Georgia Coverdell Acute Stroke Registry quarterly newsletter, 2016 Winter

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 2016

Georgia Coverdell 2016 Awards
"Georgia Coverdell Champion Hospital of the Year"
Award Winners

CONGRATULATIONS TO THE FOLLOWING 4 HOSPITALS:
St. Mary's Good Samaritan Hospital (very small hospital, 25 beds or
less)
Clearview Regional Medical Center (small hospital, 26100 beds)

South Georgia 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, 2016 through December 31, 2016 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, 2015 September 30, 2015 to April 1, 2016 September 30, 2016. 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.

Georgia Coverdell Announces the 2016 "Door to Needle Time" <45 Minutes Hospital Award Winners
Door to Needle Time (DTN) is the Golden Hour (60 minutes). The Georgia Coverdell Acute Stroke Registry has raised the bar and this award is now 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, this award is 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.
Kudos to all of you!
Hospitals improving door to needle time by 20% AND with an average door to needle time of < 45 minutes Piedmont Hospital Atlanta Redmond Regional Medical Center Rome South Georgia Medical Center - Valdosta Wellstar Kennestone Hospital - Marietta
Hospitals with an average door to needle time of < 45 minutes
Emory University Hospital - Atlanta Northside Hospital-Cherokee - Canton
Hospitals improving door to needle time by 20%
Eastside Medical Center - Snellville Emory University Hospital Midtown Atlanta Meadows Regional Medical Center - Vidalia Spalding Regional Medical Center - Griffin St. Francis Hospital Columbus University Hospital -Augusta
Once again, congratulations to all of the above hospitals for showing great improvement in reducing Door to Needle time. Ten years ago we never would have thought door to needle in less than 45 minutes would be possible. We have come so far!

Georgia Coverdell Announces the 2016 "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: Shelley Nichols "is the Stroke Program and
Outcomes Analyst at Grady Memorial Hospital. Shelley has worked in the field of education and Stroke for many years. She, along with National EMS and St. Mary's in Athens, developed via the Coverdell Pilot Project a superior program for greater patient outcomes. Since coming to Grady, Shelley has identified areas of improvement to decrease the times from field identification of stroke to revascularization and is actively working on a project with Grady EMS to enhance the chain of survival. Shelley is also Chair for the GA Stroke Professional Alliance and champions best practices across the state".
"Shelley Nichols has been one of several people in Georgia to lead an effort educating rural hospitals in Georgia on the Remote Treatment Stroke Center Designation (RTSC) process. Thus far, she has helped organize two regional RTSC educational meetings in the state which has led to numerous hospitals either obtaining the designation or inquiring more about seeking designation. In addition, to her current responsibilities, she continues to volunteer to be an ASLS instructor in Georgia. Shelley's continued commitment to stroke in Georgia is just one of the reasons I am nominating her for this year's star award".
Hospital recipient: Grady Memorial Hospital - "I want to
nominate Grady as the Star hospital. They are very responsive to our physician calls about possible stroke patient transfers all day and night. They also send us feedback regularly and are just very easy to work with. Their physicians and the neuroscience staff in the neuro unit are always receptive when we are sending them patients. Grady is doing phenomenal work in improving stroke patient outcomes".
"Grady Hospital was one of the first in Georgia to become a Comprehensive Stroke Center. From day one, they have strived to seek excellence and continue to do so. They make it easy to transfer patients to their facility and always provide feedback to us without us having to contact them. The Marcus Stroke and Neuroscience Center is one of a kind and they are constantly living up to their reputation. For this reason, I am nominating Grady to be this year's recipient of the star award hospital"
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/Stroke%20Report%20for%20Legislature_2 015.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/Stroke%20Registry_2015Data%20Summar y.pdf

