoming a Remote Treatment Stroke Center has many advantages. For example:
introduction of standard stroke care to previously underserved areas quicker, quality stroke care resulting in a decrease in disability, morbidity and
mortality
alignment with a larger health system with additional resources cooperation and collaboration between the RTSC, Primary Stroke Centers and
Comprehensive Stroke Centers
updated and streamlined processes accountability for implementation of best practices educational opportunities for physicians and staff access to quality benchmarks through registry submissions marketing opportunities in the community statewide recognition
Coffee Regional Medical Regional Center in Douglas, Georgia is slated to be reviewed for designation on October 27, 2016. By the time you read this newsletter, we should have 7 Remote Treatment Stroke Centers in Georgia!
There is opportunity for more of our hospitals to become Remote Treatment Stroke Centers by applying through the Georgia Office of EMS and Trauma. https://dph.georgia.gov/sites/dph.georgia.gov/files/Fillable%20Remote_Stroke_Ctr_App_Packa ge.pdf
There is no application or site visit fee for the designation.
Our plan is to have another informative Remote Treatment Stroke Center designation meeting the first quarter of 2017.
If your hospital is interested in becoming a Remote Treatment Stroke Center please contact Kerrie Krompf at kkrompf@emory.edu.
Submitted by Shelley Nichols, Stroke Program Manager, Augusta University Medical Center

Rockdale Medical Center & Georgia Quitline
We would like to extend a big thank you to Rockdale Medical Center for our most recent referral to the Georgia Quitline. If you should have any questions regarding the Quitline, don't hesitate to contact Kerrie Krompf at: kkrompf@emory.edu or 770-380-8998.
Engaging Your Emergency Department in Alteplase Administration
So, you have a Door to Needle (DTN) that seems to be stuck in time? I mean you've changed the batteries (processes) more than once and it still doesn't move. I reviewed my Alteplase data, I knew we had a 30% increase in administration from 2014 to 2015 but those times...oh those times just weren't where they needed to be. What else could I do?
Ever wondered, "How in the world can I get the ED more engaged"? That is exactly what I was discussing one January day. That's when we came up with the idea of a "Stroke Recognition Dinner". Sounded like a good idea; easy enough right? Now came the big questions. Who do we invite? How many awards do we give? What will be the criteria for an award? Paper or Plastic...I mean certificate or trophy. Do you include all the ED staff or just the ones receiving an award? Administration should be there but do we have their buy-in? If everyone gets an award will that really bring home what we are trying to accomplish?
Before I go any further, I want to say our recognition dinner made a tremendous impact on our ED engagement. I will share with you what has worked for me. However, this is where you have to look at your facility for what will work best for you. I began by reviewing my Alteplase log to see "who had the best times" (physicians and nurses); "who administered the most" (physicians and nurses); "which physician ordered the most Alteplase"; and finally "who administered Alteplase in less than 45 minutes" (physicians and nurses). We actually had two physicians tie for the fastest times. My log includes the nurse involved in the Alteplase administration but we all know there is more than one nurse working with the patient. Ok, that raises another question, "Will both nurses receive an award"? There was only one answer, Yes! Next came the fun part...trying to find that Pokemon Go PCR from EMS! You know the one. The one you can rarely find. Yea, that is the one. We felt it vital to include our EMS partners in this recognition dinner so we searched those accounts with the fastest times and even called one service to have the PCR faxed to us. Finally, we considered it a must to include our CT Techs who play a crucial role in our DTN times. I did not include the Radiologists in our initial dinner program, but I am evaluating their inclusion in our 2017 dinner.
Once we had decided who we would recognize, we then decided who we would invite. We elected to invite only those who would be receiving an award, the ED physicians, our Administrative representatives (CNE, CNO, Neuroscience Administrative Team; ED Administrative Team; and the Core Stroke Team). Unfortunately, spouses were only included if they worked for the hospital or were in the medical field. This did create a couple of bumps but in the end, I don't think it was a significant limitation to attendance. We opted for a certificate for everyone no matter their award and presented trophies to the MD, Nurse, EMS crew, and CT Tech for: "Fastest DTN", and to the MD who had the "Fastest Overall DTN". Along with the certificates and trophies, we also gave a brain lapel pin.
The energy created by this recognition dinner has been tremendous. Nurses even stopped by the ED that night after the dinner showing off their awards. Physicians are posting their certificates on the wall with the nurses CEN certificates; they are taking pictures of their awards and texting to other ED physicians. To say this has created a competition is an understatement. Physicians are asking, "what is the fastest time I have to beat". As a result, we have experienced a reduction of our 2016 over 2015 DTN Jan-Jun times by 15 minutes. We have had our first-ever 14 minute DTN. Our Alteplase administration went from 10.9% in 1st quarter 2016 to 19.4% 2nd quarter. Yes, it did foster a competitive spirit, however, it has increased awareness and screening for potential Alteplase candidates.
The dinner acknowledged our staff's commitment and hard work they perform on a daily basis. I would recommend hospitals consider this as not only a tool to engage your ED staff, but one to recognize their dedication to providing the highest quality stroke care for all patients.
Submitted by: Denise Goings, Stroke Program Coordinator, Medical Center Navicent Health

