1. John T. Mather Memorial Hospital
Port Jefferson, NY
Improving Stroke Outcomes among High-Risk Populations by Creating Nursing-Emergency Medical Service (EMS) Partnerships
Presenters:
Joanne Lauten, BSN, RN, SCRN
Director of Nursing Quality/Stroke Coordinator
Stacy Podlasek, BSN, RN, SCRN, CCRN
Nursing Stroke Performance Improvement Coordinator
Judith Ann Moran, DNSc, RN, NE-BC, RN-BC
Nursing Research Coordinator
Sarah Eckardt, MS, BA
Statistician
Judy to introduce
Date: March 20, 2017
NYONEL Annual Conference 2017

2. Disclosure Slide
The presenters for this presentation have disclosed no conflict of interest related to this topic.
Judy to introduce

3. About John T. Mather Memorial Hospital
A 248 licensed bed facility
2,500 employees
Magnet® designation in 2013
More than 12,000 inpatients annually
More than 43,000 emergency room visits each year
Magnet® document for re-designation in June 2017
330 Stroke cases in 2015
Joanne– 9 consecutive A’s for LEAP Frog; patient safety rating

4. John T. Mather Memorial Hospital Port Jefferson, NY
Joanne

5. John T. Mather Memorial Hospital Port Jefferson, NY
Joanne

6. Collaborative Approach to Stroke Care
The Stroke Team is managed by the Stroke Coordinator and Stroke Performance Improvement Nurse
Monthly meetings occur to review topics, such as:
Committee departmental reports
Policies
Order sets
Specific stroke cases
Community outreach
 DEPT
POSITION
Laboratory
Coordinator
Radiology
Supervisor
Physical Therapy
Clinical Staff
Nursing Professional Development
Educator
Nursing Administration
Statistician
EMS
Liaison
Medical Affairs
Assistant Vice President
Professional & Regulatory
Administrative Director
Food & Nutritional Services
Manager
Associate Vice President for Nursing
Nursing Quality
Director
Neurologist
Physician
Critical Care
Rehab
Nursing Principal Investigator
Emergency Department
Director, Manager
Occupational Therapy
Chief Occupational Therapist
Stroke Unit
Nurse Manager
Analyst
Social Work
Coronary Care Unit
Hospital Administration
Vice President
Speech Pathology
Chief Speech Pathologist
Joanne

7. Benefits of Dedicated Nursing Roles
Stroke Coordinator
Stroke PI Nurse
-Develop competency
demonstration
-Tracks and implements
latest clinical practice
guidelines, protocols and
policies
-Data analysis and reporting
-PI plans
-Data abstraction
-Data entry
-Core Measures reporting
-Round on in-house patients
-Quality department
-Community outreach (schools, community groups)
-EMS education
-Clinical staff education
-Reviews of guidelines
Joanne

8. SCRN Stroke Certified Registered Nurse Requirements:
1. Current, unrestricted licensure as a Registered Nurse in the United States, Canada, or any of the U.S. Territories
2. The candidate must be a professional nurse engaged in aspects of stroke care, including but not limited to stroke nursing clinical practice or employed as an administrator, consultant, educator or researcher clinical practice. The exam is designed for those who have had at least two years of direct or indirect Stroke Nursing practice as a Registered Nurse in the last five years at the time of application.
Joanne

9. Stroke Facts:
Stroke is a major cause of death for Americans, but the risk of having a stroke varies with race and ethnicity. Risk of stroke is significantly higher among African Americans and Hispanic Americans.
Strokes account for 1 out of every 20 deaths in the United States. Stroke is the 5th leading cause of death.
Joanne
Stroke gets a lot of attention and resources. Mather Hospital is a designated stroke center by the NY Dept of Health. This requires annual reporting to the Department of Health. To maintain that designation, we are required to monitor how stroke patients are managed. Are we providing them with evidenced-based care? Also, stroke is a Core Measure. Core Measures are linked to value based purchasing. Finally, stroke care is reported on Hospital Compare. Hospital Compare is a website that patients can use to see how well hospitals provide the recommended care to their patients. So why do these different agencies focus on stroke care?
Mozaffarian, D., et al. (2015). "Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association." Circulation.

