SWA Stroke Bootcamp Getting a Small Hospital Stroke Ready Not too small to make a big difference

SWA Stroke Bootcamp   Getting a Small Hospital Stroke Ready   Not too small to make a big difference


– [Host] Hi everybody, welcome
to the Southwest Affiliate Stroke Bootcamp Series, we are excited to offer this 15 week course as a way to educate stroke
coordinators in key components of their role, provide tools and resources to build and maintain successful programs and to assist in building
a large network of peers. Before we get started we would like to go over a few housekeeping items. To avoid background noise all lines have been placed on mute. For the question portion at the end of the presentation you
may unmute your line by pressing star six or typing in the Q and A section of WebX. Please note you will only be able to claim your CE credit at the end of the 15 week series on September 27th. A copy of today’s slides and any handouts will be sent to you within
a week of today’s call. For future webinar registration, please visit www.heart.org/swaquality. Today we have a great speaker who will be discussing how to get
small possible stroke ready. Martha is a Canadian nurse who has worked in five countries in
pediatrics, orthopedics, ICU, PACU and ED before coming to rural Texas in 2009
and beginning to work at Connally Memorial Hospital
in Floresville Texas in 2011. Connally Memorial is a county hospital licensed for 44 beds, 45
minutes outside of San Antonio. Two years later she was asked
to start the stroke program. The hospital gained its level
three stroke ready designation with the state of Texas 18 months later and won the Silver Plus Stroke Award from American Heart
Association the following year. If you are from a small facility looking for direction
in stroke designation and merits you are in the right place. And now I wanna hand it over to Martha. – [Martha] Good morning
everybody, good afternoon and welcome to Getting a Small Hospital Ready for Stroke Program. I have no financial
disclosures or relationships to declare so I’ll just
move on beyond that. I wanna welcome everybody to this. If you’re watching this
then you’re probably in the same boat that I
was in a few years ago when I knew nothing about stroke. Had never worked in a stroke program. Never been in a hospital
that had a stroke program. And I started to do my research from scratch and said what do I do now? So our objectives today to look at why a small hospital is so important to the stroke program of the country. Or to your state or your county. Number two are strategies
for stroke program development in the small hospital. Some things that we can do to
make it run a little smoother. Number three the important first steps to get a stroke team member focused on performance improvement, peer review, and multi-disciplinary planning. Just some details on how
to make a program develop towards the goals that we have in mind. And practical options
for organizing daily, weekly and monthly priorities
of a stroke coordinator. When I was trying to
get all this organized I really really leaned heavily on some people who taught me
a lot of things about stroke. About how to review with the program. And I wanna acknowledge them, one of them was Deb Motts who was
an American Heart leader in this endeavor and
I just wanna thank her for all the input that she put into our program and into
my life in particular. So being a small hospital sometimes we think we’re not that significant. We have less staff, less
resources, less practice. We don’t have the
specialties available to us. And we feel like the small
dog among the really big dogs. And believe me just being
outside of San Antonio with primary hospitals
and now just recently comprehensive hospitals
just 45 minutes away, we really did feel like what
am I doing here at the table. But it really really is important ’cause a small hospital has a huge role to play in stroke care
for the state and the country. American Heart says that
97% of stroke deaths occur in low to middle income countries where 80% of the population
live in rural areas. The rural population has been identified as being particularly
vulnerable to stroke. Partly because of
lifestyle, partly because of in Texas particularly
we’re kind of Lone Star, we’re Lone Rangers and we’re just gonna buckle up and ride it through and that’s not the best approach when it comes to stroke you want to get to a
facility as soon as possible. The development of adaptive models implementing best practice
for stroke management in rural areas is important because you’re the first line of active care. The CDC says that Americans
living in rural areas are more likely to die form
the five leading causes than their urban counterparts. Many of these deaths are
potentially preventable. Heart disease is of course on the list. Cancer is on the list,
unintentional injury. Chronic respiratory disease and stroke. All of these are preventable
to some degree by lifestyle and definitely by early intervention. And sometimes we live in a county where some ambulances are gonna have to ride 45 minutes to get to your location so early access is very very difficult and I’m sure some of you can identify
with that as well. Public Health research found
that more than 86,000 deaths in rural areas could have been prevented with better public health resources and access to appropriate care. So just getting to the hospital
of course is important. When you’re in a hospital you know that you deal with whatever comes to the door and you do
the best that you can. And sometimes you just wish
you had more education, more resources, more
available, more hands on deck. And this graph shows that
the metropolitan areas have less death from stroke
than do the rural areas. Sometimes you might think that’s just because there’s more but
actually there’s more stroke that comes to the emergency
room in the cities. But there’s more deaths
in the rural areas. I know that there’s more research that has recently been done
to challenge that statistic. But I’m gonna take that as what I found when I was doing my research. So I do have a recent, a
real brief poll for you. ‘Cause I wanna find
out who I’m talking to. I wanna find out what
size is your hospital? Is it less than 50 beds,
is it 51 to 100 beds? Is it 101 to 250 beds
or more than 250 beds? If you could just answer the appropriate letter based on your hospital we can get some feedback on that,
take a few seconds here. – [Host] Great so Martha the majority chose option C, 101 to 250 beds. – [Martha] All right so majority of you are 101 to 250 beds, so you’re a little bigger than I am, than we were when we were developing this program. But that doesn’t mean that a lot of the things that I’m gonna go through with you are not a comprehensive program. And you’re gonna have to deal, look at a lot of the things that we looked at. I don’t have my screen back yet. There we go, so less than 100 beds is what I was looking at, so if
you’re 101 a little bit more. Often we have an ED staffing of a doctor and that’s the only doctor in-house for 18 hours of the
day to the floor nurses and perhaps a tech or a clerk. So that’s really not a lot of people if you have a stroke alert going on. In fact I’ve been in an emergency room when we had two stroke alerts
going on at the same time. And it definitely, you want all hands on deck because you need to do things and you need to do things fast. So being resourceful that you don’t just have your own