Implementation of an Inpatient Stroke Alert
On August 15th of this year Northeast Georgia Medical Center Gainesville (NGMC), a Primary Stroke Center, implemented an Inpatient Stroke Alert to provide guidelines for clinical assessment and intervention when an admitted patient experiences sudden onset of stroke signs and symptoms.
Stroke Medical Director, Dr. Shaena Blevins, and Stroke Coordinator, Holley Adams, engaged members of the Stroke Steering Committee to create a process and determine resources needed to support and ensure success of the Inpatient Stroke Alert. A hybrid process was established by blending the NGMC Medical Emergency Team (MET) model for inpatient emergencies and the NGMC Emergency Department's acute stroke protocol. Benchmarks for the Inpatient Stroke Alert mirrored those of the Emergency Department. Stake holders were overwhelmingly supportive of this work. Inpatient Medicine agreed to provide urgent patient assessment and clinical management when an attending physician was unavailable. NGMC Imaging Department provided a dedicated space in CT for Inpatient Stroke Alerts including a stretcher with scale. All materials needed for alteplase administration and transfer to a comprehensive stroke center for advanced care were made readily available.
Next, job aids were created and distributed to nursing departments as well as departments supporting the Inpatient Stroke Alert. Training sessions were provided for approximately fifty MET nurses. Education topics included logistics and reasoning of the process, alteplase administration, and the introduction of thrombectomy as an additional intervention for acute stroke patients. Several mock drills were held to gauge readiness for implementation. The paging system was not observed to provide quick notification to the attending physician or Neurologist, and in some situations no notification was provided at all. The start date was postponed two weeks to provide additional work to streamline the notification process. NGMC has averaged about two alerts per week since initiation of the Inpatient Stroke Alert in mid-August. 71% of alerts have been called for medical and cardiology patients. 42% of Stroke Alert patients have been diagnosed with acute stroke. While none of these patients have been candidates for alteplase or thrombectomy, rapid diagnosis and stroke care has been made available.
Opportunities for improvement have been identified based on review of individual cases and metrics obtained thus far. There is a seven call minimum to ensure all Acute Stroke Team members are notified of the activation of the alert and additional calls are made by physicians and nursing to discuss clinical details of the case. Work is ongoing to create a more efficient notification system. Additional MET nursing education is needed to provide information related to stroke mimics and consideration of differential diagnoses. Nursing administration is evaluating use of dedicated nurses to respond to the Inpatient Stroke Alert. Lastly, attending physicians need clarity that emphasizes their responsibilities as well as the support provided to them by Inpatient Medicine and Neurology. Additional information is being shared in physician section meetings.
The passion for improving stroke care at NGMC Gainesville was evident through development of the Inpatient Stroke Alert and endures as the focus now shifts to improvement of the process. The establishment of the Inpatient Stroke Alert has been successful in that it resolves the previously existing gap for in-hospital acute strokes through alignment of resources and availability of treatment options.
Submitted by: Holley Adams, BSN, RN, Stroke Coordinator, Northeast Georgia Medical Center

What Exactly is Defect Free Care?
On the last Coverdell Conference call one of the topics was Defect Free Care. The following is a short overview of what it is and the importance of using it with your Stroke Program to improve processes. This can be added to your Stroke Committee Scorecard if you are not already using it. Defect Free Care: CDC/COV Defect-Free: Defect-free measure gauges how well your hospital does in providing all the appropriate interventions to every patient
It includes all 10 Consensus Measures with case inclusion by Clinical Diagnosis (including Stroke and TIA)
Patients which are included in the denominator for Inpatient admissions: - IV rt-PA 2 Hour - Early Antithrombotics - VTE Prophylaxis - Antithrombotics - Anticoag for AF - LDL 100 or ND - Smoking Cessation - Dysphagia Screen - Stroke Education - Rehabilitation Considered
(The red highlights are the AHA/ASA Achievement Measures and the blue are from the AHA/ASA Quality Measures.)
Patients that are "Not admitted = Yes, not admitted " are included in Defect Free care with the following measure(s): (These will be patients that are transferred out to a higher level of care; i.e. Drip and Ship or for Comprehensive Services)
- Dysphagia Screen - Door to IV rt-PA in 60 Min - IV rt-PA Arrive by 3.5 Hour, Treat by 4.5 Hour - NIHSS Reported
Your Stroke Program can compare your facility to other Coverdell hospitals in Georgia.
CDC/COV Defect Free

