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
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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
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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
Patient arrives in ER
From Clinic
Patient family drives in
Treatment decisions based on:
Not a stroke
Further orders per
provider
•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
Outside treatment
window
(> 4.5 hours)
Not a t-PA candidate
Ischemic Stroke/
TIA Orders
CT over-read received
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.)
Ischemic stroke
Potential t-PA candidate.
Contact Sanford Neurologist
Within treatment window
t-PA candidate
Call helicopter if not done previously
Follow t-PA
Administration Protocol
Transfer to Tertiary Care
or
Medical Management
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
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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:
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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