little niche in the team. A stroke alert happens, we will use our RT tech to do things that might be outside of the scope of what they had originally thought but it’s all hands on deck in a small hospital. Anybody will take the lab to the lab. It’s just a matter of the best use of the resources that you have. And if you’re a small hospital
you’re familiar with that. So why is the small hospital
stroke program so important? It’s time time time, we all know that. If you’ve been doing these WebXes you know that time is brain, the sooner that we can make the right decision the sooner we can go to the right place. The sooner we can preferably
get the right outcome. The treatment decision is made usually within the first 30 to 45 minutes. Hopefully 45 minutes, if you have your timelines you know that everything needs to be back to the physician so he can make an appropriate decision within 45 minutes, and doing that in a small hospital is very challenging. But we found that with practice
that was definitely doable. Also making the decision,
destination decision. It’s important to make that decision early because you have an ambulance ride. You have to call the ambulance, if locally they aren’t available they have to come from 45 minutes away. And you’ve decreased your time. You may use a helicopter
to try to expedite that but that may not always be an option depending on whether your
location and availabilities. So the sooner you can
make these decisions, the sooner you can make
the right decision. The right treatment decision, the right destination decision, the
better the outcome will be. And outcome is what we’re looking at. It’s trying to decrease the disability and the death related
to stroke, that’s our goal for everything that we do. A brief look at Texas which
is obviously where I am. And discuss this is Texas and each of those numbers is
the rack that we’re in. We’re in T rack which you can see in that area there in that red circle. When I started looking
at getting designated by the state I thought well
there must be somebody close to me that could help
me walk through this. And as I looked in 2014 there was only 11 hospitals in all of Texas that were level three or stroke rated. And they were none of them were near me. The little green area that you see in the upper right hand corner, those indicate the level
three stroke ready hospitals which are the smaller hospitals that don’t have a neurologist and really
it’s very difficult for us to get a higher level of
certification or designation. So in our whole south Texas we became the first in that area, since then there has been another
and it’s slowly becoming more, there’s been more and more interest and I’m very happy to have this boot camp ’cause it makes it accessible for those who can’t necessarily travel to bigger locations to get this information. But every small hospital
in a rural area could get certified if they just took
the time to do the education, put the protocols in
place and run some mocks. Yes there are some other facilities, other departments that are important. Like must have a CT 24 hours a day. CT tech 24 hours a day, you have to be able to run a PT-INR at any time during the day and day or night. And so they don’t have TPA available in the emergency room
so those kinda things. But those are doable for most of us. So I just encourage that
if you’re a small hospital in some rural area and you think it’s not doable, it is doable. We’re 44 beds, we typically
have less than 25 patients in our inpatient area
and our ICU is minimal. It’s only four beds, of those four beds usually only one or two are
occupied and sometimes none. We have 10 emergency room beds and still we were able
to get this designation within 18 months and I don’t think that we are exceptional, I
think that anybody could do it. And as we progress you’re gonna see that this made a huge
difference in the care of stroke that we deliver
from our facility. STRAC which is South Texas
Regional Advisory Council which is the RAC that we were in was very crucial in helping our facility get to where we were, a lot of networking with the other regions and
their resources helped. So don’t go this alone,
I don’t think you have to do it alone, there’s always
somebody you can buddy with. So a lot of education offerings that I went to but one of the best ones was the Boot Camp that was offered where Laurie Dowd was the speaker and told us how to use the guidelines. So that was an exceptional opportunity and it really did help me to
get my feet on the ground. Those educational offerings are offered sometimes outside of your area, they might be a little driving distance. But most of the larger hospitals will have a neurological
education weekend or day once a year because it’s required. And if you can get connected with them and attend theirs you’re
gonna learn a lot. And it’s gonna help you stay on track with what is already being communicated to the larger hospitals but what the expectations are for stroke care. Facilitating the collection
of regional statistics. The RAC was really great about that. Rather than us having to submit all of our registry to the state, we submitted it to the RAC and the RAC submitted it to the state for us. And that took one step out of it because as the stroke
coordinator in a small hospital you’ll probably have multiple things that you’re doing, you’re not just being a stroke coordinator and you don’t have the time to do,
to do all the details. You don’t have all of the triage to do your auditing for you or people to send stuff for you so you have to do it all alone and you have to be creative about how you do that. So having the RAC available or whatever the group that you’re a part of and working together with them makes it, can take one
thing off of your plate. Also promoting the process improvement through shared knowledge, I mean. We did a PI, our PI meetings, whatever problem we were facing typically was faced by the other hospitals as well. So jointly coming together,
detecting possible solutions, really crucial, really crucial in finding an answer that was doable for all of us. One of the things available also was a buddy mentoring system
for new stroke coordinators. You could log in or you could request a buddy who had been
through the process already and would help answer your questions and guide you along the way, very helpful. And the local resource
for expert knowledge. You’re gonna have to bring knowledge back to your facility, so networking with a larger group gives you access to people who you can then invite to come back to your facility and do your four hours of stroke training for the year and bring all your people up to speed. So you don’t have to do it all yourself, you can bring in the experts and they’re usually very happy to do that. Strategies for stroke program development in the rural hospitals,
so this is our story. This is not everybody’s story
but this is how I learned so this is how I’m gonna tell
you how it worked for us. In 2002 our facility made a commitment to stroke, we would voluntary
report stroke core measures. And there was stroke training added to the annual competency
but at a very basic level. NIHSS training was offered to
all nurses through electronic message and independent
study but it wasn’t required. The next year they
increased that commitment by adding TeleHealth partnership provided to TeleHealth stroke consults so that we had a
neurologist that’s available in the emergency room through TeleHealth who could help us make good decisions. NIH was required by all the ED nurses. The community awareness
of CM, our hospital’s stroke capabilities was done