Benchmark Group

Time Period

Defect-Free Patients

Total Patients

% Defect-Free Patients

My Hospital

2015 2016

163 173

188 176

86.7% 98.3%

GA Coverdell DSA Site

2015 2016

13833 8733

17293 10810

80.0% 80.8%

Georgia Coverdell recognizes the importance of looking at the over-all program and includes this as part of the annual Georgia Coverdell Awards. The Defect Free category offers your facility the highest available points towards the award which supports providing quality outcomes to your patients.

25 points are awarded to one hospital in each bed size category achieving: Highest percentage increase in defect free care For defect free care the period of April 1, 2015 September 30, 2015 to April 1, 2016
September 30, 2016 is compared. If a hospital has six consecutive months from April 1, 2016 September 30, 2016 of meeting 85% performance or higher on defect free care they will automatically receive the allotted points.

The point system is based on the following criteria:

Participation Points Allotted

Hospital attendance on GA Monthly Coverdell Call 1

Published "Blurb" (250 words) in Coverdell Quarterly Newsletter 2

Workshop attendance (per hospital) 5

Hospital presenting on GA Monthly Coverdell Call 5

Published Q-Tip in Coverdell Quarterly Newsletter 5

Published Article in Coverdell Quarterly Newsletter 10

Published Stroke Survivor Story in Coverdell Quarterly Newsletter 10

Physician Champion presenting on GA Monthly Coverdell Call 10

Defect Free Care 25



Four hospitals receive the awards annually based on hospital size.



very small hospital, 25 beds or less



small hospital, 26100 beds



medium hospital, 101350 beds



large hospital, over 350 beds



Submitted by: Debbie Camp, Stroke Program Manager- Piedmont Newnan Hospital

Once Again, Gov. Nathan Deal Proclaimed October 29th- World Stroke Day

Once again this year, many of our Coverdell Hospitals and EMS partners participated in a very important presentation on October 12th at the capital in Atlanta, GA when Governor Nathan Deal proclaimed October 29th World Stroke Day as Stroke Awareness Day in Georgia. We are proud to be part of this movement and to push efforts forward every day to decrease the effects that stroke has on individuals in Georgia.
A big thanks to all of you, for all you do for our stroke patients in Georgia.

Looking for Creative Education Ideas

Those of us participating in the care of Stroke patients are so fortunate to have many great learning opportunities. For example, the Georgia Stroke Curriculum, Advanced Stroke Life Support, Stroke Certified Nurse exam review, International Stroke Conference and local hospital Stroke conferences to name a few. We also recognize the need to educate our communities about Stroke and to offer our staff many opportunities to learn. We often need a few quick, easy and creative ways to relay an important message to a variety of audiences. Some of us just happen to be more creative that others The good news is that we are a group of collaborators who share our best with our colleagues around the state. As we look for ways to educate our staff and communities, we know that using stimulating educational activities help people better retain the information and learning grows exponentially! There are basically 3 categories of learning behaviors according to Bloom (1956). These categories are not independent of each other. In health care we typically focus on cognition or knowledge and psychomotor skills. In order to enhance learning and cause a change in behavior, we should also incorporate the affective or feelings category into our teaching as much as possible. This is not as easy as it sounds and is not really the topic of this article. The purpose here is to showcase some quick and easy educational ideas into our bag of tricks to add variety and spice when teaching.
For example, I know you all have seen the short Stroke Heroes video. This video has been around for a while and I have shown it hundreds of times to a variety of audiences from young to old, corporate to community stroke events. The tune is catchy and it quickly gets the point across. If you haven't seen it, the link is here for your convenience. https://www.youtube.com/watch?v=YHzz2cXBlGk. I know there are plenty of other youtube videos that can achieve the same objective.
I have also used art and literature to make an educational point. This is not stroke related but you will get the idea. Using select portions of the movie Wit you can educate on patient advocacy and incorporate a discussion on end of life care. If you haven't seen this movie, it is worth watching.