10. Stroke Facts:
Every year, more than 795,000 people in the United States have a stroke.
About 87% of all strokes are ischemic strokes.
Stroke is the leading cause of serious long term disability in the United States.
Stroke costs the United States an estimated $33 billion each year. This total includes the cost of health care services, medications to treat stroke, and missed days of work.
Joanne
Stroke gets a lot of attention and resources. Mather Hospital is a designated stroke center by the NY Dept of Health. This requires annual reporting to the Department of Health. To maintain that designation, we are required to monitor how stroke patients are managed. Are we providing them with evidenced-based care? Also, stroke is a Core Measure. Core Measures are linked to value based purchasing. Finally, stroke care is reported on Hospital Compare. Hospital Compare is a website that patients can use to see how well hospitals provide the recommended care to their patients. So why do these different agencies focus on stroke care?
Mozaffarian, D., et al. (2015). "Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association." Circulation.

11. Stroke Risk Factors
High blood pressure. High blood pressure is the main risk factor for stroke
Diabetes.
Heart diseases. Coronary heart disease, cardiomyopathy, heart failure, and atrial fibrillation can cause blood clots that can lead to a stroke.
Smoking. Smoking can damage blood vessels and raise blood pressure. Smoking also may reduce the amount of oxygen that reaches your body’s tissues.
Joanne
Department of Health and Human Services. (2016, June 22). Who Is at Risk for a Stroke? Retrieved July 06, 2016, from National Institutes of Health:

12. Stroke Risk Factors
Age and gender. Risk of stroke increases as you get older. At younger ages, men are more likely than women to have strokes. However, women are more likely to die from strokes.
Personal or family history of stroke or TIA.
Brain aneurysms or arteriovenous malformations (AVMs).
Race and ethnicity. Strokes occur more often in Black/African American and Hispanic adults than in non-Hispanic white.
Joanne and Sarah
Department of Health and Human Services. (2016, June 22). Who Is at Risk for a Stroke? Retrieved July 06, 2016, from National Institutes of Health:

13. Brookhaven Demographics
Sarah
Although these are close to the hospital, the next slide shows the higher variety in demographics. As our catchment area broadens…
United States Census Bureau

14. Brookhaven Demographics
Sarah
Low volume, high risk for demographic groups
United States Census Bureau

15. Barriers to Stroke Care in the Targeted Populations
Health Literacy – Educational Facts
Poor recognition of stroke symptoms – results in delay in pre-hospital arrival.
Seriousness in identification of stroke – results in lack of activation of 911.
Preconceived beliefs that there is no treatment for stroke, or a lack of awareness of treatment for stroke.
Lack of robust studies on certain ethnic and racial groups leaves less evidence-based treatment options and interventions.
Sarah – these are the overall educational information
National Women’s Knowledge of Stroke Warning Signs, Overall and by Race/Ethnic Group
Results—Half of women surveyed (51%) identified sudden weakness/numbness of face/limb on one side as a stroke warning sign; this did not vary by race/ethnic group. Loss of/trouble talking/understanding speech was identified by 44% of women, more frequently among white versus Hispanic women (48% versus 36%; P<0.05). Fewer than 1 in 4 women identified sudden severe headache (23%), unexplained dizziness (20%), or sudden dimness/loss of vision (18%) as warning signs, and 1 in 5 (20%) did not know 1 stroke warning sign. The majority of women said that they would call first if they thought they were experiencing signs of a stroke (84%), and this did not vary among black (86%), Hispanic (79%), or white/other (85%) women.
Conclusions—Knowledge of stroke warning signs was low among a nationally representative sample of women, especially among Hispanics. In contrast, knowledge to call when experiencing signs of stroke was high.
Race and Sex Disparities in Prehospital Recognition of Acute Stroke
Results: There were 10,719 patients discharged with primary diagnoses of stroke. Of those, 3,787 (35%) were transported by emergency medical services providers. Overall, 32% of patients ultimately diagnosed with stroke were identified in the prehospital setting. Correct prehospital recognition of stroke was lower among Hispanic patients (odds ratio [OR] = 0.77, 95% confidence interval [CI] 0.61 to 0.96), Asians (OR = 0.66, 95% CI 0.55 to 0.80), and others (OR = 0.71, 95% CI = 0.53 to 0.94), when compared with non-Hispanic whites, and in women compared with men (OR = 0.82, 95% CI = 0.71 to 0.94). Specificity for recognizing stroke was lower in females than males (OR = 0.84, 95% CI = 0.78 to 0.90). Conclusions: Significant disparities exist in prehospital stroke recognition.
Patient Refusal and Informed Consent-related Delays for Stroke Thrombolysis in Chicago
(abstract only)
Results: There were 1,029 (39.1% white, mean age 65.1 years) tPA-eligible patients presenting through emergency departments at the 15 PSCs. Among these, 324 (31.5%) received tPA 60 minutes, and 569 (55.3%) did not receive tPA. Of those with delayed or no treatment (n=705), 72 (10.2%) experienced consent-related failures. There was a trend toward higher rates of consent-related failures in non-whites vs. whites (12.1% vs. 7.4%; p=0.056).
Conclusions: At Chicago’s PSCs, consent-related delay or refusal of consent occurs in at least 7% of tPA-eligible patients. Furthermore, non-whites may be more likely to experience consent-related failures than whites. Consent-related delays, as with any treatment delay in tPA eligible patients, may result in worse outcomes. Further research should focus on barriers to informed consent in stroke thrombolysis, specifically addressing potential race-ethnic disparities in the informed consent process.