through newspaper advertising. And some of the public events that we had, we would have a booth
there to just say that, help them be aware how to recognize stroke and that we were capable
of dealing with it. They didn’t have to just fly past us to go to a larger facility. We also joined the Get With The Guidelines stroke registry program which helped us to know in the data collection, they guided us to what’s
important there that they collect. How to analyze it and abstracting
the stroke information. That was very helpful
in helping us to know okay what’s the important question to ask. That’s a process that if you’re starting from scratch with a spreadsheet or some kind of audit
tool you’re gonna find that at the end of the year oh, they’re gonna ask you that question and I never thought to ask that. Like one simple one was how many of our transfers were by
air and how many by ground? It wasn’t a question I was asking so that first year I had to go back and look through all
my stroke and say okay, how many went by ground
how many went by air? Now I know that that’s
something I need to collect. But Get With The Guidelines
did a lot of that work for me. And then that was what the hospital did. In November of that year they hired me as the stroke coordinator
and I started doing my research on how we
could improve our program and get to a designation of stroke ready. We also had a speech therapist
available occasionally. We increased her to five days a week so that helped us with assessments. We developed a mission
statement for our program which was to reduce the
incidence and impact of stroke in Wilson county
through implementation, monitoring, and improvement
of evidence based care of stroke patients and education of those impacted by or at risk for stroke. That included our emphasis
on the community education which you’re gonna find is important when you come to survey it’s important to educate your community about
what capabilities you have. But also how they can
sooner recognize stroke. And what to do and what not to
do when they do recognize it. For the following year we appointed a stroke medical director,
developed a stroke committee. The stroke team or stroke committee was sent to the STRAC emergency conference which is again one of the things that our RAC did for us, they
had an emergency conference which had four tracks, one for trauma, one for stroke, one for
disaster, and one for heart. And so we had a whole track so if he went to the three days of the conference you had all your CEs for the year. And you had some really
good current knowledge that was based on a best practice. We also, I went regularly to the stroke coordinator’s meeting
at STRAC which is our, it was in San Antonio but it was where we all collaborated together. So process improvements
for different problems, for how to like for example
how to transfer quicker and better, how to
communicate that better. How to get the person to
the appropriate facility. All those conversations
happened at the STRAC and were very helpful in
developing our program. Community education that year,
I was just trying to learn. They said you have to
do community education but they didn’t say how much. They didn’t say what it need to look like. So we did a stroke lunch and learn which we have been doing lunch and learns once a month for our facility already. So that drew about 75 people. We did a video, we had a stroke survivor that came to our facility and her walk through her process of coming
back to functioning fully at her previous level and
that was made available through YouTube and we put
it out there on our website. And that was just one
way to get the story out. She was a very good candidate to do that. But then we heard that we would have to prove that we had done something to educate the public in our therapy. We would have to have
some numbers for that. And I thought what do
I do, I have no budget, what do I do for that, so I just went to SurveyMonkey and I sent out some questions about FAST and we started listing that out to every email
that was in the community. And we got responses
back and so we were able to prove that the level of knowledge of how many people knew
what FAST stood for and that they could answer it correctly. And I’ll show you a
slide about that later. Another thing we did with stroke education competency for staff and for EMS. Don’t forget the EMS, we don’t
own an EMS in our hospital, doesn’t own an EMS they’re all volunteer in their own little county around us. But we don’t have any direct
response affiliated for them. But we did reach out to
them and included them in all of our education so we had four hours of stroke education which was required by the ED staff and some of the unit staff that was
for the inpatient areas. But particularly for the ED and for, for the unit managers so that they could communicate that
message down to their staff. That what the expectations
were for stroke care. Another thing was Get With The Guidelines training and baseline data collection. Take a look at the guidelines
is a very good tool for gathering data but you have to start with the baseline so I had gone to the year prior to my
hire and gone through everybody that had a stroke diagnosis. And I had to have a minimum of 30 to enter into the system so that we had a baseline data of what, so we could measure our progress against that. And that took some work and some learning but it’s the groundwork
that needed to be done. And then we submitted our application, remember you can’t wait
’till you’re all ready until you submit your application. You do it as soon as you have
the major pieces in place because it’s gonna be
about a year in advance that you’re submitting the application. You have time after
that to improve things. To correct mistakes or develop stuff. So go ahead and submit that
application as soon as you can. In 2015 we developed a
stroke support group. I say developed, there had
been one 20 years earlier and it had kinda become a bingo night rather than a very educational. So we revised it and we
made it more stroke oriented with a component of education,
a component of sharing and emotional support
and some socialization. We started doing mock strokes. We did a competency provided
by the Primary Stroke Center that was nearby us, we have again utilized those that are nearby
that have more education, more resources and have
more experience with stroke. And we bring them into
our community so that they can teach us what they know
and that’s very helpful. We started our PI process
and we did a mock survey again with a stroke coordinator from our Primary Stroke Center who came and reviewed what we had done and what we had set up and gave us some encouragement and some
tips on how to improve. We had our survey and got our
designation within 18 months. So although you may be
small don’t be discouraged. You are trainable and yes that is my dog. Although you may be small you can still be really really efficient. Sometimes having more
is not always better. Being better always requires some work. Being small doesn’t mean
you’re not effective. For those people that come to
the door you are effective. We had had our stroke designation for about six months
when our CNO’s brother came to our department and this
is a public story so I’m not telling anything that’s not
already out in the public. He gave a report about his care there. He came and he was seen
and left the hospital with a not stroke diagnosis,
he’s 52 years old. And 30 minutes later
