Stroke is the third-leading cause of death in the United States and the leading cause of disability, according to the American Stroke Association. Prompt diagnosis and treatment is key to saving lives and reducing permanent disability. In June 2008, Delaware County Memorial Hospital joined a select group of hospitals that deliver expert stroke care by becoming a certified Primary Stroke Center by The Joint Commission, the first in Delaware County. In March 2009, Crozer-Chester Medical Center became certified, and Taylor Hospital is currently pursuing certification.
“Stroke center certification signifies that the hospital has met higher standards for evaluation and treatment of acute stroke patients as defined by The Joint Commission,” explains Joseph Lubeck, D.O., chief of the Section of Neurology at DCMH.
“The stroke initiative is consistent with the mission of the Crozer-Keystone Health System, which is to continually improve the care of our patients and to provide new or refined services,” notes Maureen DePrince, RN, stroke coordinator for DCMH.
Certification Ensures Consistency and Excellence
Certification is based on guidelines developed by the Joint Commission, American Heart/ American Stroke Association and the Brain Attack Coalition. They require applicants to have a stroke team and neurological services available around the clock, written diagnosis and care protocols, and close coordination between the emergency department and emergency transport, in addition to specific clinical expectations.
Earning certification requires optimal performance from everyone involved in transporting, evaluating and treating a stroke patient. Four months of treatment data is submitted during the application process.
DCMH cut a ceremonial ribbon when they received Primary Stroke
In addition to certification, DCMH and Crozer have each earned the American Heart and Stroke Association’s Get With the Guidelines (GWTG) Bronze Achievement Award for Excellence in Stroke Care. The Bronze Award is given in recognition of 90 consecutive days of consistently following the treatment guidelines set by the American Heart Association/American Stroke Association with at least 85 percent compliance in each of seven core GWTG-Stroke measures.
Taylor Hospital is the only CKHS hospital that has earned the GTWG Silver Achievement Award from the American Heart and Stroke Association in recognition of 12 consecutive months of consistently following the treatment guidelines with at least 85 percent compliance.
“Starting a stroke program takes a lot of hard work and can only be done with the support of hospital leadership and the entire multidisciplinary team,” DePrince says.
The stroke teams at DCMH, Crozer and Taylor include nursing, neurologists, emergency physicians, internal medicine physicians, rehabilitation and speech therapists, a pharmacist, nurse educators, case managers, and representatives from Quality, Radiology, Lab and pre-hospital emergency medical services (EMS).
“Nurses have primary responsibility for implementing the new stroke protocols developed by the teams,” notes Suzanne Jenkins, RN, BSN, stroke coordinator for Crozer and Taylor.
Taylor's stroke committee gathers to recognize their "Get with the
Timing is Key
Primary stroke centers are required to diagnose possible stroke patients quickly since time is critical in treating strokes. For example, tPA (tissue plasminogen activator), a thrombolytic agent to dissolve clots, is most effective when administered within three hours of the onset of stroke symptoms. This means that patients have to reach the hospital and be evaluated within that window.
However, tPA and similar drugs carry major risks as well, the greatest of which is bleeding in the brain, which can cause more damage. The bleeding risk of clot-dissolving drugs increases with time and, after about three hours, exceeds their limited benefit.
The three-hour window of opportunity for treatment begins when symptoms begin. “A nurse is usually the first person a patient encounters upon arrival at the ER,” notes Jenkins. “Nurses play a key role in rapidly triaging the patient, identifying stroke symptoms, alerting physicians, and determining whether the patient is a potential candidate for thrombolytic therapy.”
On inpatient units, nurses also must be vigilant for symptoms of stroke in their patients, and call a rapid response team to perform triage and begin care when appropriate.
"Excellent stroke care has been ongoing for some time at Crozer but extra effort has been put forth to bring all aspects of our care into compliance with the new American Heart Association and Joint Commission guidelines,” says Bradley Grayum, M.D., chief of Neurology at Crozer. “The (enthusiasm and willingness to take on additional responsibilities) of the 2 North and Emergency Medicine nursing staffs was instrumental in achieving certification as a Primary Stroke Center.”
At Crozer, eight nurses have stepped up as stroke champions, acquiring additional education about stroke care and serving as resources for their fellow nurses, according to Jenkins.
In addition, nurses on the stroke units at Crozer, DMCH and Taylor receive additional stroke-specific education and know the importance of preventing and recognizing complications for this patient population.
“These nurses provide support and education about strokes to patients and their families with a focus on secondary prevention,” adds Jenkins. “They help to identify personal risk factors for each patient, and work with the patients to make modifications to their medication and lifestyle.”
Since July 2008, Crozer nurses have been making rounds for stroke patients with Grayum. “The nurses are very enthusiastic about this opportunity,” says Jenkins. “Rounds are very educational, giving the nurses exposure to many types of stroke patients, while reflecting the value that nurses bring to stroke care.” Similar rounds are expected to begin at Taylor this spring.
During rounds, Crozer nurses have observed that many stroke patients are very depressed, and recent reports in the literature confirm that a high rate of depression exists among stroke patients. Studies also show that a year after a stroke, patients with untreated depression do much more poorly than patients who are treated. In response, Crozer nurses have been working with physicians to develop a depression screening protocol for stroke patients.
Scheduled to roll out in May, the new protocol calls for nurses to conduct depression screening on the third day after a stroke to allow chemicals in the brain to settle from the insult. Based on the results, the nurse could request a psych consult, notify neurology, or call the attending physician. The protocol team is also considering a screening tool to be given to stroke patients on discharge and taken to the post-discharge follow-up visit with their primary care physician or neurologist.