# Presentation: 016417

## Addressing the Stroke Continuum through Policy and System Change:  A Brainstorming Session

- Kathy Foell, MS, RD
- Hilary K. Wall, MPH
- Heart Disease and Stroke Prevention and Control Program
- Massachusetts Department of Public Health (MDPH)
- Mary G. George, MD, MSPH, FACS
- Paul Coverdell National Acute Stroke Registry
- Centers for Disease Control and Prevention

## Policy and System Changes

- Policies – include laws, regulations, and rules (both formal and informal)
- Laws and regulations that restrict smoking in public buildings
- Organizational rules that provide time off during work hours for diabetes self-management activities
- System change – includes changes to economic, social, or physical environments
- Implementing stroke standing orders in hospital Emergency Departments

## Why Focus on Stroke?

- Leading cause of disability, third leading cause of death overall
- Common perception is that there is no medical treatment
- Improvements in treatment (thrombolytics) can stop brain loss
- National guidelines published
- Stroke has gone from a hopeless condition to a treatable condition
-  Shift in treatment paradigm; non-emergent to emergent condition

**Notes:**
Misconception by public as well as health care providers.
Most effective treatments need to be given as soon as possible (within three hours of symptom onset).  Hospital needs an hour for diagnostics; people need to get to hospital w/in 2 hours of onset.

## Resource

- Recommendations for the Establishment of Stroke Systems of Care; Recommendations From the ASA’s Task Force on the Development of Stroke Systems
*Stroke. *2005;36:1-14

**Notes:**
Recommendations from the ASA’s Task Force on the Development of Stroke Systems – responsible for developing recommendations on the organization and operation of systems of care for the treatment of stroke patients throughout the US

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
prevention encompasses Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events)

Continuous quality improvement activities throughout the continuum.  

## Stroke Prevention

- MA Health Disparities Collaborative
- Quality improvement initiative in Community Health Centers
- Includes hypertension and high cholesterol
-  Working towards a system change

**Notes:**
Future work to include improving blood pressure measurement and hypertension control

MHP and WHN – CVD risk screening w/ under or non-insured populations.

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events) prevention

Continuous quality improvement activities throughout the continuum.  

## Recognition

- Stroke Heroes Act FAST
- Educational kit
- Media Campaign
- Cultural and linguistic adaptations
-  Supports a regulatory policy
-  Population-based education
- Key Partners
- Stroke Signs and Symptoms Advisory Committee
- AHA/ASA
- MDPH Office of Multicultural Health

**Notes:**
Fulfills Primary Stroke Service community education requirement and the lack of statewide stroke symptom recognition
Face, Arm, Speech, Time
Train the trainer model

Animation DVD and VHS
Brochures and posters
PowerPoint presentations (long and short) and educator’s guide
Cultural and linguistic adaptations

## Recognition (cont’d)

- Data Sources
- BRFSS
- Mortality data
- US Census language data
- Literature search/environmental scan
- Evaluation
- Focus groups/concept testing
- Materials and kit distribution tracking
- Message retention pilot
- Knowledge change random-digit dial survey

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events) prevention

Continuous quality improvement activities throughout the continuum.  

## 9-1-1

- Telephonic Interpreter Service Provision
- Available to all 9-1-1 call centers in MA
- Over 200 languages
-  Policy (funding stream) and system change
- Key Partners
- Statewide Emergency Telecommunications Board
- MDPH Office of Emergency Medical Services
- MDPH Office of Multicultural Health
- AHA/ASA

**Notes:**
Gap in 9-1-1 data collection
HSPC and OEMS (internal partners)
 Funding by SETB

## 9-1-1 (cont’d)

- Data Sources
- 2005 Survey of Public Safety Answering Points (PSAPs)
- US Census
- Evaluation
- Service utilization tracking data
- (Eventually) out of hospital deaths for non-English speakers

## 9-1-1 (cont’d)

- Emergency Medical Dispatch
- Standardized protocol for responding to all medical emergencies including stroke
- Electronic data collection via software to improve surveillance
- Quality assurance to insure response standards
-  Working towards a system change and potential policy recommendation
- Key External Partners
- Statewide Emergency Telecommunications Board
- Public Safety Answering Points

## 9-1-1 (cont’d)

- Data Sources
- 2005 Survey of PSAPs
- Evaluation
- EMD data from participating 9-1-1 call centers
- Process data about challenges encountered, needed resources

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events) prevention

Continuous quality improvement activities throughout the continuum.  