they’re in the restaurant and he shows sign of facial drooping and the CMO, she’s a friend of mine, but she’s looking at him
and she’s thinking. (gasps) What would Martha do,
what would Martha do? And she remembered the
things that we had learned and the things that had been told to her. And did exactly the right thing, got him back to the emergency room. And there was a test and had TPA and is a fully-functioning adult now. So it really does pay off when
you have stories like that. You can be effective, you can be good, you can make a huge
difference in the lives of the people in your community. By taking a directed role
in how you communicate to your community, by how
you train your facility. And how you practice you are not too small to make a big difference. So I know that this is
taxing for many of you. You don’t have 100% of your
job caring for stroke patients. So I’m gonna ask you what percent of your job is dedicated to stroke for your facility, 25, 50, 75, or 100? – [Host] So it looks like the
majority is choosing D 100%. – [Martha] 100%, that’s
amazing and that’s awesome. That means that your facility has bought into stroke care and that is great. ‘Cause when you have to, many of us in the past have had to share an ED shift. Or work the quality
and we do other things. Some are emergency room managers and they also do this on the side. So having 100% dedicated to this really does make a difference and I have to applaud my little hospital gave me a good portion, I was
90% stroke so that was great. Can you give me my screen back? There we go, so important how do you make good use of your time? So the first important
steps that you have to do is you have to get good data. You can collect a lot of data, there’s a huge amount of data out there but some of it’s not
gonna be that important and it’s hard to know what’s
the most important thing. So focusing on performance improvement, that really makes a difference
to the program which will make a difference to the people
that are affected by stroke. How to do a chart audit and review, ah that’s a mistake, review review. Well it’s not bad, we review review review and it gets good data,
multi-disciplinary planning. Don’t do it all by yourself again. Get the help of others in your facility. The more you include in your process the more trained they’ll be and the more you’ll have to move you program forward. The application will guide
you with some of those goals. The appointment of what
needs, or who needs to be at the table, who needs
to be involved in the team. The stroke medical director
obviously and yourself. The lab, the CD techs
and the unit managers and then your people
in the emergency room. And then by and obviously if you’re 100% in stroke you already have admin buy-in. And so that’s a good
thing, the educational requirements, this is
gonna be your headache. Because the requirements for the state and you may be going
with another facility. Another designation,
but we went with state. And there are requirements
for the ED doctors that they have eight hours of stroke designated education every two years. That has been discussed to change that to a lesser amount but
it has not been changed so that last survey that we
had that was still required. Although they were a little bit forgiving. We are very generous with
that when we’re looking at the education for the ED doctors. Because if you’re like us you have a revolving door of doctors. Many small hospitals have a company that supplies them and those doctors work in an area so they may not be always at your facility and it’s hard to get them to buy into your program. But to get them to do the education and get it to you is a
recognized challenge. So I’d encourage you to not wait with sending in your application ’till you have all those requirements. Tell them that you’re
working on it and continue to communicate with your
doctors until you have them. We included a lot of things so with the education requirements you could use anything that was related to hypertension, anything
related to coagulation. Anything related to neurology and those specific stroke things. So look at all those things when you’re looking at the doctor’s education. The nurse requirements, we took care of that with competency, at competency we did TPA administration certification. We did small studies and
screenings certifications. And everything except the NIH was included in the competency. So if you attended the hospital competency then you had the education required except for the ACLS and the NIH. Which we could, ACLS of
course was done separate time and NIH was done through
a self-study module. So that was easy enough to do. Policies and procedures, keep them simple. Don’t make them overcomplicated. Improve your process and outcomes. The administrative structure changes are pretty much designated
by the application guidelines that you can
get and have to monitor your stroke care and then go ahead and apply for the level three. Look at it we’ll go
through this a bit more. The key steps, the appointment of people. We already talked about that,
stroke medical directors. Stroke program manager
and the stroke team. I tried to use somebody
from every department that was involved in a stroke alert as well as the head of the department so that we could get a broad picture and when we wanted to communicate process and program it was quite easy to get it to the different departments. Because everybody heard of that,
the team at the team level. Our meetings were, we’re
a very small facility. So having a meeting
every month, every week, it didn’t make sense because people on shift work and so we scheduled a meeting for every other month. Which meant that we had it at least once a quarter which met the requirements. And then we had smaller
meetings in between times. Like for instance me
and the stroke program, me and the stroke medical director and the ED manager would meet quite frequently if there was ever an issue. And we would start working on a process before it ever went to the team. You have to be creative that way because not everybody’s working nine to five in a small hospital there’s
a lot of variation in shifts. Education requirements like I told you. NIH, Swallow Screen, and ACLS, and TCA administration or Activase. Policies and procedures, the basics are that you have to have a triage policy. How are you gonna triage people so that you catch, you want to have this net that’s big enough to catch all your stroke that
you, and like most triage you want to have at least
a 15 to 18% over-triage. You wanna catch more than
are actually strokes. Which is hard for our ED to understand, they just wanted to do the minimum. It’s like no we wanna catch a few more. Because we should be catching
a few false positives. And then remove them out as something else and we take them out of the basket. But make sure that your net is big enough to catch 90 to 100% of your strokes. So that requires good triage questions. Your stroke alert policy,
what does that include? Who does that include, how does it run? Your admissions and transfer, who do you admit and who do you transfer? We did not keep any
hemorrhagic strokes at all because we didn’t have a neurologist there with the capabilities
in dealing with that. And we didn’t keep anybody
that was significantly affected that would need a neurologist assessment beyond the first, after the first day. If they would benefit from a neurology more often than that we
would definitely send them. If they were young we tended to send them more often because we have PT every day but we felt that sometimes there was PT that would definitely be better for them if it was specific for stroke on a stroke unit and
