2017 data summary: Georgia Coverdell Acute Stroke Registry

The Georgia Department of Public Health

2017 Data Summary
Georgia Coverdell Acute Stroke Registry

DISEASE BURDEN In 2015, about 22,298 Georgians were hospitalized
for acute stroke or transient ischemic attack in 126 Georgia hospitals. Total stroke hospitalization charges were over $1.1 billion, with a median charge per patient of about $31,140. Based on the Georgia Coverdell Acute Stroke Registry and Georgia death data, mortality from stroke and its complications in Georgia during 2016 was estimated to be:
o 9.8% at 30 days post-incident o 20.4% at 1 year post-incident
PROGRAM OVERVIEW
The Georgia Coverdell Acute Stroke Registry (GCASR) is named in honor of the late Senator Paul Coverdell of Georgia who died of a massive stroke in 2000.
GCASR is funded by the Centers for Disease Control and Prevention (CDC) as part of the Paul Coverdell National Acute Stroke Program.
GCASR is a partnership between the Georgia Department of Public Health (DPH) Epidemiology, DPH Office of EMS, Emory University, American Heart Association, American Stroke Association, Georgia Medical Care Foundation, Georgia Hospital Association, CDC, and the participating hospitals, rehabilitation centers, and Emergency Medical Services (EMS) agencies in Georgia.
GOALS OF THE GCASR
Reduce fatalities and disability due to stroke and the incidence of recurrent stroke in Georgia by: 1. Monitoring and improving the quality of prehospital, in-hospital, and post-hospital discharge care of stroke patients. 2. Encouraging collaboration among EMS providers, hospitals, rehabilitation facilities, home health services, and other institutions in Georgia concerned with stroke care quality improvement.

PARTICIPATION
Hospitals, rehabilitation facilities, home health services, and EMS agencies join GCASR voluntarily.
In Georgia, currently 20 EMS agencies and 68 hospitals participate in GCASR, of which 44 are Joint Commission- or Det Norske Veritas-certified comprehensive or primary stroke centers and 10 are Georgia DPH-designated remote treatment stroke centers.
Based on the 2015 hospital discharge data, GCASRparticipating hospitals serve about 90% percent of stroke admissions in Georgia.

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October 2017

2017 GCASR Data Summary

DATA COLLECTION
Data about stroke patient characteristics and care received are collected by participating hospitals for patients admitted with acute stroke or transient ischemic attack from the GCASR.
Data about EMS performance are obtained through the Georgia EMS Information System (GEMSIS).
The purpose of data collection is to measure and monitor the quality of pre-hospital and in-hospital stroke care delivery.
QUALITY IMPROVEMENT ACTIVITIES
Hospitals and EMS agencies participating in GCASR receive:
Individualized stroke care quality improvement consultation
Regular educational conference calls and newsletters to share best practices among participating hospitals and EMS providers
Regular trainings to enhance skills and exchange best practices
Organized mentorship among the participating facilities
Acute Stroke Life Support training Quality improvement efforts focused currently on
thrombolytic treatment for eligible stroke patients and door-to-needle time
Development of tools to strengthen EMS-hospital communication
QUALITY INDICATORS
Quality of care received by stroke patients is measured by indicators representing care processes that have been included in clinical recommendations.
Quality indicator calculations include identification of patients for whom a care process would have been recommended, and a determination of how many of those patients received the recommended care.
The 13 GCASR in-hospital care quality indicators are: 1. Administration of tissue plasminogen activator 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. Smoking cessation counseling or treatment 8. Rehabilitation assessment 9. Prescription for antithrombotic medication at
discharge 10. Prescription for anticoagulant medication for
patients with atrial fibrillation 11. NIH stroke scale score recorded 12. Door-to-image time 13. Intravenous Alteplase within 60 minutes of
hospital arrival
Defect-free care is defined as the delivery of care meeting all quality indicators for which a patient is eligible
Based on GEMSIS data, three performance measures are used to monitor the quality of pre-hospital care:
1. On-scene time < 15 minutes 2. Transports with a stroke screen completed and
recorded 3. Transports with a blood glucose checked and
recorded
STROKE REGISTRY & GEMSIS DATA
Analysis included data from 84,893 stroke patients' admissions to GCASR-participating hospitals during 2012 to 2016 and 3,991 presumable stroke patients transported by 20 EMS agencies from the field in 2016.
In Georgia during 2016, among patients transported by EMS with provider impression of stroke/cerebrovascular accident or transient ischemic attack: 37.0% had pre-hospital stroke assessment done 62.7% had their blood sugar measured the median 911 call to hospital arrival time was 41 minutes the median travel time from scene to hospital was 14 minutes

2017 GCASR Data Summary

the median on-scene time was 15 minutes, and 49.4% had an on-scene time less than 15 minutes
Figure 1. Types of Stroke, GCASR Admissions, 2016 (n=19,587)
In 2016, among acute stroke admissions in GCASR facilities: Ischemic stroke and transient ischemic attack accounted for 84 percent of the admissions (Figure 1). Forty-seven percent of stroke admissions were for patients brought to the hospital by EMS, 37 percent by private transportation, and 16 percent were transferred from one healthcare facility to another. Hospitals received pre-notification on 63 percent of the stroke admissions brought by EMS. Of the total 19,587 GCASR patients in 2016, 27% were previously admitted with stroke and 10% had a previous TIA admission. Seventy-nine percent of stroke admissions had a history of hypertension, of which 78 percent were on antihypertensive medication during the week prior to admission for acute stroke. Of the 19,587 GCASR patients, 221 were newly diagnosed with diabetes during admission for acute stroke.

