1. 1 Improving Stroke Care in NEBRASKA Improving Stroke Care in NEBRASKA Nebraska Department of Health and Human Services Nebraska Cardiovascular Health Program and Nebraska Department of Health and Human Services Nebraska Cardiovascular Health Program and

2. 2 The mission of the Nebraska Stroke Advisory Council (NSAC) is to raise awareness of stroke, promote stroke prevention, and improve systems of stroke care throughout Nebraska

3. 3 Continually assess the needs and assets of stroke care in Nebraska and create action plans to improve systems based on evidence. Identify barriers and issues related to stroke care in Nebraska, especially among priority populations. Promote and advocate health policy recommendations regarding stroke care in Nebraska. Purpose of the NSAC

4. 4 Stroke in the United States  Each year about 795,000 people experience a new or recurrent stroke.  7 million stroke survivors (3% prevalence)  Stroke is the leading cause of disability.  Stroke is the fourth leading cause of death after heart disease, cancer, and chronic lower respiratory disease.  Each year about 795,000 people experience a new or recurrent stroke.  7 million stroke survivors (3% prevalence)  Stroke is the leading cause of disability.  Stroke is the fourth leading cause of death after heart disease, cancer, and chronic lower respiratory disease. Heart Disease and Stroke Statistics – 2011 Update, American Heart Association

5. Taylor et al, Stroke 1996 Roger et al, Circulation 2011  Cost to Society  40.9 Billion/Year  Lifetime Cost Stroke 2009 CPI Adjusted  Ischemic  $147,458  Hemorrhagic  $200,269  SAH  $369,581 Stroke in the United States Heart Disease and Stroke Statistics – 2011 Update, American Heart Association

6. Stroke in Nebraska Population 1.7 Million 3,453 Strokes 825 Stroke Related Deaths 26,000-36,000 Stroke Survivors (2.3%) Nebraska Behavioral Risk Factor Surveillance System 2009 Nebraska Vital Records 2008 Nebraska Hospital Discharge Data 2008

7. 7 Stroke in Nebraska  Stroke is the fourth leading cause of death in Nebraska and claimed the lives of 825 Nebraska residents 1.  Stroke death rate 15% higher in men in 2008 1.  Stroke death rates were 63% higher in African-Americans and 24% higher in Native-Americans compared to Caucasians 1.  In 2007, only 22.3% of Nebraska adults surveyed could correctly identify the stroke signs and symptoms 2.  In 2005, 64.2% of acute care hospitals in Nebraska have a written protocol in the emergency department for acute stroke 3.  Stroke is the fourth leading cause of death in Nebraska and claimed the lives of 825 Nebraska residents 1.  Stroke death rate 15% higher in men in 2008 1.  Stroke death rates were 63% higher in African-Americans and 24% higher in Native-Americans compared to Caucasians 1.  In 2007, only 22.3% of Nebraska adults surveyed could correctly identify the stroke signs and symptoms 2.  In 2005, 64.2% of acute care hospitals in Nebraska have a written protocol in the emergency department for acute stroke 3. 1Nebraska Vital Records 2008 22008 Nebraska BRFSS 3 Nebraska Heart Disease and Stroke State Plan 2007-2012, Nebraska Cardiovascular Health Program, NDHHS

8. Stroke Hospitalization Outcomes, Among Nebraska Residents, 2008 Ischemic StrokeHemorrhagic Stroke Number of Hospitalizations 2651563 Hospitalization Rate (Age Adjusted in %) 13.32.9 Number of Residents that Received (One or More) Hospitalizations 2449513 Average Length of Stay per Hospitalization (in Days) 3.97.3 8 Stroke in Nebraska Nebraska Hospital Discharge Data 2008

9. 9 Stroke in Nebraska  Total hospital charges for stroke increased from $54.4 to $98.8 million between 2001 and 2008 1.  The average charge per stroke hospitalization was $28,600 in 2008 1.  Medicare paid an estimated $64 Million for hospitalizations due to stroke, accounting for approximately 65% of all hospitalization charges for stroke in 2008 1.  Nebraska paid an estimated $38.1 Million for medical costs due to stroke from Medicaid enrollees in 2007 2.  Total hospital charges for stroke increased from $54.4 to $98.8 million between 2001 and 2008 1.  The average charge per stroke hospitalization was $28,600 in 2008 1.  Medicare paid an estimated $64 Million for hospitalizations due to stroke, accounting for approximately 65% of all hospitalization charges for stroke in 2008 1.  Nebraska paid an estimated $38.1 Million for medical costs due to stroke from Medicaid enrollees in 2007 2. 1Nebraska Hospital Discharge Data 2008 2Estimated for CDC Chronic Disease Cost Calculator