we would transfer them. We transferred all of our
TPAs, we never kept a TPA. And we didn’t keep, we
never kept like I said the hemorrhagic unless they opted for comfort care measures only. That was the only reason
that we would keep them. And then change them to
hospice and keep them but otherwise you have to
remember what can you do what can you do well
and what can you not do? And if you design that very well it helps your ED doctors,
your ED department to know okay that says
that transfer process go on right away or we can
maybe admit this person. We did find that those admissions that came to us and stayed in the hospital that were local that were
not severely affected. They had PT, they recovered a lot of their function within the first 48 to 72 hours, they really did prefer to stay local, family could be close. They knew people, the
same physical therapist that saw them in the hospital
saw them as outpatient. That kind of thing they really preferred to stay local so not everybody’s
appropriate for transfer. And that needs to be well
identified in the policy. Inpatient care, there’s
some very specific things that need to be done for inpatient care. We had to educate our hospital staff and our inpatient units. We did an NIH on admissions
and then we did it, we did it every 12 hours
for the first while and then we changed it to daily. Then we do the NIH daily to see if there was a change at all. And that they all had to be checked, swallow study before anything was given. PTOT-ST is involved and
sorry, anticoagulants. Within the first 24 hours and
then the discharge teaching. Let me tell you right
now that American Heart has been amazing for
us as a small facility. We go to discharge teaching, well how are we gonna, what are we gonna do? I went to the American Heart website for stroke and I went to
their educational page for stroke and I downloaded and printed exactly what they had there and I made a packet that had everything that was required by the state to be taught. So we had a grab and
go pack for discharge. And it just had a page on the front that listed everything that was included in the pack that signed off. And we had one little segment in there that we added that was like
okay you’re going home now. These are the things that we talked about that are gonna be affecting your life from here going forward,
do you recognize stroke? Do you know what to do
when you have a stroke? Do you know how to call 911, do you know how to manage your anticoagulants? But the one thing that we did ask them and we recorded on that front page that we kept in their chart was what’s one thing in your lifestyle that you think that you
could do differently that would decrease your risk of stroke? And I’m gonna tell you that
that very important survey when they came that we had somehow taken something that was very
packaged from the American Heart but we had personalized it for ourselves. And they really like you to
do that so keep that in mind. Improving the process and outcome. We have to audit, we have
to evaluate what to audit. And then use your information
to plan improvement and then measure how you improve. And a lot of that, Get With The Guidelines will help you with if you’re
using Get With The Guidelines or whatever tool you’re using. And American Heart is very
good at helping us with that. Administrative structure changes. It’s a changing culture because most of the doctors that
came to our department, came from different
countries some of them. And sometimes came from
different experiences and many of them wanted to be original in their treatment of stroke and to try to make it like this is the policy. This is how we do it, this is the code set of what orders we need so everybody has a stroke alert these are the orders that we do on everybody, don’t be creative and try to do this one or not this one. Okay we’re gonna do CT
of the neck on this one. You know, just make sure that you include the things that are on the policy. And it’s a culture
change and that’s having a good relationship with your ED doctors. Getting buy-in from your ED administration so that you can make sure that that culture changes to say
let’s catch these strokes. And one of the ways you do that, don’t forget to celebrate the victories. I’m gonna go into that a little bit later. And having a direct line of communication with the stroke medical director that has to show up on your org chart as well as in your relationships, you need to have a good relationship with your stroke medical director so
that you can communicate the process improvement
that needs to happen. And he can communicate that with the others, the other doctors. Because they do really drive the team. Although they take in most situations they take their cues from
the stroke program manager. Monitor your stroke care, develop the tools that will work for you. Don’t make them too complicated but make sure they capture what you need. Develop team leads, one of the best things that came after our first survey and our first designation was that they encouraged us to
develop stroke champions on each unit and that took a big load off of me because I felt
like I was doing everything. And I got stroke champions,
I incentivized them by taking them to some further educations. Gave them some applause but also gave them some responsibility. And they really, it really helped. When I went on vacation there was somebody to take over auditing for
me or monitoring stuff. So develop your champions
and it’ll help you. Okay and go ahead and
apply, the stroke team. Admin buy in, I told you about that. Keep them in the loop, keep them in the loop of what’s going on. On what needs to happen in the next year. The stroke medical director, pick someone with interest, someone who has a passion and not just someone who says yes but is not really interested. Because that will be a
hard hard row to hoe. I’m just, it’s a big deal,
it’s best if you get somebody that has good passion and
good buy in for stroke. And they’re out there, involve
your radiology, lab, and RT. PT OT ST, unit managers, quality. Quality’s a good partner
to have in this process. And your stroke champions I’ve already covered this, I’m gonna move on. Education, stroke alert
criteria and process. When I first started this that seemed to be a moving target, I would send out a tool and say okay let’s audit every stroke alert that comes in the door. And this is the tool we’re
gonna use to measure it. And we did it and then I
learn a little bit more and it’s like oh we need
to change this audit tool. And they came a little frustrated with the changing, the
moving of the goalposts that why couldn’t this stay the same? So if you can borrow
something from somebody else, learn from somebody else’s
experience, that’s helpful that you don’t have to keep
on changing the criteria. It’s out there but you just have to partner with someone
that’s about your size or someone that’s bigger than you in hospital size so that you
can avoid those mistakes. The NIH like I said it’s just a module that everyone does and they
supply us a certificate. The Swallow Screen was
taught by our PTO, our ST. She came in and made it quite easy for people to do, there
was a simple policy that just here’s the
things that you need to do in order to do a swallow study and it was built into our electronic medical record within the first year so then they could do it that way and it would score for them, this is that definitely a pass, this
