Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Deb Motz; Dicky Huey; Tracy Moore; Byron Freemyer; Tommye Austin

doi:10.1161/str.44.suppl_1.awp363

Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Stroke ◽

10.1161/str.44.suppl_1.awp363 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Deb Motz ◽

Dicky Huey ◽

Tracy Moore ◽

Byron Freemyer ◽

Tommye Austin

Keyword(s):

Administrative Support ◽

Medical Center ◽

Academic Medical Center ◽

Stroke Care ◽

Multidisciplinary Teams ◽

Hospital System ◽

Order Sets ◽

Primary Stroke Center ◽

Stroke Center ◽

Evidenced Based

Background: In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified. Methods: The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care. Results: This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters. Conclusion: In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.

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Abstract T P333: Impact of Tele-Stroke Network on Door to Needle Times and TPA Use in Rural and Urban Community Hospitals

Stroke ◽

10.1161/str.46.suppl_1.tp333 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Erin A Greene ◽

Jeri Braunlin ◽

Julie Neff ◽

Tari Walker ◽

Ivy Thoman ◽

...

Keyword(s):

Patient Outcomes ◽

Care Delivery ◽

Nurse Specialist ◽

Community Hospitals ◽

Stroke Patients ◽

Hospital System ◽

Order Sets ◽

Primary Stroke Center ◽

It Training ◽

Stroke Center

Background: This project describes one healthcare system’s journey to expand the outreach of the Primary Stroke Center. Premier Health (PH) is a hospital system based in Dayton Ohio that provides services for over 2,200 stroke patients annually. Premier Health consists of 5 community hospitals 3 of which are Joint Commission certified Primary Stroke Centers. The requirement for Stroke Specialized Physicians on-call 24 hours a day had become more difficult with expansion of services to respond to community needs. With a limited number of Stroke Physicians within system, it was not feasible for available Physician’s to cover the 50 mile radius. A Tele-Stroke Network was developed to provide lifesaving services as well as 24/7 coverage for stroke call. Program results include synergistic unity of best practices and improved patient outcomes with the majority of patients remaining in their community. Purpose: Implement a Tele-Stroke System to provide specialty coverage and favorable patient outcomes for a Primary Stroke Center that provides coverage for a large region in the Midwest. Methods: In 2013 a stroke telehealtlh Clinical Nurse Specialist role was added and became pivotal in facilitating the following outcomes: 1) Restructuring of the Stroke Alert Call Schedules across the system. 2) Streamlining Stroke Alert Process across the system and redesign of work flows 3) Development of standard system order sets to streamline care delivery. 4) Providing IT training to end users and physicians at five hospitals. Results: • 304 Tele-Stroke consults conducted since implementation. • 33% increase in the volume of patient’s receiving T-PA • Average of 20 minutes reduction in Door to Needle for 2 of the 5 hospitals • Post telemedicine implementation there was a reduction in transfers from spoke hospitals to hub. On average, 83 % of the PH Tele-Stroke patients were able to stay in their respective communities while receiving Primary Stroke Center Care via telemedicine. Conclusion: Telemedicine implementation with standardization of stroke alert processes and order sets, restructuring of physician scheduling and IT training for the Primary Stroke Team resulted in improved t-PA use, lower door to needle time and reduction in unnecessary transfers of patients.

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In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

The Neurohospitalist ◽

10.1177/19418744211007001 ◽

2021 ◽

pp. 194187442110070

Author(s):

Felix Ejike Chukwudelunzu ◽

Bart M Demaerschalk ◽

Leonardo Fugoso ◽

Emeka Amadi ◽

Donn Dexter ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Statistical Significance ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Community Based ◽

Chi Square ◽

Stroke Team ◽

Primary Stroke Center ◽

Stroke Center

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

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Abstract 2197: Telestroke: Optimizing Access to Emergency Interventions in Acute Stroke Care

Stroke ◽

10.1161/str.43.suppl_1.a2197 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Rayetta Johnson

