STROKE INITIATIVE Sanford Tracy Medical Center Danette Ronnfeldt, PA-C Jeri Schons, CNO Jean Metcalf, R.PH
SANFORD TRACY Duluth Twin Cities Tracy Sioux Falls, SD
SANFORD TRACY 25 bed Critical Access Hospital Service Area of 6,000 people Part of the Sanford Network which includes 440 providers and 10,000 employees 128 Clinics 23 Hospitals 12 Nursing Homes 18 Assisted Living Facilities & Congregate Living 27 Home Health Services 19 Pharmacies
OUR START Sanford promoted the development of a Stroke Program CT was approved for installation in Tracy
OPPORTUNITY IDENTIFIED Lack of community understanding for early recognition of stroke symptoms and the need to seek help Immediately. Lack of hospital emergency room protocols for stroke management Lack of uniform protocols with tertiary care center (Sanford USD Medical Center, Sioux Falls, SD). Lack of overall focus on primary care stroke prevention in primary care clinics.
PROJECT TEAM The Stop Stroke initiative moved forward with the development of a multidisciplinary project team.
Stroke Team Members Physician Physician Assistant Quality/PI Nursing CT Pharmacy Administration Safety Lab
Stroke Team Members Home Care Medical Clinic Rehabilitation Services Emergency Medical Services Marketing Social Services
Project Improvement Method PDCA: Plan, Do, Check, Act method is the tool used in the development of Sanford Tracy quality improvement projects. Small focus groups divided off from the larger team to assume responsibility for various phases/parts of the project.
PLAN: January 2008: Initial Stop Stroke team meeting Reviewed resources/materials available Participated in tele-conference on stroke care in rural hospitals presented by Great Lakes Regional Stroke Network Chose project logo and overall theme Set date for campaign kick-off event Identified five project focus areas
Plan: Five focus areas 1) Raise community and staff awareness of stroke symptoms and importance of early treatment 2) Develop pre-hospital stroke management EMS assessment, intervention, transport to ED and handoff to ED staff
Plan: Five focus areas (continued) 3) Address ED stroke management, transfer and handoff to tertiary stroke center (Sanford USD Medical Center) 4) Address stroke rehabilitation management and care 5) Address stroke prevention education in primary care clinics
DO: (Action) COMMUNITY AND STAFF AWARENESS Education and Communication Numerous avenues were used to educate and raise the awareness of stroke symptoms, early treatment and prevention.
DO (Action) Employee and community newsletters Awareness stickers Bulletin board postings E-mail Press releases Posters Counter Cards Magnets Brochures All staff meetings Additional teleconference and audio conference participation Blood pressure screenings Community Education programs Live radio programs Local access cable Website Presentations at Tricommunity Health Fair Developed a 30 minute video
DO (Action) Expanded staff education and participation in related events Team members attended Sanford USD Medical Center sponsored Stroke Symposium. Physician champion attended Park Nicollet Stroke Readiness seminar.