is definitely a fail. It was pretty fool-proof, ACLS Activase. Now the Activase training, it’s best if it’s done as a group or
in person or one-on-one. We did have a DVD that we played and we let people do it on their own but we found that that’s
not really as useful as doing it in person, as doing hands on. If you can keep an
Activase models and tubes from a previous admission so that people can actually practice and do
it, the best case scenario. So that’s in a small hospital you’re not gonna always have, the
pharmacy’s not always there. There’s not always somebody
who’s given it before. So practice is really important. Tele use, that became something that helped us a lot
because we had tele use and it very good but it wasn’t
being used appropriately. Until we started to push and say if that patient arrives in six hours of last known well, we encourage that you use telehealth
because we want to, it’s a good fail-safe for the doctor to say yes this was a good choice or this is not a good decision. He doesn’t have to be alone in making that decision unless
it’s obvious of course. But if it’s not sure and
it’s within six hours and we started just
tracking those statistics and posting those
statistics and we increased our tele use from minimal to about 80% of those that arrived within
six hours were using tele. And that helped us to
make better decisions. So if you have the tool, use it. EMS we did a lot of EMS training in trying to get seen
times down to 10 minutes. And to get them to call stroke alerts prior to arrival and based
on what they had assessed. And to use a stroke scale to assess their patients before they arrive. So like I said they were all volunteers and that was a bit of a feat
but we did manage to do that. Policies procedures,
I had gone over these. Triage, stroke alerts,
admission transfers. Inpatient care discharge and
then there’s another policy that you’ll need about how you’re going to audit your strokes and the registry and the process improvements, those are pretty much the basics that
will be required for you. If you’re a small hospital
looking for designation. Improvement process said if we need to communicate a clear objectives to our end users, to our front lines. And one of the most helpful things we did is to make a grab and go
package in the ED package. It’s just a grab and
go, you just grab this. If you grab this and the glucometer you can assess this
patient, you can do the NIH. You can do the swallow screen, you can everything within that package. And we also color coded everything, everything that we did
with stroke was purple. So that was a purple
binder and we made badges that say badge cards
that they could attach to their ID badge and that on there there was a stroke alert that times for each thing that’s needed
to do for a stroke alert. What was included in the stroke alert. How to assess all those things were on that little badge
so they could just look at it real quick and remind themselves. Because we don’t use them
that often, a small hospital. The first year we had
30 stroke assessments. Patients that were assessed for
stroke in our ED department. And this last year there was 99. So it has gone up with public education. And we are happy to report that but it’s not that often and so people need signage, grab and go packs, and the badge helps were very helpful. We also had a grab and go pack upstairs ’cause our inpatient strokes were even less frequent than our ED strokes. So we would have a grab
and go purple pack there that would help them walk through the process because stroke
care was very infrequent. And again your mock strokes
helped that situation. A timely audit, we’ll talk a little bit more about that when we talk about the daily, weekly, and monthly schedules for the stroke program manager. Evaluate your care, involve the frontline people and be outcome focused. Sometimes it becomes really easy to focus on the little
things that weren’t done. And yes sometimes there’s a reason that it’s not done but
let’s look at the outcome. We’re happy with this patient. If you bring back news, if
you give back information. I mean you did this, you gave TPA and he was discharged three days later from a large facility and
it was a great outcome. That’s really encouraging, you know? Because if they can see
that what they’re doing is making a difference it helps them to comply with those policies
that we have in place. Measure your outcomes
and communicate them. To the EMS I would report back to the EMS to say hey great call on that last patient,
this is what happened. He was sent out and this is the outcome. As much as you can
communicate with them do so because it helps them to
improve their process as well. When you’re finding your improvement it can be tempting to be individual. You were the charge nurse
and this didn’t happen but you know there’s
always a bigger picture of what happened in the
emergency department. Why it didn’t happen so try and look at this system when you’re
planning you’re improvement. Look at is there a system
thing that we can change? Like is it a process we can change? It’s not always that the
person didn’t just do it. Maybe that person was really busy with the next stroke in the next room and if there’s a process or a system thing that we can change it helps a lot. We did a lot with our
electronic medical records. One of them was a stroke alert criteria. Okay when do we call stroke alerts? What makes it good,
what makes it not good? When’s it right to call and why did we call on this one and not this one? And we went from calling none to calling on everybody that had a stroke in the last week,
I mean they would call a stroke on anybody that
had any stroke-like symptoms that had been, and that was
like okay that’s too much. Let’s narrow that, now we’re good. Now let’s see more
specifics so I gave them a stroke alert criteria
in their triage packet. And in the electronic medical record we built it in that they did it quickly. Since they faced FACT
they did the FACT exam. They did a last known well,
they did a discovery of symptoms and their glucose reading
and with those things automatically the system would say call a stroke alert or not call a stroke alert based on those answers. So that kind of helped
clarify for them a little bit and we got better at calling stroke alerts that were appropriate rather than just exhausting everybody
with doing a stroke alert on people that it didn’t really apply to. So that was a system
thing that we changed. We did a little
electronically and it worked. Using the telehealth loft,
that was a system thing that helped us improve our stroke care. So look at the whole picture and see if there’s a system or a process thing that will make it easier
for your end users to make the right decision
and do the right thing. And of course celebrate the victories. We’re a small hospital, can a small hospital make a difference, I
can tell you that right now. We amazed ourselves we
gave TPA within 38 minutes of arrival, that was
our best case scenario. And the very good outcome on the patient. But 38 minutes is, that’s
something to celebrate. And so we did, we always, we would when we had a TPA that was given within 60 minutes we would come back the next day or the next
time that team was on. We would celebrate it, take a picture, and post something in the newsletter of our hospital so that