Georgia Coverdell Acute Stroke Registry 2016 Performance Measures
Happy New Year and what a wonderful start so far. Starting in July 2015, the Georgia Coverdell Acute Stroke Registry (GCASR) was successful, as you all know, in receiving the new 5-year grant cycle. As a result and 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. GCASR, partners, and collaborators have agreed on important performance measures based on the draft CDC measures to be assess in 2016, these measures are: 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 GCASR

Georgia Tobacco Quit Line (GTQL) Updates
As we continue to serve stroke patients in Georgia and partner with the Tobacco Quit Line, we at the Georgia Coverdell Stroke Registry would like to provide you with updates on the Tobacco Quit Line
There is a NEW more concise Georgia Tobacco Quit Line fax Referral Form GTQL Fax Referral Form download it from DPH's website
We will be sending each stroke coordinator the new Referral Form There is a FREE ONLINE TRAINING- Engaging Tobacco Users that
health care providers can participate in and receive CME CREDITS www.GAtobaccointervention.org We are investigating how to further incorporate the Tobacco Quit Line into the Stroke Registry activities We will be contacting stroke coordinators to schedule a shadow day to determine barriers to implementing the Tobacco Quit Line Referral Program We are working to determine the feasibility of making the Referral Form electronic GTQL resources will be distributed to stroke coordinators
As health care providers, please remember to ASK all patients about tobacco use, ADVISE them about the benefits of tobacco cessation, REFER them to the Georgia Tobacco Quit Line (1-877-270-STOP), COMPLETE the Georgia Tobacco Quit Line fax Referral Form, and INFORM the patient that they will be contacted by GTQL staff member.
For more information, please contact Victoria N. Davis at 404-463-8917 or victoria.davis@dph.ga.gov
GCASR Updates
Quality Improvement Our quality team strives to provide continuous improvements utilizing QI tools and common frameworks. The quality improvement consultant for the Georgia Coverdell Stroke Registry provides a variety of services including:
Facilitation of mock survey visits
PDSA/PDCA assessments
Analysis of data quality report
Identification of opportunities for improvement
Educational review and interpretation of data elements
During this year, we will be reaching out to non-primary stroke centers (PSC) on a quarterly basis to evaluate needs for each facility. Beginning March 2016, we will be scheduling site visits for facilities that we are unable to contact via phone or email. Our objective is to enhance the relationship we have with each of our non-primary stroke centers and continue the facilitation of efforts while discovering improved methods to deliver enhanced stroke care and service.
Hospital Mentorship Program
In addition to the technical assistance we provide via our QI consultants, we also have a Hospital Mentorship Program that partners hospitals who are non-Primary Stroke Centers with hospitals who are primary stroke centers. The Program builds and enhances relationships between hospitals to provide technical assistance where there is a need. Over the next couple of months, we will be assessing which hospitals are interested in becoming a mentor and which hospitals are interested in receiving assistance.
These activities builds upon and enhances our mission of providing defect-free care to stroke patients in Georgia.
Submitted by: Victoria Davis, GCASR Evaluator and Sanita Floyd, GCASR QI Consultant