10. 10 Assessment of Acute Stroke Treatment in Nebraska Hospitals Study (2006) Four structure/process elements define readiness to treat acute stroke –Complete a CT scan within 25 min. –Obtain report of the CT scan results within 20 min –Written protocol to administer IV tPA –Able to obtain neurosurgical services within 2 hours 21% of hospitals ready-all four elements in place 54% near-ready – have CT scan available but lack at least one of the other four elements of readiness 25% not ready – CT scan not available 24 hours/day NHHS 2006

11. Study Conclusions (2006) Readiness matters: –Of the 17 hospitals that were ready, 15 (88%) had administered tPA. –Of the 44 hospitals that were near-ready, 20 (45%) had administered tPA. Rural populations in Nebraska are least likely to treat stroke patients with tPA –Percentage treated with tPA 2-5 times > in Eastern and Southeast regions than remainder of state Over 90% of hospitals support development of statewide system to coordinate public education and EMS related to stroke

12. NSAC Steering Committee Community Awareness EMS Clinical Task Force Rehabilitation Stroke Registry/Policy 12 Steering Committee --Sets direction for priority activities & projects --Advises NE CVH Program on stroke issues, trends, & newest research Task Forces --Implement activities, projects, and programs --Meet by conference call

13. 13 NSAC Steering Committee Community Awareness EMS Clinical Task Force Rehabilitation Stroke Registry/Policy  Standardize public education identifying stroke as a medical emergency in PSA’s and messaging  Utilize partners to disseminate information  Develop a social media plan

14. 14 NSAC Steering Committee Community Awareness EMS Clinical Task Force Rehabilitation Stroke Registry/Policy Standardize & disseminate public education identifying stroke as a medical emergency Secure additional funding for online heart attack and stroke continuing education for NE dispatchers Support and partner on the development of EMS medical director training to include updated information on stroke

15. 15 NSAC Steering Committee Public Education Task Force EMS Clinical Task Force Rehabilitation Stroke Registry/Policy Increase clinical task force and council membership to include more physicians and CAH representation Educate and Disseminate evidence-based Emergency Department stroke protocols Maintain protocols and level of readiness in long term (year 3 Audit)

16. 16 NSAC Steering Committee Public Education Task Force EMS Clinical Task Force Rehabilitation Stroke Registry/Policy Ensure access to Standardized Assessments (e.g. www.rehabmeasures.org) that can be used to: reliably quantify and document a patient’s baseline status, progress, and outcomes; 1 determine need for additional therapies; support quality improvement (QI) by assessing organizational and provider performance; 2 and facilitate team communication.www.rehabmeasures.org Develop stroke rehabilitation levels of care that are consistent with the resources available in an organization. The intent of these levels is to develop a statewide system of stroke rehabilitation that increases the likelihood that persons with stroke and their caregivers achieve functional and societal participation goals. Educate rural healthcare professionals to use standardized assessments, evidence-based guidelines, quality improvement approaches and an inter-professional team approach when deciding the appropriate level of and site of care for persons with stroke. 1.Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-43. 2.Using health status measures in the hospital setting: from acute care to 'outcomes management'. Med Care. 1992;30:MS57-73. 3."It's hard to tell": the challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of neurorehabilitation. BMC Health Serv Res. 2008;8:217.

17. 17 NSAC Steering Committee Public Education Task Force EMS Clinical Task Force Rehabilitation Stroke Registry/Policy Policy: Expand legislative stroke champions and educate on current/future state Identify a physician champion within the Nebraska Medical Association Increase task force membership (NHA, NMA) Registry: Obtain funding to support CAH with stroke registry participation Aggregate state data collection and analysis Increase task force membership (CAH, NHA, NMA, etc)

18. 18 Improving Stroke Care in NEBRASKA Improving Stroke Care in NEBRASKA Thank You for your interest in

19. References Adams HP et. al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655–1711. Liang, B., Lew, R., & Zivin, J. Review of tissue plasminogen acitvator, ischemic stroke, and potential legal issues. Neurology. 2008. 65(11). 1429-1433. Lees et al, Lancet 2010 375:9727:1695-1703 Nebraska Vital Records 2008 Nebraska BRFSS 2008 Nebraska Hospital Discharge Data 2008 Taylor et al, Stroke 1996 Roger et al, Circulation 2011 Jones et al, Assessment of Acute Stroke Treatment in Nebraska Hospitals Study, NHHS 2006 Stroke-Unit Care for Acute Stroke Patients Lancet 2007:369:299-305 Schwamm et al, Recommendations for the Establishment of Stroke Systems of Care Stroke. 2005;36:690-703 Del Zeppo et al. Expansion of Time Window for Treatment of Acute Ischemic Stroke with Intravenous Tissue Plasminogen Activator, Stroke 2009. Alberts et al., Recommendations for Establishment of Primary Stroke Centers, JAMA 2000: 283 (23) 3102-3109. 19..