we could celebrate that. This is not unfamiliar to you if you’ve been doing stroke so you know about it. The stroke timeline that we went for is onset of tPA with onset of symptoms to tPA in less than three hours. Door, and this is some of the stuff that was on the badge that I mentioned that we had, the purple badge that we gave to people that they could put on their ID badge so they could just quickly look at what’s the time for this. The patient has to be to
the CT within 25 minutes. The patient has to have the
CT interpretation within 45. Just gonna say as a small hospital your CT’s around the corner from your ED. And if you, I feel like that’s quicker than it is in the big facilities sometimes because it’s just right next door. And there’s only three
people in the ED that night. So most of the time we’d get our CTs done within seven to eight minutes. And our reports were very seldom that they weren’t back within 25 minutes. Door to EKG lab and x-ray
results was within 45 minutes. That was more difficult to
get because our CT machine takes 30 minutes to spin and get a result. So 30 minutes out of 45, if you don’t get the lab drawn and to the lab within the first 15 minutes you’re already late. So that became a challenge
but we got better at it. We changed our process, when they called a CT alert we would do a glucose. Straight to the CT on the
x-ray, on the EMS stretcher. As soon as the CT is
done lab was encouraged to draw blood on the CT table so that they could start their process and then we would take the patient back to the ED and do the
EKG and start the IVs. And doing that little thing helped us to get our PT primary
back within 45 minutes. We may extend the onset
of tPA to 4.5 hours but every minute increased
brain loss so don’t forget that. Throughout the process evaluate for a large vessel occlusion
because that’s just, as you know the guideline’s changed and that’s been something
we’re all looking at. So as a rule of thumb we’ve said if they’re in less than six hours from the last known well,
NIH is greater than six. Affecting more than one body region, definitely use tele and let’s assess for that, a large vessel occlusion. The six hours I know is changing. As you all know it’s new
all the wake up strokes are being treated successfully and I’m very happy about that but we have not incorporated that yet. I mentioned the electronic EMR and triage where we gave them an alert to say call a stroke alert on this patient. Because something’s abnormal. And that was one of the
process improvements we did that helped things
move in a good direction. Administrative changes, we had commitment. We had culture, communication with administration is important. And making your committees useful. So don’t just have everybody at the table but make sure that they’re useful. And that’s when it’s
important to have CT there. Rather than have the head of x-ray at our meetings we had our CT techs there. Because they were the first line users, they were the ones that
were having trouble getting it sometimes we
didn’t do CTAs very often. So that was a challenge
when that became important with large vessel occlusion doing a CTA to rule in rule out sometimes. We had a tech that hadn’t done one before. So getting that education for them. So having the CT techs on our team became very important and very useful. The monitors that we used, the tools. You gotta audit every, you
gotta audit every stroke that comes to your
department in order to know where you can make improvements
and how the outcome is. So a very simple first line audit and then translate that
into a spreadsheet. I became an Excel expert
and it worked for me. It helped me pull stats really quickly. So make your audit tool work for you. Sometimes you have to
increase your knowledge in some kind of tech tool like Excel or something like that
to make it work for you. But I would say that’s a good investment to go for it and do that. Because doing it all by
hand, it’s not always as useful and it’s not definitely is not the best use of your time. The registry can help
you with some of that. I’m not gonna speak to that, I think there was a WebX already about using Get With The Guidelines
and pulling reports. Full learning what those reports say is really important ’cause I found that I was putting
people into the registry and then in the report
they didn’t show up. And it thought what happened here? I had to do some education on what is that report actually pulling? But sometimes my Excel spreadsheet was actually more useful for my, to get the small picture of just my facility and what
happened in this case. Reports, the reports go to state. To your RAC or your regional area. We would report on a broad spectrum to administration and all the details to the stroke team and to their departments whenever they were affected. Your team leads, your
champions in each department. Your charge nurses and give
them the changes I covered that. So I’m gonna stroke ahead here because I’m talking too much. Get With The Guidelines is a data registry that helps you a lot, that’s
got extensive reporting. Benchmarking, what I really liked is it would benchmark me against the other hospitals that were zero to 100 beds. So it wasn’t measuring myself against the big comprehensive centers. I was measuring against other hospitals that were the same size as I was. There was consistency, apples to apples. Data tape interpretation
and results was consistent. I did have to learn some of that, like why did I, why did that person not qualify for this statistic when I entered them in I know they did? And I would find out that it was because they’re some idiosyncrasy that
took them out of that measure and I learned how to figure that out. Education, there’s a lot of education webinars available to them and they also give you recognition through awards. Which helps with publicity,
you get on their website. And also you can use that, we used that as a huge celebration at our hospital. And we were able to
communicate to the community that we are qualified for an award. Apply early, at least one year. Have time to work on your deficiencies. Prep for the survey, do a mock survey. We did that and that was very helpful in letting us know how were we doing. Make sure you include community education involvement and that means simple things like you know if you do a health fair, take some pictures,
email them to yourself. You have a time-stamped
email and it has pictures in it so that’s proof that you did it. It doesn’t have to be
complex, just some kind of time stamp record
of what you have done. And then don’t forget to celebrate. And there we got our
Get With The Guidelines again in 2018 we got it in 2015 and then. And you might be wondering
we get silver plus, it’s very hard for us
to go to the next level. Because in order for us
to go to the next level we would have to give six
tPAs as a minimum that year and 80% of them would
have to be in 60 minutes. I’ll show you our statistics
here in a few minutes. This is by year from the year, the baseline is the first column and then the years
following our NIH reporting went up very quickly and it stayed high. Our dysphagia screening went up quite quickly and stayed high. We weren’t even doing it
and then it got better. Each year it got better
and LDL documentation. We weren’t recording it and now we weren’t doing consistently
on stroke patients, but now obviously we’re
doing 100% this year. So that got better, Statin
prescribed at discharge. I’m not sure why the baseline was so high but we got better at
making that appropriate because I think the first year when I said Statin was prescribed at discharge I wasn’t measuring how much Statin was prescribed. And it’s gotten more stringent if you’re LDL of 70 which is hard for any of us if we’re not a jogger and a vegetarian but anyway if you’re not on a statin and you’ve got