## Emergency Medical Services

- Stroke Point of Entry Plan
- Includes stroke symptom education for EMS responders
-  Regulatory policy change
- Stroke EMS Quality Improvement Collaborative
- Developing performance measures
-  System change
- Key Partners
- MDPH Division of Health Care Quality
- MDPH Office of Emergency Medical Services

**Notes:**
POE prescribes which hospitals EMS bring stroke patients

Mandatory data collection for licensed EMS agencies
 National Emergency Medical Services Information System (NEMSIS)

## EMS (cont’d)

- Data Sources and Evaluation
- Out-of-hospital deaths
- NEMSIS
- Others to be determined

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events) prevention

Continuous quality improvement activities throughout the continuum.  

## Emergency Department and Inpatient Hospitalization

- Primary Stroke Service (PSS) Designation
- Creation of a new hospital licensure category based on:
- Written guidelines-based protocols for acute stroke care
- Ability to meet time target goals for assessment, management, and treatment
- 24/7 capacity for thrombolytic therapy, imaging, laboratory, and neurological services
- Community education required
-  Regulatory policy change

**Notes:**
Data collection for thrombolytic treatment of acute strokes:
Demographics
Date/time patient arrival to ED
Date/time of symptom onset
Date/time to CT/MRI
Date/time to IV thrombolytics
Reasons tPA not given
Discharge Destination

## Emergency Department and Inpatient Hospitalization (cont’d)

- Paul Coverdell National Acute Stroke Registry
- QI registry that complements PSS data collection
- Acute ED treatment
- In-patient treatment
- Treatment at discharge
-  System change
- Key Partners
- AHA/ASA
- CDC

**Notes:**
Stroke Collaborative Reaching for Excellence – combines multiple quality improvement projects into one data collection platform
76.5% of eligible hospitals are participating

Data Sources and Evaluation
Registry data
[insert qualitative sources and process data]

## Prototype States

- Participating States

## Consensus Group for Stroke Performance Measures

**(PCNASR)**

## Performance Measures & Underlying Process Measures

- Agreed to a single set of uniform performance measures with AHA and TJC (including joint data elements & abstraction guidelines)
- Collect data to evaluate processes that underlie the performance measures

## QI Activities

- States choose which performance measures they focus on, and in what order
- Encouraged to use CQI within their Coverdell logic model
- Encouraged to track baseline capabilities, improvements, barriers to implementation of QI at all hospitals

## PCNASR Benefits

- Provides organized QI assistance to hospitals
- Creates environment for sharing ideas and discussing barriers between hospitals and states
- Fosters collaboration between hospitals and states
- Provides expertise for data collection

## The Stroke Continuum

- Prevention

- Recognition

- 9-1-1

- Emergency Medical Services

- Emergency Department

- Inpatient Hospitalization

- Rehabilitation

- Re-integration to the Community

**Notes:**
Primordial (risk factor), Primary (acute event), and Secondary (recurrent acute events) prevention

Continuous quality improvement activities throughout the continuum.  

## Rehab and Re-integration

- Linking Discharged Stroke Patients to Primary Care
- Ensure follow-up with discharge orders for stroke patients with regards to meds, rehab
- Increase compliance and communication
-  System change
- Key Partners
- Hospitals
- Insurance Companies
- Pharmaceutical Companies

## Rehab and Re-integration (cont’d)

- Data and Evaluation
- Discharge summaries
- Insurance Claims
- Pharmacy
- Rehab services (PT, OT, speech, etc.)
- Decreased secondary events

## For More Information

- Kathy Foell
- kathy.foell@state.ma.us
- Hilary Wall
- hilary.wall@state.ma.us
- Mary George
- coq5@cdc.gov