2020 data summary: Georgia Coverdell Acute Stroke Registry

2020 Data Summary Georgia Coverdell Acute Stroke Registry (GCASR)

DISEASE BURDEN In 2019, 20,929 Georgians were hospitalized for
acute stroke or transient ischemic attack in 120 Georgia hospitals. Total stroke hospitalization charges were more than $1.6 billion, with a median charge per patient of about $41,257. Based on the Georgia Coverdell Acute Stroke Registry and Georgia death data, mortality from acute ischemic stroke and its complications in Georgia during 2019 was estimated to be:
o 6.9 percent at 30 days post-incident o 16.1 percent 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 (PCNASP).
GCASR is a partnership between the Georgia Department of Public Health (DPH) Epidemiology, DPH Office of EMS, Emory University, American Heart Association, Alliant Health Solutions, Georgia Hospital Association, CDC/PCNASP, and the participating hospitals, rehabilitation centers, and Emergency Medical Services (EMS) agencies.
GOALS OF THE GCASR Reduce morbidity, mortality, 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, post-acute care facilities, and EMS agencies join GCASR voluntarily.
During 2020 in Georgia, 46 EMS agencies and 83 hospitals participated in GCASR, of which 48 were Joint Commission- or Det Norske Veritas-certified comprehensive or primary stroke centers and 21 were Georgia DPH-designated remote treatment stroke centers.

Based on the 2019 hospital discharge data, GCASR-participating hospitals serve about 96 percent of stroke admissions in Georgia.
DATA COLLECTION Data about stroke patient characteristics and care
received are collected by GCASR-participating hospitals for patients admitted with acute stroke or transient ischemic attack. Data about EMS performance measures are obtained through the Georgia EMS Information System (GEMSIS). The data collection aims at measuring and monitoring the quality of pre-hospital and in-hospital stroke care delivery in Georgia. 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.
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Organized mentorship among the participating facilities.
Acute Stroke Life Support (ASLS) 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
The quality of care received by stroke patients is measured by indicators representing care processes 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 prehospital care:
1. On-the-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 105,608 stroke patients' admissions to GCASR-participating hospitals during 2015 to 2019 and 8,157 presumable stroke patients transported by 42 EMS agencies from the field in 2019.

In Georgia during 2019, among patients transported by EMS with provider impression of stroke/cerebrovascular accident or transient ischemic attack: 75 percent had a stroke screen completed and recorded 50 percent had their blood glucose checked and recorded Median on-the-scene time was 15 minutes, and 46 percent had an on-scene time less than 15 minutes Median travel time from scene to hospital was 14 minutes Median time from 911 call to hospital arrival was 43 minutes
Figure 1. Types of Stroke, GCASR Admissions, 2019 (n=24,343)
In 2019, among 24,343 acute stroke admissions in GCASR facilities: Ischemic stroke and transient ischemic attack accounted for 83 percent of admissions (Figure 1). Forty-four percent of stroke admissions were for patients brought to the hospital by EMS, 38 percent by private transportation, and 17 percent were transferred from one healthcare facility to another. Hospitals received pre-notification from EMS for 57 percent of the stroke admissions brought by EMS. Of the total 24,343 GCASR patients in 2019, 27 percent were previously admitted with stroke and 9 percent had a previous TIA admission. Seventy-nine percent of stroke admissions had a history of hypertension, of which 75 percent were on antihypertensive medication during the week prior to their admission for acute stroke. Of the 24,343 GCASR admissions, 261 were newly diagnosed with diabetes during admission for acute stroke. About 55 percent of all stroke admissions in Georgia resulted in discharge to home.
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Table 1. Most frequent co-morbidities among stroke patients (n=24,343) and prevalence among adult Georgians, GCASR, 2019

Co-Morbidity
Hypertension Dyslipidemia

Acute Stroke Patients (%)a
79.2
44.0

Adult Georgians
(%)b
34.81
32.4

Diabetes Mellitus CADc/Prior MI

35.8

12.0

20.5

6.4

Atrial Fibrillation/Flutter

14.3

--

Smoking

21.5

16.3

Note: a - GCASR 2019; b - Georgia Behavioral Risk Factors Surveillance System 2019; c - Coronary Artery Disease