16. Results of Barriers
Black/African Americans are less likely to receive tissue-type plasminogen (t-PA) due to greater pre-hospital delay
Higher post-stroke disability
National surveys and other recent studies have noted differences in stroke mortality rates between Hispanics and non-Hispanic whites, and even within Hispanic subgroups*
Black/African Americans are less likely to discharged home to care givers post-acute stroke**
Higher percentage of readmission within 30 days
Higher percentage needing long term rehabilitation***
Sarah
Phenotype vs genotype vs environmental: Cholesterol, certain lipids can biologically/genomically be affected by the environment. Not enough research supports these differences in these high risk groups in detail; currently, most of the data seems driven by phenotype; studies that address genotypes that are “current” so far have mostly been for European/target groups rather than looking at both racial and ethnic groups.
Currently, there’s not enough research or studies done specifically on the Hispanic population and the groups that make up Hispanics, for ex: Cubans, Puerto Ricans, Mexicans, etc. See excerpt: Summaries of national data surveys have suggested that among Hispanics subgrouped as Mexican Americans, age-specific mortality rates for stroke may be lower than those in whites (5). Stroke mortality rates in Hispanic subgroups such as Cubans and Puerto Ricans have been reported to be higher than those in Mexican Hispanics, but the relation between these mortality rates and stroke incidence rates among Hispanics needs further explanation (5). Vital statistics data collected over a 30-year period from New Mexico initially showed lower mortality rates for stroke among Hispanics than among whites. However, more recent statistics suggest that risk of stroke mortality among Hispanics in New Mexico has increased and that it now exceeds the white stroke mortality rate (4). Northern Manhattan Stroke Study Collaborators, Ralph L. Sacco,Bernadette Boden-Albala, Robert Gan, Xun Chen, Douglas E. Kargman,Steven Shea, Myunghee C. Paik, and W. Allen Hauser-Stroke Incidence among White, Black, and Hispanic Residents of an Urban Community: The Northern Manhattan Stroke Study.
European Study on Genotype” Apolipoprotein E genotype, cardiovascular biomarkers and risk of stroke: Systematic review and meta-analysis of stroke cases and pooled analysis of primary biomarker data from up to individuals
“In people of European ancestry, APOE genotype showed a positive dose-response association with LDL-C, C-IMT and ischaemic stroke.”
Race Differences in 1-year Outcomes after Stroke can be Largely Explained by Race Differences in Physical Functioning before Stroke
Results: African Americans had significantly poorer covariate-adjusted 1-year outcomes than Whites on 8 of the 12 outcome measures examined. However, physical functioning before the stroke, as indexed by the Physical Component Summary (PCS) of the SF-12, was significantly lower in African Americans (adjusted Mean = 43.6) than Whites (adjusted Mean = 47.7; p = .005). When these pre-stroke PCS differences were added as additional covariates, many of the race differences in stroke outcome were no longer statistically significant.
Conclusions: A substantial portion of the race differences in functional outcomes after stroke appear to reflect extensions of race differences in physical functioning that are present before stroke. In addition to ensuring adequate care after stroke to minority patients, disparities in stroke outcomes might also be further reduced by better risk factor modification and health promotion efforts for African Americans.
*Northern Manhattan Stroke Study Collaborators, Ralph L. Sacco,Bernadette Boden-Albala, Robert Gan, Xun Chen, Douglas E. Kargman,Steven Shea, 
Myunghee C. Paik, and W. Allen Hauser-Stroke Incidence among White, Black,
and Hispanic Residents of an Urban Community: The Northern Manhattan Stroke Study.
**Roth, D. L., Haley, W. E., Clay, O. J., Perkins, M., Grant, J. S., Rhodes, J. D., … Howard, G. (2011).
Race and Gender Differences in One-Year Outcomes for Community-Dwelling Stroke Survivors with Family Caregivers.
Stroke; a Journal of Cerebral Circulation, 42(3), 626–631.
***Ellis, C., Hyacinth, H. I., Beckett, J., Feng, W., Chimowitz, M., Ovbiagele, B., … Adams, R. (2014).
Racial/Ethnic Differences in Post stroke Rehabilitation Outcomes. Stroke Research and Treatment, 2014,