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Health Care Providers ◽

Positive Impact ◽

Medical Center ◽

Stroke Care ◽

Nurse Specialist ◽

Care Providers ◽

Acute Stroke Care ◽

Evidenced Based

Background and Issues: The burden of stroke in North Carolina is one of the highest in the nation (approximately 28,000 stroke hospitalizations from 2003-2007). The number and high costs of stroke have made it incumbent to improve the numbers of patients receiving effective treatment. There are two major barriers for treatment of acute stroke: time and access. The utilization of telestroke in community hospitals aids in decreasing these barriers by providing immediate access to a stroke neurologist. In order for telestroke to be successful, awareness and education regarding acute stroke care must be provided for health care providers as well as the communities. Thus, the development of a telestroke system requires nursing and medical expertise. The Primary Stroke Center Team at Wake Forest Baptist Medical Center in Winston-Salem, N.C. implemented a telestroke network system (Intouch's Health's RP-7 Robotic system) in January of 2010 to provide 24/7 access to the medical center's acute stroke experts and the latest advancements in stroke interventions. There are eight hospitals in the network at the present time. Methods: Our team identified that many of the network hospital's staff are not experienced in taking care of a stroke patient and that a “roadmap” is useful to guide them in these steps.The stroke nurse specialist developed a quality improvement plan for the network hospitals which included: an evidence-based algorithm for patient care; stroke education, in particular, neurological assessment and tPA administration classes for the ED staff; quarterly meetings to provide outcome and feedback data with each network hospital; stroke awareness events for the community. Mock telestroke consults were also performed prior to “going live” with telestroke for each of the network hospitals. Of utmost importance is the early involvement and education of the EMS system in the respective county of the network hospital. The buy-in of EMS was found to be a key component in the success of the network. Finally, attention to customized quality improvement efforts for each of the facilities are required to accomplish integration into the telestroke network. Results: The data has been analyzed, and thus far, a 24% rate of tPA administration has been seen with our network hospitals (an increase from the 3.6% national average). Comparisons between each of the eight network hospitals' rates of administration of tPA prior to and after joining the network show a trend of increase (10%-40%). The effectiveness of the algorithm has also been explored by analysis of feedback and initial results have shown a positive impact. Conclusion: A combination of improving access to stroke neurologists in conjunction with a focus on improving the level of care via evidenced based stroke care teaching and implementation of algorithms at a network hospital is required for implementing and building a successful telestroke network.

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Abstract W P345: Strength in Numbers: Stroke Coordinators Improving Care Through Collaboration

Stroke ◽

10.1161/str.46.suppl_1.wp345 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Kathy Morrison ◽

Keyword(s):

Best Practice ◽

Medical Center ◽

Academic Medical Center ◽

Stroke Care ◽

Direct Care ◽

Emergency Responders ◽

Program Manager ◽

Group Data ◽

Suspected Stroke ◽

Host Organization

Background: Stroke care evolution has been remarkable since 2000, when the Brain Attack Coalition published their recommendations for Primary Stroke Centers. For the first time, hospitals had evidence-based standards to improve patient outcomes. Today, many states require emergency responders to take suspected stroke patients only to certified stroke centers. As a result, many hospitals have established the role of stroke coordinator to oversee the myriad facets of stroke care. Coordinators are overwhelmed with the opportunities - and responsibilities - to improve care processes. Method: In 2009, the stroke program manager at a Magnet academic medical center established a regional stroke coordinators’ group. Eight coordinators met and established milestones for success. Information has been shared and nurses have traded services, providing education for each other’s organization. The group of now 28 coordinators meets every other month. Results: Positive outcomes of membership in this dynamic group include a 65% increase in professional membership in American Association of Neuroscience Nurses. In addition, the coordinators report confidence and empowerment to impact change in their own organization that improved care and outcomes. Aggregate group data demonstrates improvement in the following measures: thrombolytic administration 44%; door-to-needle time 16%; & patient education 12%. Nine additional hospitals (from 6 to 17, a 183% increase) have attained Advanced Primary Stroke certification and the host organization achieved Comprehensive Stroke certification. Conclusion: Neuroscience nurses are influential leaders - not just within their own organization. These outcomes demonstrate the mutual benefit of stroke coordinator colleagues working together and sharing best practice strategies. Through multi-organizational collaboration, they have become empowered to establish programs and become experts within their organization, able to guide and improve the care provided by their own direct-care nurses.

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Surge capacity and capability of intensive care units across a large healthcare system: An operational blueprint for regional integration

American Journal of Disaster Medicine ◽

10.5055/ajdm.2021.0400 ◽

2021 ◽

Vol 16 (3) ◽

pp. 179-192

Author(s):

Abhijit Duggal, MD, MPH, MSc ◽

Erica Orsini, MD ◽

Eduardo Mireles-Cabodevila, MD ◽

Sudhir Krishnan, MD ◽

Prabalini Rajendram, MD ◽

...