Recognition of Stroke Systems and Fast Response by Safety and Medical Personnel get Stroke Victim Advanced treatment
Most people look forward to retirement, but Nancy Kilby of Rabun County enjoyed working as a hairdresser until the age of 75. Her love for her clients kept her going, but in November 2015 she suffered a massive stroke.
Fortunately for Kilby, she received immediate medical care within the three-hour window for stroke patients. It was actually the Sheriff of Rabun County, her neighbor, who recognized Kilby was having a stroke and called 9-1-1. She was transported by Rabun County EMS to Habersham Medical Center in Demorest, a Certified Primary Stroke Center, less than 40 miles from her home. There, she was given the tissue plasminogen activator clot-busting drug to help dissolve her partial brain blockage. She was then transported by medical helicopter to Grady Memorial Hospital in Atlanta for endovascular rescue treatment.
Upon arrival at Grady, Kilby underwent an advanced stent placement and arterial blood clot removal and within a few days she was discharged with remarkably, only minor motor limitations. She did, however, have aphasia, which is difficulty with speech, slight facial paralysis and loss of fine motor grasping.
According to Dr. Chris Ratchford, her attending ED physician at Habersham Medical Center, "Ms. Kilby was at the right place at the right time. The medical advances in stroke care are remarkable and not only save lives, but also get patients back on their feet; doing what they love to do. A good quality of life with very little limitations after a stroke is very important. Habersham Medical Center is fortunate to have partnerships with area EMS services and advanced stroke care facilities, like the Marcus Stroke and Neuroscience Center at Grady. Their exceptional endovascular treatment and fast response times greatly enhance the treatment options available to patients from rural areas."
For Kilby, she was grateful to be home for the holidays surrounded by her supportive family. Submitted by: April James, Director of Business Development, Habersham Medical Center
Seeing Stroke from the Other Side
Experiencing stroke from the family member perspective really opened my eyes to what our patients' and families' experience when they are suddenly admitted for a stroke or any other unplanned event. My father was admitted to Gwinnett Medical Center during the night on a weekend in September. I got a call around 22:00 that EMS had been called for my Dad because he may be experiencing a stroke. I was already in bed, and had just fallen asleep, so I felt disoriented momentarily before the panic set in. As healthcare workers, we tend to imagine the worst!
Fortunately, my husband drove me to the hospital while I made all the calls to my brothers and sister. On arrival I was shown to my father's room while the CT and CTA were done. Initially, no one recognized that I am the Stroke Program Coordinator, and yet the staff frequently checked in with me and my family to keep us updated and to provide reassurance. It seems that you tend to loose objectivity when it is your own loved one, and yet I had to help make important decisions about my father's care. It made me reflect on how our patients' families, that do not have any healthcare background, must struggle to make decisions when they themselves are stressed.
The census was high, so we spent most of the night in the Emergency Department while my poor dad endured frequent reassessments by the hospital staff and myself. My dad's symptoms deteriorated before they improved, and this added additional stress and worry. Weariness from exhaustion and worry began to set in making it hard to hold back tears. As healthcare professionals, we witness patient changes so often that we don't realize the impact on our families. I was at the bedside less than 24 hours, and yet some of our families rarely go home. I can see why some of our families are rather emotional or short tempered!
Though my dad had a minor stroke, it took a big emotional toll on me and my dad. I cannot imagine anything life threatening like we see every day. I would not have gotten through this without the support of the staff every step of the way from the Emergency Department, our terrific Neuroscience staff, physicians (from our system and Grady), Rehab services, imaging, dietary and so many more. As healthcare workers, we do not realize how much a kind word or deed impacts the patient and family for months to follow. So, besides making sure each of our patients meets all our Core Measures, remember the emotional impact each one is experiencing.
Submitted by: Susan Gaunt, Stroke Program Coordinator, Gwinnett Medical Center

Coverdell Highlights
December Conference Call Thank you to Teri Newsome, Director of Quality and Patient Safety Officer at Habersham Medical Center; Nancy Palmer, Manager of Medical Records and coding at Habersham Medical Center and Priscilla Adams, Quality Clinical Coordinator at Habersham Medical Center, who presented on ICD-10 Codes. Teri, Nancy and Priscilla helped clarify all the challenges that they are faced with regarding the new codes.
February Conference Call Our February 1st Conference Call had several presentations. Dr. Frankel, the Lead Neurologist for the Georgia Coverdell Acute Stroke Registry, reviewed the new FDA recommendation for tPA, Dr. O'Neal, the Health Protection Director at DPH, discussed "Telemedicine in Georgia" and Rana Bayakly, the PI for the GCASR and Victoria Davis, the evaluator for the GCASR, continued discussions regarding the Georgia Quit Line. We would like to take this opportunity to thank Dr. Frankel, Dr. O'Neal, Rana and Victoria for presenting on the February call.
March 30th. Abstraction Training Workshop and ICD-10 Codes
The Coverdell Stroke Registry will be offering a workshop on March 30th 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.