17. Community Intervention
Mall, health fairs, schools, libraries, churches and community senior centers (focusing on Coram, Middle Island, and Rocky Point.)
Promoting health literacy
Interactive material (crossword puzzles, coloring books, FAST materials)
Stacy
Our community intervention focused on the populations in Coram, Middle Island and Rocky Pt.-the areas where our low risk high/ volume pts live. Our goal was to promote health literacy across the lifespan. We used multimodal and interactive materials to provide developmentally appropriate educational material.
At health fairs we took blood pressures--high blood pressure is the leading modifiable risk factor for stroke.
PPT presentations were done at community centers and school age children were provided with crossword puzzles and coloring books.

18. Community Interactive Initiatives
Stacy
We decided to focus on children for several reasons. First, children can positively influence the health behavoirs of family members, specifically parents aand grandparents. Also, Grandparents are often the caregivers for children. Children can take the information they have learned about stroke and discuss it with their families.

19. Nature of Problem
Much emphasis has been placed on stroke education for primary care physicians and emergency medicine physician and the community.
Emergency Medical Services (EMS) providers are a vital link in the chain of acute stroke care.
Emergency communicators or emergency medical dispatchers have a poor recognition of stroke.
Stacy
What is the nature of the problem? In the past, stroke education has focused on the inhospital providers like physicians and nurses. At the same time, we were educating the community about stroke. EMS providers are the vital link between the community and the acute care setting. Often stroke is not identified in the prehospital setting or if it is, it is not communicated to the next provider as the patient passes from home to EMS to the hospital. What is being communicated during the transitions of care is critical to timely care for a stroke patient.

20. 2015 NYS Measures Advanced notification by EMS
Date/Time patient last known well
Pre-hospital stroke screen performed
Stacy
In 2015, the NYS department of health initiated the following measures. Prior to this time, strategies to reduce door to tPA times had evaluated processes within the hospital. Now, the prehospital setting is being evaluated to find ways to reduce door to tPA times. By enhancing communication between EMS and hospitals, the door to tPA times will be reduced further. The first measure is advanced notification by EMS. Did EMS notify the hospital that they were bringing in a potential stroke patient. This is a class I, level B recommendation from the AHA for the early management of acute stroke patients. Secondly, did EMS identify LKW. This is critical to identify if patients are eligible for tPA. tPA is FDA approved up to 3 hours after LKW; it is used off label up to 4.5 hours after last known well. Third, was a Cincinnati Stroke Scale performed. The CSS is a three part evidenced based scale to identify stroke patients. It looks for a facial drop, arm weakness, and slurred speech. Fourth, did EMS prenotification contain CSS findings and LKW. Finally, was the stroke team activated prior to the patient’s arrival.
Did EMS pre-notification contain pre-hospital stroke screen findings and last known well?
If advanced notification by EMS, was the stroke team activated prior to arrival?

21. Evaluated Current Process
Paper trail / log was weak
No area in EMR to document pre-notification
Inconsistent documentation
EMS perception: “we are not part of the team.”
Stacy
These are the challenges that were identified in meeting the EMS measures. First, the paper trails and logs were weak. There was no specific fields to document prenotification and prenotification content. It would need to be free texted into the EMR. There was an issue with inconsistant documentation. This was especially problematic for identifying LKW. Multiple times of LKW would be documented by various providers-neurolgy, ED physician, ED nurses, and EMS providers. Finally, EMS perceived that they were not part of the team. They did not feel that their care of the stroke patient was valued by the other members of the healthcare team.

22. EMS as Mather’s Community Partner
EMS is made up of volunteers from the community, so it was important to include them in Mather Hospital’s initiatives to provide better care for all members of the community.
Mather Hospital encouraged discussion by identifying knowledge gaps.
Joanne and Stacy

23. Nuances to EMS in a Suburban Community on Long Island
Predominantly volunteer (~98%)
No minimal school educational requirements
Mather Hospital receives patients receives patients from ~25 EMS agencies
10 private ambulance companies
4,132 members
Stacy
All the firehouses represent the different departments that bring patients to Mather Hospital. Educating EMS was difficult due to the structure of local EMS agencies.
Read slide
There a lot of members to reach and they are a diverse group with a wide range of ages, knowledge, and backgrounds. I am going to tuen the presentation back over to Joanne.

