Debbie Camp remembers when hospitals didn’t know how to treat stroke patients.
“There were no uniform guidelines. They put them in the back of units, gave them fluids, tried to lower their blood pressure and sent them to rehab,” said Camp, RN, MHA, CCM, evidence-based stroke manager at Atlanta Medical Center.
Since 1980, when Camp helped start the first neurology unit at then-Georgia Baptist Hospital, she has witnessed a dramatic rise in brain research and much-improved treatment methods, like the clot-busting drug, tPA (tissue plasminogen activator).
Yet, Georgia remained in the “Stroke Belt,” with higher than average incidence and death rates for the disease. Real progress began with the development of the Georgia Coverdell Acute Stroke Registry (GCASR) in 2001. Named in honor of the late Sen. Paul Coverdell, who died of a massive stroke in 2000, the primary goal of the program was to improve the care of acute stroke patients in hospitals.
“It’s amazing how quickly we’ve moved the bar for stroke care in 10 years,” Camp said.
That more hospitals have adopted best-practice guidelines for treating strokes is reflected in the rise of patients receiving defect-free care.
“Defect-free care means that the patient got everything he needed in terms of screenings, medication and education appropriate to his diagnosis,” Camp said.
In 2005, the percentage of stroke patients receiving defect-free care in Georgia was 19 percent. In 2010, it reached 75.7 percent.
Sixty-two Georgia hospitals now participate in the state’s stroke registry; almost half of which are Joint Commission-certified as primary stroke centers. The hospitals on the registry account for almost 70 percent of stroke admissions in Georgia.
“That’s a lot of progress,” Camp said.
The beginning
In 2001, Emory University received funding from the Centers for Disease and Control Prevention to pilot a stroke registry in Georgia.
“Our goal was to define and implement a prototype registry for collecting information about stroke patients and using the data to improve care,” said Dr. Michael Frankel, lead neurologist for the Georgia Coverdell Acute Stroke Registry. Frankel is also a professor of neurology at Emory University, chief of neurology for Grady Health System and director of Grady’s Marcus Stroke and Neuroscience Center.
In 2004, Georgia’s state health department received additional funding to continue its battle against strokes.
“Our state is only one of five to have a stroke registry and one of two to have had it continuously for 10 years,” Frankel said. “Georgia has accomplished a lot, but there’s a great deal more to do.
“This is a very deadly disease. Stroke will happen to 20,000 Georgians this year. Everyone knows someone who has been affected by it, and you don’t have to see many [cases] to realize how devastating it is.”
Stroke is the fourth-leading cause of death in Georgia. That’s down from third, but it’s still the greatest cause of adult disability.
“People’s greatest fear is to have a stroke and be a burden on loved ones for the rest of their lives,” he said.
Frankel, who was part of the first clinical trials for tPA, conducts cutting-edge research and implements it into care at Grady’s stroke center. He credits the Georgia Coverdell Acute Stroke Registry’s collaborative model for much of the progress in the state.
“Everyone has been on the same mission to treat stroke aggressively and put our best practices into place,” Frankel said.
In the best-case scenario, new research would immediately result in doing things differently but, in reality, achieving evidence-based practice takes time, Frankel said.
“Building trusting relationships has been at the heart and soul of Georgia’s battle against stroke,” he said.
Trust was in short supply when the registry was started. Getting competing organizations to share best practices and resources wasn’t easy.
“The assistance of the Georgia Hospital Association was very important in the beginning,” Frankel said.
Through its Partnership for Health and Accountability Initiative from 1999, the GHA had brought hospitals together to share data and talk about quality of care issues, said Joyce Reid, RN, MS, director of community health connection for the Georgia Hospital Association.
“I believe we were a benefit in getting hospitals to participate in the registry, and we made meeting space and other resources available,” Reid said. “Even competitive hospitals are now willing to share what they do in order to improve care and increase public awareness.”
The association encouraged partnerships with other organizations, including the American Heart Association, whose Get With the Guidelines program of best practices for stroke helped more hospitals achieve better outcomes.
Building trust
“When the first network of GCASR hospitals sat across the table from each other, no one talked,” said Kerrie Krompf, hospital coordinator for the stroke registry at Emory University. “They thought that their protocols, order sets or pathways to treat stroke should be kept secret.”
But as officials began meeting monthly, they saw the benefit of reaching across institutional barriers to fight a common enemy.
“Now you can’t shut them up,” Krompf said. “This is one of the most exciting and rewarding projects I’ve ever worked on, because it’s all about the patient. Everyone is trying to measure and improve the quality of care. Dedicated professionals moved beyond registry expectations when they formed the Georgia Stroke Professional Alliance.”
When the group started, it was comprised of a handful of clinicians sharing dinner. While they had different titles and responsibilities at their health care facilities, improving stroke treatment was a common focus.
“We were all trying to do the same thing, and it just made sense to build on what other people had tried and learned,” Camp said. “We began meeting together regularly to share the latest research and what was working.”
Recent conference calls have been aimed at reducing the door-to-needle time for tPA. The drug is only appropriate for ischemic strokes and must be administered within four-and-a-half hours of the onset of stroke to be effective.
“Every minute is precious. Millions of neurons are dying with every hour you lose before treatment,” Camp said. “So you have to educate the public and emergency medical technicians to recognize the symptoms and to bring patients to stroke-ready hospitals.”
The group created online education for EMTs and continues to help hospital emergency room staffs shave minutes off the time it takes to perform triage, CT scans, lab tests and to get results.
When patients are given tPA in time, the outcomes can be amazing.
“We’ve seen people come in to the hospital partially paralyzed and not able to speak, receive tPA and walk out 24 to 48 hours later. It’s like a miracle,” Camp said.
The Georgia Stroke Professional Alliance has grown to about 165 members. The group presented an abstract at the International Stroke Association Nurses Symposium this year.
“Georgia has become a leader in stroke care, with Dr. Frankel and Kerrie [Krompf] pushing us forward. Our aim is for Georgia stroke patients to get the right care, no matter what hospital they’re in,” Camp said.
In 2008, legislators passed the Coverdell-Murphy Act, which established a two-tiered certification system for stroke-ready hospitals in the state: primary stroke centers and remote treatment stroke centers. It’s an unfunded mandate, but thanks to the success of the registry and its partners, Frankel said hospitals were already sharing expertise via telemedicine.
“Our goal now is to see more of Georgia’s 140-plus hospitals participating in the registry,” Frankel said. “It would mean a lot of lives saved and strokes prevented.”
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