Keyword(s):

Resource Allocation ◽

Intensive Care ◽

Healthcare System ◽

Regional Integration ◽

Medical Center ◽

Academic Medical Center ◽

Healthcare Services ◽

Surge Capacity ◽

Hospital System ◽

The Individual

Objective: Many hospitals were unprepared for the surge of patients associated with the spread of coronavirus disease 2019 (COVID-19) pandemic. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system.Setting: A large academic medical center in the Cleveland metropolitan area, with a network of 10 regional hospitals throughout Northeastern Ohio with a daily capacity of more than 500 intensive care unit (ICU) beds.Results: At the beginning of the pandemic, an equitable delivery of healthcare services across the healthcare system was developed. This distribution of resources was implemented with the potential needs and resources of the individual ICUs in mind, and epidemiologic predictions of virus transmissibility. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system. We also describe an additional level of surge capacity, which is available to well-integrated institutions called “extension of capacity.” This refers to the ability to immediately have access to the beds and resources within a hospital system with minimal administrative burden.Conclusions: Large integrated hospital systems may have an advantage over individual hospitals because they can shift supplies among regional partners, which may lead to faster mobilization of resources, rather than depending on local and national governments. The pandemic response of our healthcare system highlights these benefits.

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Abstract W P296: Establishing a Stroke Protocol Based on the Trauma Model

Stroke ◽

10.1161/str.45.suppl_1.wp296 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mary Ann Blosky ◽

E. Andrew Raposo

Keyword(s):

Program Development ◽

Medical Center ◽

Clinical Signs ◽

The State ◽

Joint Commission ◽

High Performing ◽

Time Of Application ◽

Primary Stroke Center ◽

Stroke Center ◽

Trauma Model

Background and Purpose: In the summer of 2012, the state of Pennsylvania adopted legislation mandating EMS providers to deliver all patients with clinical signs of stroke to a certified stroke center for evaluation. In response to this change, development of a new stroke program began at a tertiary medical center located in the northeastern region of the state. The facility was a certified trauma center and also held various other disease specific certifications through the Joint Commission. This project sought to examine the needs of a newly developing primary stroke center within the context of a healthcare organization with numerous other specialized medical and surgical programs. Specifically, the investigators hoped to illustrate the similarities between stroke and other specialized services to demonstrate that many of the requirements of these programs are shared. Method: The site stroke clinical coordinator and system stroke program coordinator kept detailed records of all phases of stroke program development. As resource needs were identified, notation was made indicating whether or not those resources were already available in the hospital. By examining these records, the coordinators were able to identify how many of the resources needed to develop an effective stroke program were already present within the system. Results: Information was collected beginning at the inception of program development in 2012 through the time of application for Joint Commission Primary Stroke Center certification in August of 2013. During these 9 months, many of the needed resources were found to already exist in the facility, with most having been created or added as a result of the hospital’s trauma program development several years earlier. Conclusion: The hospital was able to develop a high performing stroke center with comparative ease due to the preexisting resources from the institution’s trauma program. It is the belief of the stroke team that these results could be easily duplicated in other facilities with trauma services that wish to expand into stroke specialization as well.

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Abstract WP455: Memorial Hermann Hospital System Stroke Coordinators: Working as One

Stroke ◽

10.1161/str.51.suppl_1.wp455 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sandi G Shaw ◽

Isabel Gonzales ◽

Hari Indupuru ◽

Nicole Harrison ◽

Sean Savitz ◽

...

Keyword(s):

Best Practice ◽

Quality Care ◽

High Volume ◽

Work Load ◽

Joint Commission ◽

Large Hospital ◽

Hospital System ◽

Primary Stroke Center ◽

Stroke Center ◽

The Joint Commission

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention. Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification. Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS). Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%. Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

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Abstract 2623: Racial Disparities in Hospital Length of Stay among Native Hawaiians and other Pacific Islanders with Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2623 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Kazuma Nakagawa ◽