24. Plan Evaluate current process Review all EMS documentation
Check
Act
Evaluate current process
Review all EMS documentation
Feedback from EMS on barriers
Joanne
Pre-Hospital Form

25. Do
Plan Do
Check
Act
January 2015 – Mather Hospital conducted a survey of EMS providers who attended the organization's monthly EMS meeting
Joanne
knowledge base of pre notification/stroke scale / LKW

26. Check - Results 15 EMS units surveyed (Participants n=75)
Plan Do
Check
Act
15 EMS units surveyed (Participants n=75)
46 (61%) responded they pre-notified
35/46 (75%) responded they pre-notified within 2 blocks from the hospital
51 (68%) said they where able to document Last Known Well (LKW)
32 (42%) said they did some form of the stroke scale, but not consistently
Joanne and Stacy

27. EMS Measures
Initiative from the NYS Department of Health that aims to increase pre-notification for suspected stroke patients
Evaluate existing pre-notification practices and communication between EMS and designated stroke centers
The goal is to decrease treatment times for stroke patients and improve outcomes for stroke patients
Joanne and Stacy
This brings us to the EMS measures.; pre data was 2014, but initiative was 2015.

28. Act - Empowering EMS
Plan Do
Check
Act
Educated EMS on national benchmarks for pre-notification and pre-hospital Stroke Scale, and Last Known Well
RN EMS Liaison – Peter Razka
Liaison leads monthly EMS meeting
Mather Hospital hosts an annual EMS dinner
With awards and recognition for Stroke t-PA cases
Joanne

29. Challenges to Meeting EMS Measures
Pre-hospital Care Record (PCR) does not provide a specific place for last known well or stroke scale results; this must be free texted into the note
Legibility of pre-hospital form
Joanne
Educating all EMS providers about the measures
Mather Hospital’s Electronic Medical Record (EMR) did not have fields for capturing EMS measures

30. 2015 Interventions
Attended Rocky Point, Coram, Middle Island, Gordon Heights, quarterly EMS meetings and Fire Prevention Week to educate on:
Signs and symptoms of stroke
Importance of pre-notification, last known well
Presented data from Get With the Guidelines
Identifying at risk populations –
high risk, low volume
Added fields for EMS measures into EMR
Participating in NYS Coverdell Stroke Quality Improvement and Stroke Registry Program
Joanne
Send hand-written “thank you” note to the EMS unit after a t-PA case

31. Hand-Written Thank You

32. EMS Data
Joanne These are factors that the community, and therefore members of EMS, did not realize contribute to better stroke care. Explain pre, intervention and post, and follow up plans.

33. EMS Data
Joanne
These are factors that the community, and therefore members of EMS, did not realize contribute to better stroke care. Explain pre, intervention and post, and follow up plans.

34. Findings Pre-notification:
Prior to the 2015 interventions, EMS activation <40%
Post intervention, EMS at the highest was ~70%
Pre-hospital stroke scale:
Prior to the 2015 interventions, EMS performed stroke scale <20%
Post intervention, EMS at the highest was ~80%
Joanne

35. Findings
Jan 2014 – Apr 2016
Joanne and Sarah
Low volume, high risk.
2015 – 1 Black/African American; 1 Hispanic-White who received t-PA
10% of Hispanic population got t-PA
4% of Black/African American population got t-PA

36. Future Plans
Hip Hop Public Health -
“Our extensive research on Hip Hop Stroke proves that the program works-children leave us with an understanding of what stroke is, how it occurs in the body, how to recognize the signs of symptoms of stroke, and what to do in a stroke event. In fact, we’ve found that this knowledge persists up to 15 Months Later.”
Cardiac Caregiver’s Education Group
Adding more materials for EMS on culturally competent care—not necessarily just for stroke.
Joanne and Stacy

37. Thank You!
Contact Information:
Joanne Lauten, BSN, RN, SCRN
Director of Nursing Quality/Stroke Coordinator
Stacy Podlasek, BSN, RN, SCRN, CCRN
Nursing Stroke Performance Improvement Coordinator
Judith Ann Moran, DNSc, RN, NE-BC, RN-BC
Nursing Research Coordinator
Sarah Eckardt, MS, BA
Statistician