DO (Action) PRE-HOSPITAL MANAGEMENT EMS SERVICES Purchased National Stroke Association EMS stroke care training program Began training of four community ambulance groups Adopted/trained EMS (EMT and First Responders) groups on Cincinnati Scale stroke patient evaluation (chosen for user friendliness ) Addressed communication/hand-off of patients to emergency room personnel
DO: (Action) HOSPITAL EMERGENCY PATIENT MANAGEMENT Adopted NIH Stroke scale and achieved certification of medical and nursing staff Installation of in-house multi-slice CT Developed stroke algorithm and standing order sets including t-pa for ischemic stroke Adopted standardized protocols aligned with tertiary care center (Sanford, Sioux Falls) Developed quiz for RNs on administering t-pa
STMC STROKE ALGORITHM Patient Call to 911 or Hospital Ambulance responds Assess with Cincinnati stroke scale Notify hospital (include onset time) Bring home meds Hospital Response Call Provider, Lab, X-Ray Call CT - obtain approx. response time Consider Dispatching Helicopter (based on stroke scale results) From Nursing Home Cincinnati Scale Symptom onset time Further orders per provider Patient family drives in Not a stroke Hemorrhagic stroke Not a t-pa candidate Intracerebral Hemorrhage Orders (Consider contacting on-call Sanford neurosurgeon) Other CT Factors * CT time for test Transmission time Overread (15-120 min.) Patient arrives in ER Treatment decisions based on: Patient History Symptoms and NIH stroke scale Neurologist Consult Treatment time window = Total of: Time since symptom onset CT tech response time Other CT factors (minimum of 30 min. see * below) Within treatment window (< 4.5hours) Potential t-pa candidate Initiate stroke standing orders Do CT, Labs, X-Ray Complete t-pa screening Calculate t-pa dose CT over-read received Within treatment window t-pa candidate Call helicopter if not done previously Follow t-pa Administration Protocol Transfer to Tertiary Care or Medical Management From Clinic Outside treatment window (> 4.5 hours) Not a t-pa candidate Ischemic Stroke/ TIA Orders Ischemic stroke Potential t-pa candidate. Contact Sanford Neurologist Failed t-pa screening or Outside treatment window
STROKE STANDING ORDERS
DO: (Action) REHABILITATIVE CARE Updated policies and procedures for care of stroke patients including assessment and interventions
DO: (Action) PREVENTATIVE EDUCATION IN CLINIC Re-develop clinic flow sheet to include stroke prevention measures Strongly encourage all clinic staff to address stroke education with each patient encounter. Continue radio and other community education programs Refocus brochures to reflect prevention measures Continue to provide additional materials such as magnets Implement a Risk Assessment Tool.
Stroke Risk Scorecard
Side 2 -Risk/symptom Information
CHECK: COMMUNITY AND STAFF AWARENESS: Understanding increased yet delays continue in patient arrivals at our ED
CHECK: PRE-HOSPITAL MANAGEMENT EMS Training process bigger than anticipated Issues with use and communication of Cincinnati Stroke Scale
CHECK: HOSPITAL EMERGENCY PATIENT MANAGEMENT: Algorithm Developed Protocols in place CT Tech response time Timely CT over-reads Staff Trained
CHECK: REHABILITATIVE CARE: Physical & Occupational Therapy Services Available Challenges Providing Speech Therapy
CHECK: PREVENTATIVE EDUCATION IN CLINIC: Goal met, preventative measures in place Ongoing discussions with medical and nursing staff to enhance stroke awareness
REACT: CONTINUING COMMUNITY AND HOSPITAL RE-EDUCATION EFFORTS Local Newspaper CEO articles Hospital Newsletter Presentation at Community BBQ Grocery store bag stuffers Re-present video
REACT: ONGOING AMBULANCE EDUCATION Refresher education for volunteer ambulance personnel (Cincinnati Stroke Scale) Host education event for all area ambulance services; featured speaker: Sanford Health Neurology Champion.
REACT: HOSPITAL EMERGENCY PATIENT MANAGEMENT Expanded treatment window of 4.5 hours approved at Tracy. Additional criteria added to protocols.
REACT: PREVENTATIVE EDUCATION IN CLINIC Providers reminded to address stroke at each clinic appointment Primary prevention Prompt use of ED for stroke symptoms
ONGOING: STROKE TEAM RE-EVALUATION 2010: Minnesota Stroke Registry Quantitative data Chart reviews Turn-around times Patient interviews/surveys
FUTURE: Continue presenting stroke prevention education at summer health fairs Use video for ongoing education Refocus community awareness with events during National Hospital Week Minnesota Department of Health Rural Flex Grant Collaborating with American Heart Association/Stroke Association Adapting for Electronic Medical Records (DocZ)
TEAMWORK = SUCCESS Teamwork has produced a successful initiative that we believe could be the basis for saving lives and lifestyles. STROKE
Sanford Tracy * COMING TOGETHER IS THE BEGINNING * STAYING TOGETHER IS PROGRESS * WORKING TOGETHER IS SUCCESS Henry Ford
THANK YOU