an LDL of greater than 70 then you need to have documentation about why that didn’t happen or have it prescribed at discharge, so
we did get better at that. Stroke education, we got definitely better at that with that grab and
go package this last year. Evidently there was some perhaps changes that didn’t get educated and there was used quite
a bit of agency that year. And we realized that
that made a difference if they didn’t grab that package to go and educate their
patients at discharge. It was very easy for them
to just grab the package and go teach it, get it signed,
but it just didn’t get done. IV tPA treat within 4.5 hours, we got definitely better at that. You know you look at this you think oh man that’s great,
that’s a lot of numbers. We’re a small hospital, in 2013 there was, that was just the baseline data. We didn’t, we weren’t, didn’t have a stroke program at that time. 2014 I started measuring,
there was no tPAs given. In 2015 there was three
and 16 there was five. And then in 2017 there was seven. So that’s not a lot, that’s not a lot. And so if you fall out on one it makes a huge difference in the statistics. If you fall out in one of two that’s 50%. So our tPA door to needle time, we did go up in the number
of times we gave tPA. We have a lot of pushing with the doctors, a lot of pushing with the team
who called the stroke alert. Why aren’t you giving it,
give it give it give it. And they would, they gave it more often. The getting it, give
FAST was not that often. I did brag about our 38 minutes but that wasn’t very
common, we gave a whole lot more in 2016 than we had before. But we only gave one of
those within 60 minutes. Some of them were 63
minutes, some were 67. Not 60 minutes though, so that was the push for 2017 let’s get faster. So specific comparisons, the IV tPA within three hours compared
to other small hospitals. And we are on par, so a small hospital can make a big difference. Organizing your priorities, briefly. Daily I would go through the ED log of admissions, transfers, and deaths. So that’s what they’re required to do. And I would check on what was the, what happened to each of those patients. On a daily basis I’d look at that log. The other thing I kept on the
side was the stroke alerts. Those that were stroke
alerts that ended up not being a stroke, it
was a neurological change but it was glucose or
it was something else that they were calling stroke alerts. I would check and just see
what happened with those. I’d enter them in my spreadsheet and the log and do a brief audit but not a detailed audit at that point unless it was a tPA then
I would do it right away. Interdisciplinary, look
at the inpatient cases. We have rounds every
three days of the week. So I would go and use
that as an opportunity for education but also to
assess each person’s care. And make sure that their, that they were getting their stats,
that they were getting their anticoagulants within the 24 hours. That they were getting PTOT-ST, that they were, the NIH
skills were being monitored. Just use that as an education time and also to look at the overall care. Weekly I would abstract cases in detail. Initiate the PI loop
closure, plan education if it’s a system-based
thing, is there something I can do to change the system? Is there something I can
do to change the process? Or is there something I can do to educate individuals or departments to make a better outcome for this? One thing I did on that was that I would give feedback to the individuals but I’d always ask them what could we have done to make the outcome
of this better or different? Try and involve them in that process. And then of course enter
everything into the registry. Monthly I would run my reports. Submit my reports to
RAC and STRAC, to state. Have stroke meetings every
other month we had ours. And I would attend the stroke meetings at the RAC monthly just to get
more information from them. Make sure I was on par with others that were doing the same
thing at that point. We had a support group for stroke in our community and we had that monthly. Education, I would have
something every month. A staff meeting where I would
help work with something. A mock stroke, a stroke alert. Or I would just email
educational offerings to doctors or EMS, EMS and then I would always do new employee education. One thing you can do is
collaborate with others. I would never have been at STRAC, I would never have
given this presentation. I would never have done this research if it hadn’t been for the
other stroke coordinators who had worked together with us. And I was just pointing at my name there. We presented that at the
National Stroke Conference and I got to have my name on there. Because I collaborated with others. You don’t have to do everything yourself, you can collaborate with others. Utilize the technology,
the SurveyMonkey was used. So and then community education, I’ve already gone over most of this. Use your newsletter, use your newspaper. Use YouTube, emails, one way to reach out. You have to include your
doctors in your education. So whenever I had an opportunity that came along for stroke education for doctors I would just forward that email, forward it to myself, make a copy of it and
there’s my education. It’s not your responsibility to see that they went it’s your responsibility to see that they were notified of it. One thing we did was we joined the local parades with our cars. And we had FAST supply the FAST tee shirts and FAST magnets and
we put them on the cars and we had FAST stickers for people that put them on their fridges. And that was our education
for the community. That’s pretty much my presentation, is there any questions? – [Host] Thanks Martha,
please press star six to unmute your lines or type in the Q and A section where
it asks for questions. So we did have a question come in. Do you do a swallow
evaluation on all patients or just those with stroke symptoms? – [Martha] Only those
with stroke symptoms. – [Host] Do you use tele neuro for your stroke patients’
initial evaluation? – [Martha] Only if they fall within the basket within the last six hours. So if the last onset of symptoms or especially if it’s,
if the last known well’s within the last six hours,
now that was our goal. We have expanded that a little bit to those with wake-up strokes. We included tele with wake-up strokes now because of the LVO emphasis
that’s come in the last year. But if it’s beyond the
24 hours then we don’t. – [Host] Another person asked if you could send a badge example of your stroke alert cheat sheet and the contents
of your grab and go packet? – [Martha] Sure, yes I could send it to you and you could forward it up? – [Host] Yeah, perfect.
– [Martha] Okay. – [Host] I’d say if any
of you guys have questions press star six to unmute your line or type in the Q and A section of WebX. (voices murmuring in background) Great well if there
are no other questions, we would like to thank our speaker one last time for presenting. A couple reminders before signing off. Please note you will only be able to claim your CE credits at the end of the 15 week series on September 27th. And a copy of today’s
live and any handouts will be sent to you within today’s call. Thank you Martha and
we will see all of you next week.
– [Martha] Thank you. – [Man] Are you sure about that, I don’t think they’ve changed the thing. – [Soft Voice] A little bit.
– [Man] Okay that’s what I.

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