For ischemic stroke patients, prompt thrombolytic treatment, if eligible, is critical for better survival and functional outcomes. In 2019, among ischemic stroke patients admitted
to GCASR-hospitals with symptom onset time noted, 31 percent (2,890/9,458) arrived at the emergency department within 2 hours from the last time they were known to be well. Among these, 72 percent (2,067/2,890) had their brain image taken within 25 minutes of hospital arrival and 37 percent (1,071/2,890) were eligible, without contraindications, for Alteplase. Among the Alteplase-eligible patients, 93 percent (1,000/1,071) received intravenous thrombolytic treatment within 3 hours after symptom onset. Among eligible patients treated with a thrombolytic agent, 46 percent (519/1,028) and 70 percent (763/1,028) received intravenous Alteplase within 45 minutes and within an hour of arrival at the emergency department, respectively. In 2019, the median time to receive Alteplase for eligible ischemic stroke patients arriving within two hours of symptom onset was 45 minutes.

Figure 2. Percentage of ischemic stroke patients receiving intravenous or intraarterial Alteplase treatment, GCASR, 2015-2019 (n=74,464)

16

15.8

14.0

14.5

13.2

12.2

12

Percent

8

4

0 2015 2016 2017 2018 2019
Note: In 2008, only 4.9 percent received IV Alteplase.

CHANGES OVER TIME (GCASR HOSPITALS), 2015-2019
Overall, Alteplase administration among ischemic stroke patients increased from 12.2 percent in 2015 to 15.8 percent in 2019 (Figure 2).
The percentage of patients who received defect-free care showed no consistent increase from 2015 to 2019 (79 percent) (Figure 3).
The median time from symptom onset to hospital arrival among patients with ischemic stroke has fluctuated between 2015 and 2019 (Figure 4).
A stroke alert system expedites in-hospital patient care. However, the percentage of patients transported by EMS with hospital pre-notification increased from 54 percent in 2015 to 57 percent in 2018, albeit inconsistently (Figure 5).
The percentage of eligible ischemic stroke patients who received intravenous Alteplase within 3 hours of symptom onset increased from 75 percent in 2015 to 93 percent in 2019.
Those who received the treatment within 45 minutes of hospital arrival increased from 40 percent in 2015 to 50 percent in 2019 (Figure 6).
The median times from hospital arrival to take a brain image and administer Alteplase intravenously (door-to-treatment time) were shortened from 15 and 52 minutes in 2015 to 14 and 45 minutes in 2019, a reduction of 7 and 13 percent, respectively (Figures 7 & 8).

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Figure 3. Percentage of acute stroke patients who received defect-free care, GCASR, 2015-2019 (n=82,694)

100

80

77

79

78

76

79

60

Percent

40

20

0 2015 2016 2017 2018 2019
Note: In 2008, 37 percent had defect-free care.

Figure 5. Percentage of stroke patients transported by EMS with hospital pre-notification, GCASR, 2015-2019 (n=45,527)

100

80

60

54

59

52

54

57

Percent

40

20

0 2015 2016 2017 2018 2019
Note: In 2008, 48.4 percent of stroke patients transported by EMS had hospital prenotification.

Figure 7. Trend in median door-to-imaging time among ischemic stroke patients who arrived at a hospital within 120 minutes of symptom onset, GCASR, 2015-2019 (n=12,058)

50

Minutes (Max= 1,397)

40

30

31

28

29

29

27

20

15

13

15

15

14

10

7

7

8

8

8

0 2015 2016 2017 2018 2019

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

Figure 4. Trend in median symptom onset to hospital arrival time among Acute Ischemic Stroke patients, GCASR, 2015-2019 (n=34,590)

450

404

406

424

414

375

300

Minutes (Max = 14366)

150

120

130

130

124

125

58

60

60

58

59

0 2015 2016 2017 2018 2019

Note: In 2008, the median symptom onset to hospital arrival time was 122 minutes.

Figure 6. Percentage of eligible ischemic stroke patients treated with intravenous Alteplase within 45 minutes of hospital arrival, GCASR, 2015-2019 (n=4,627)

60

50

45 40

41

43

46

Percent

30

15

0 2015 2016 2017 2018 2019
Note: In 2008, 8.7 percent of eligible ischemic stroke patients received IV alteplase within 45 minutes of hospital arrival.
Figure 8. Trend in median door-to-treatment time among eligible ischemic stroke patients treated with intravenous Alteplase, GCASR, 2015-2019 (n=4,627)
100

Minutes (Max = 214)

80

71

60

67

66

65

62

52

51

50

48

45

40

37

37

35

36

33

20 2015 2016 2017 2018 2019
Note: In 2008, the median door-to-treatment time was 82 minutes.

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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: difficulty of 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-strokeregistry

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