Matthew Koenig ◽

Todd Seto ◽

Susan Asai ◽

Cherylee Chang

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Medical Center ◽

Parameter Estimate ◽

Hospital Length ◽

Pacific Islanders ◽

Native Hawaiians ◽

Hospital Length Of Stay ◽

Primary Stroke Center ◽

Stroke Center

Introduction: Native Hawaiians and other Pacific Islanders (NHPI) with ischemic stroke are younger and have more comorbidities compared to other major racial-ethnic groups. However, their impact on hospital length of stay (LOS) after ischemic stroke has not been studied. Hypothesis: We assessed the hypothesis that NHPI race is associated with a longer hospital LOS after ischemic stroke. Methods: Data from 2004 to 2010 were retrospectively obtained from the Get With the Guidelines-Stroke (GWTG-Stroke) database from The Queen’s Medical Center, the only primary stroke center for the state of Hawaii. Multivariable analyses were performed using a stepwise linear regression model to identify factors predictive of hospital LOS after ischemic stroke. Results: A total of 1921 patients hospitalized for ischemic stroke (NHPI 20%, Asians 53%, whites 24%, blacks 0.8%, others 2%) were studied. Univariate analyses showed that NHPI were younger (mean ages, NHPI 60±14 vs. Asians 72±14, p <0.0001; vs. whites 71±14, p <0.0001) and had higher prevalence of diabetes (NHPI 53% vs. Asians 67%, p <0.0001; vs. whites 22%, p <0.0001), hypertension (NHPI 82% vs. whites 22%, p <0.0001), prior stroke or TIA (NHPI 30% vs. Asians 23%, p =0.01), smoking (NHPI 19% vs. Asians 14%, p =0.01), dyslipidemia (NHPI 43% vs. whites 34%, p <0.01), and longer hospital LOS (NHPI 11±17 days vs. Asians 7±9 days, p <0.0001; whites 8±17 days, p <0.05). After adjusting for age, race, gender, and risk factors with predefined significance ( p <0.1), independent predictors for hospital LOS were NHPI race (parameter estimate, 2.67; 95% CI, 1.09 - 4.22, p =0.001), atrial fibrillation/atrial flutter (parameter estimate, 2.22; 95% CI, 0.53 - 3.90, p =0.01), and age (parameter estimate, -0.04; 95% CI, -0.09 - -0.002, p =0.04). Conclusions: Native Hawaiians and other Pacific Islanders with ischemic stroke have a longer hospital length of stay compared to Asians and whites. Further studies are needed to assess if other socioeconomic factors contribute to the observed differences.

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Abstract T MP75: Facilities Available in Chinese Hospitals From China Stroke Research Network

Stroke ◽

10.1161/str.46.suppl_1.tmp75 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Chunjuan Wang ◽

Zixiao Li ◽

Yilong Wang ◽

Yong Jiang ◽

Xingquan Zhao ◽

...

Keyword(s):

Acute Stroke ◽

Mainland China ◽

Stroke Care ◽

Research Network ◽

Level Of Care ◽

Minimum Level ◽

Stroke Patients ◽

Stroke Research ◽

Primary Stroke Center ◽

Stroke Center

Background and Purpose: Stroke is the first leading cause of death in China and millions of patients were admitted to various levels of hospitals each year. However, it is unknown how many of these hospitals are able to provide an appropriate level of care for stroke patients since the certification program of comprehensive stroke center (CSC) and primary stroke center (PSC) has not been initiated in China. Method: In 2012, we selected all 554 hospitals that joined into the China Stroke Research Network (CSRN) to start a survey. These hospitals were from 31 provinces or municipalities, covered nearly the entire Mainland China. A six-page questionnaire was sent to each of them to obtain the stroke facility information. We used the same criteria and definitions for CSC, PSC, and minimum level for any hospital ward (AHW) admitting stroke patients with that of the European Stroke Facilities Survey. Results: For all the hospitals in CSRN, 521 (94.0%) returned the questionnaire, 20 (3.8%) met criteria for CSC, 179 (34.4%) for PSC, 64 (12.3%) for AHW, and 258 (49.5%) met none of them and provided a lower level of care. Hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 70 052 (8.8%), 334 834 (42.2%), 88 364 (11.1%), and 299 806 (37.8%) patients in the whole of last year. There was no 24-hour availability for brain CT scan in 4.3% of hospitals not meeting criteria for AHW, while neither stroke care map nor stroke pathway for patients admission in 81.0% of them. Conclusions: Less than two fifths of Chinese hospitals admitting acute stroke patients have optimal facilities, and nearly half even the minimum level is not available. Our study suggests that only one half acute stroke patients are treated in appropriate centers in China, facilities for hospitals admitting stroke patients should be enhanced and certification project of CSCs and PSCs may be a feasible choice.

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