About 55 percent of all stroke admissions resulted in discharge to home.

Table 1. Most frequent co-morbidities among stroke patients (n=19,587) and prevalence among adult Gerogians

Comorbidity
Hypertension Dyslipidemia Diabetes Mellitus CADc/Prior MI

Acute Stroke Patients (%)
79.1 41.5 36.0 21.7

Adult Georgians
(%) 35.7a
36.5a
12.6b
6.9b

Atrial Fibrillation/Flutter

14.1

--

Obesity/Overweight

28.1

66.2b

Smoking

21.3

19.1b

Note: - GCASR 2016; - Georgia Behavioral Risk Factors Surveillance System 2015 (a) or 2016(b) data; c Coronary Artery Disease

For ischemic stroke patients, prompt thrombolytic treatment, if eligible, is critical for better survival and functional outcomes. In 2016, among ischemic stroke patients admitted to
GCASR-hospitals with symptom onset time noted, 33 percent (2,323/7,091) arrived at the emergency department within 2 hours from the last time they were known to be well. Among these, 68 percent (1,585/2,323) had their brain image taken within 25 minutes of hospital arrival and 42 percent (972/2,323) were eligible, without contraindications, for Alteplase. Among the Alteplase-eligible patients, 90 percent (874/972) received intravenous thrombolytic treatment within 3 hours after symptom onset. Among eligible patients treated with a thrombolytic agent, 40 percent (362/896) and 68 percent

2017 GCASR Data Summary

(607/896) received intravenous Alteplase within 45 minutes and within an hour of arrival at the emergency department, respectively. In 2016, the median time to receive Alteplase for eligible ischemic stroke patients arriving within two hours of symptom onset was 51 minutes.
Figure 2. Percentage of ischemic stroke patients receiving intravenous Alteplase treatment, GCASR, 2012-2016 (n=58,077)

Alteplase intravenously (door-to-needle time) were shortened from 22 and 65 minutes in 2012 to 13 and 51 minutes in 2016, a reduction of 41 and 22 percent, respectively (Figures 5 & 6). The percentage of patients transported by EMS with hospital pre-notification increased from 56 percent in 2012 to 63 percent in 2016, albeit inconsistently. (Figure 7)
Figure 3. Percentage of acute stroke patients who received defect-free care, GCASR, 2012-2016 (n=66,978)

Note: In 2008, only 4.8% received IV Alteplase.
IMPROVEMENTS OVER TIME (GCASR HOSPITALS) Overall, intravenous Alteplase administration among
ischemic stroke patients increased from 8.3 percent in 2012 to 10.4 percent in 2016 (Figure 2). The percentage of patients who received defect-free care increased slightly from 75 percent in 2012 to 79 percent in 2016 (Figure 3), indicating improvement in all ten performance measures on aggregate. The percentage of eligible ischemic stroke patients who received intravenous Alteplase within 3 hours of symptom onset consistently remained at around 90%. Those who received the treatment within 60 minutes of hospital arrival increased from 43 percent in 2012 to 68 percent in 2016 (Figure 4). The median times to take a brain image and administer

Note: In 2008, 37% had defect-free care.

2017 GCASR Data Summary

Figure 4. Percentage of eligible ischemic stroke patients treated with intravenous Alteplase within 60 minutes of hospital arrival, GCASR, 2012-2016 (n=3,599)

Figure 6. Trend in median door-to-treatment time among eligible ischemic stroke patients treated with intravenous Alteplase, GCASR, 2012-2016 (n=3,599)

Note: In 2008, 24% of eligible ischemic stroke patients received IV alteplase within 1-hour of hospital arrival.
Figure 5. Trend in median door-to-imaging time among ischemic stroke patients who arrived at a hospital within 120 minutes of symptom onset, GCASR, 2012-2016 (n=9,398)

Note: In 2008, the median door-to-treatment time was 82 minutes.
Figure 7. Percentage of stroke patients transported by EMS with hospital pre-notification, GCASR, 2012-2016 (n=37,477)

Note: In 2008, the median door-to-imaging time was 31 minutes.

Note: In 2008, 51% of patients transported by EMS had hospital prenotification and received IV Alteplase.

2017 GCASR Data Summary

DEFINITIONS
Stroke: brain tissue death; can be the result of a thrombus (blocked artery) or a hemorrhage (ruptured artery) which prevents blood flow to the brain
Transient ischemic attack: temporary blockage of cerebral blood flow that causes a short-lived neurological deficit
Deep Vein Thrombosis (DVT): blood clot located in a large vein; a potential complication of stroke
Dysphagia: problems swallowing; a potential complication of stroke that can lead to pneumonia

Antithrombotic: medication administered to prevent platelets or clotting factors in the blood from forming a blood clot
Anticoagulation: administration of medications to prevent clotting of the blood
Tissue plasminogen activator (Alteplase): a thrombolytic medication administered to eligible acute ischemic stroke patients to reestablish blood supply to the brain

FOR MORE INFORMATION ON GCASR, PLEASE VISIT http://dph.georgia.gov/georgia-coverdell-acute-stroke-registry