20. NSAC Membership Committee Members 2012 NSAC Chair Denise Gorski, The Nebraska Medical Center 2012 NSAC Steering Committee James Bobenhouse, M.D. - Neurology Associates PC Karen Bowlin - NE EMS Association Cherie Boxberger - American Heart Association Jose Cardenas, MD, Neurology Associates of Great Plains Tam Christen - Bryan LGH – StarCare Teresa Cochran - Nebraska PT Association Dean Cole - NDHHS – EMS Scott Crawford - Omaha Fire and Rescue Janet Dooley - CIMRO of Nebraska Jill Duis - Jefferson Comm. Health Center & Stroke Survivor Pierre Fayad, M.D. - UNMC Dale Gibbs - Nebraska Telehealth Network/Good Samaritan Hospital Maria Hines - Minority Health Mary Ellen Hook – Bryan LGH Katherine Jones – UNMC Brian Krannawitter - American Heart Association Beth Malina - St. Elizabeth Regional Medical Center Mitch Marsh – St. Elizabeth Regional Medical Center Marcia Matthies – NE State Stroke Association Rita Parris - Public Health Association of Nebraska Joann Schaefer, M.D. - NDHHS – Chief Medical Officer Francis Sparby, St. Francis Medical Center Bill Thorell, M.D. – UNMC Thaddeus Woods, M.D. - Critical Care Associates 2012 NSAC Ad Hoc Members P.J. Richards - Genentech, Inc. NSAC Staff Support: NDHHS – Cardiovascular Health Program Staff Jamie Hahn - Program Manager - (402) 471-3493 Kari Majors - Heart Disease & Stroke Prevention Coordinator - (402) 471-1823 David DeVries - Health Surveillance Specialist - (402) 471-3279 20 Verify Members

21. Accomplishments and Continuing Activities Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Standardize & disseminate public education identifying stroke as a medical emergency Assess and standardize EMS protocols Disseminate evidence-based Emergency Department stroke protocols Conduct stroke-related continuing education Assist providers to implement, evaluate stroke quality improvement programs Conduct regional planning to ensure suspected stroke patients receive evidence-based care at nearest location

22. Accomplishments Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Standardize & disseminate public education identifying stroke as a medical emergency –Strike Out Stroke Campaign: 2004-2009 http://www.strikeoutstroke.org/ –Mass mailing of stroke FAST educational materials –Stroke awareness PSAs http://www.nestrokecouncil.org/resources.html –Development of broad multi-media campaign on CVD including stroke call “What If…” Interior bus billboard in Omaha and Lincoln Development of an interactive website Development of additional print materials –NE Stroke Patient Hospital Discharge Packet

23. Accomplishments Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Assess and standardize EMS protocols –Survey of EMS transfer and evaluation protocols –Standardized EMS curriculum developed by NSAC members who conducted a train the trainer for EMS instructors –Regional EMS trainings Over the past 24 months, 104 trainings have occurred with approximately 1,670 EMTs attending –Survey of Public Service Answering Points (PSAPs) to collect information such as response to stroke and heart attack, dispatcher training, and protocols for heart attack and stroke

24. Accomplishments Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Assess and standardize EMS protocols 119 EMS stroke trainings occurred from June 2009-December 2011. The trainings were attended by 59.7% of the EMS services statewide and a total of 1,341 people were trained of which 83% were EMS personnel (First responder, EMT-B, EMT-I, Paramedic). 12 weeks of online continuing education for Heart Disease, Stroke was provided for 64 Nebraska Dispatchers in 20 Counties. A revision to include the recognition of stroke as a medical emergency and the FAST assessment was completed on the Emergency Medical Dispatch (EMD) cards used by approximately 62% of Public Safety Answering Points (PSAPs) in Nebraska. Two trainings were held for Nebraska dispatchers during their 2011 Spring and Fall statewide conferences. EMS Medical Director training… (I’ve requested this information from Dean Cole or his staff as I think it is important to include, as it was one of the objectives of the EMS task force and is being addressed currently)

25. Accomplishments Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Disseminate evidence-based Emergency Department stroke protocols –Developed Stroke Center designation criteria for all NE hospitals –Developed sample acute stroke protocols and accompanying Emergency Department, transfer, and admission order sets for Level 3 & 4 stroke centers Conduct stroke-related continuing education –Annual State and Regional Stroke Symposiums –Heart Disease and Stroke Practitioners Institute –Healthcare Professional Curriculum –Support for speakers at bi-annual dispatch conference

26. Accomplishments Based on Recommendation in “An Assessment of Acute Stroke Treatment in Nebraska Hospitals” Assist providers to implement, evaluate stroke quality improvement programs –Evolving…Now seven JCAHO Certified Stroke Centers (2 in Lincoln, 5 in Omaha) –LB395 Stroke Registry Bill –Get with the Guidelines Stroke – 10 hospitals Conduct regional planning to ensure suspected stroke patients receive evidence-based care at nearest location –Video “Improving Stroke Care in NE Hospitals” http://www.nestrokecouncil.org/resources.html –Trauma System use of the Nebraska Telehealth Network as a pattern for a statewide tele-stroke system