Using children's books to make a point is also fun. When teaching the importance of

co

correct clinical documentation, I have used the book Amelia Bedelia. If you don't

U

remember this book, you might want to read it to get the gist.

The Wizard of Oz can be incorporated when educating to a new way of documenting in the clinical record. For example, there will be pitfalls but at the end of the yellow brick road....use your imagination! Incorporating a story from history or recent events can also help the learner retain information. We all know the value of incorporating case studies into clinical learning situations and the value that brings to the educational experience. I love this method below helping to remember the cranial nerves:
Have you ever thought about using music to remember something? For example, the Twenty One Pilots song Stressed Out, My Name is Blurry Face and I care what you think.cranial nerve 7? Or Tommy Roe and Dizzy- I'm so dizzy my head is spinning, like a whirlpool it never ends.cerebellar infarct? Ok maybe too much of a stretch?
Catherine Whitworth, Spalding Wellstar Stroke Coordinator led a group to develop the handout below for community education: Know the Risk: Saving Hearts and Heads

Whitney Smith, Fairview Park Stroke Coordinator developed these PowerPoint slides and poems to educate both staff and community.

Thanksgiving: Stroke Awareness

T

Today is the day to be thankful

This time of year is tranquil

H

Hayrides, pumpkins, hip-hip hooray

It's nice to be home for hearth and holiday

A

Autumn is nice, warm, and colors abound

Dcor, garnish, and trimmings all around

N

New adventures to discover in November

Are all good things I want to remember

K

Kin in the kitchen cooking good things to eat

Remember No extra salt or additional treats!

S

Strokes lurk in the dark, this is no surprise

Beware of the fries, pies, and portion size

G

Gobble, Gobble, Gobble it's time to do a trot

And say a little thanks for all that you got

I

Infarctions and ischemia run awry

During this wonderful time of pumpkin pecan pie

V

Vessels and arteries sometimes occlude

Causing detrimental effects to ensue

I

I shall give one piece of advice

Learn stroke signs/symptoms and their price

N

Now is the time to act F.A.S.T.

Before a stroke becomes a part of your past

G

Gobble, Gobble, Gobble it's time to learn about stroke

As you already know, stroke is not a joke!

That spells THANKSGIVING, to remember joy while you live Please remember this during the care that you give

*Educate your brain patients Time is Tissue, Time is the Issue!*

I'm sure there are many other education examples that you all have used in the past to capture the attention of your audience. Maybe we should think about housing a repository that we could all access? I have one more idea that I think might be able to come to fruition here in Augusta. A Putt Putt type golf course in the shape of the Circle of Willis, again, use your imagination. I'm just the idea person, let me know if you can execute!

Submitted by Shelley Nichols, Stroke Program Manager, Augusta University Medical Center

Coverdell Highlights
October Conference Call
We had three speakers on our October Coverdell call. Rana Bayakly, PI for the Georgia Coverdell Acute Stroke Registry, briefly spoke about the ICD 10 and case ascertainment updates for the Coverdell National Acute Stroke Registry Program. Holley Adams, Stroke Coordinator at Northeast Georgia Medical Center, presented on improving response times for in hospital stroke alerts (see page 4) and Debbie Camp, Stroke Program Manager at Piedmont Newnan Hospitals presented on defect free care (see pages 5-6). We would like to thank all three presenters for contributing their time to our October Call.
Advanced Stroke Life Support (ASLS) Instructor Course
On Tuesday, October 25th, the Georgia Coverdell Acute Stroke Registry sponsored an ASLS Instructor Class. We had two classes running simultaneous and each was filled to capacity. The classes not only had some of our very own ASLS instructors but we also had two instructors from the University of Miami who assisted with the class as well. Thank you to Georgia's Shelley Nichols (Augusta University), Denise Goings (Medical Center Navicent Health), Teri Newsome (Habersham Medical Center) and David Briscoe (National EMS) for taking the time out of your busy day to teach this full day class.
Abstraction Training and Advanced Reporting Workshop
The Georgia Coverdell Acute Stroke Registry held an Abstraction Training and Advanced Reporting Workshop on Wednesday, October 26th. We reviewed charts and went over the data elements that presented the most confusion. In addition, time was allotted to show attendees how to drill down the data. Thank you to Debbie Camp, Stroke Program Manager at Piedmont Newnan Hospital, not only for facilitating and teaching the workshop but also for hosting this all day workshop. In addition, we'd like to thank Denise Goings (Medical Center Navicent Health) and Shelley Nichols (Augusta University) for assisting in teaching the class.