Improving Stroke Care through Collaboration and Education
Keith Jones, MD, MSDH Stroke Rules & Regs Committee Chair; Rebecca Sugg, MD, MSDH Stroke Advisory Committee Chair; Ruth Fredericks, MD, MSDH Stroke PI Committee Chair; Dee Howard, RN-BSN, MHCA Executive Director; Heather Muzzi, MPA, MSDH Director of Acute Care Systems; Angie Carter, MHCA Administrative Assistant; Not pictured: Harper Stone, MD, Mississippi Healthcare Alliance President
When the MS State Department of Health (MSDH) approved the new Stroke System of Care developed by the Mississippi Healthcare Alliance (MHCA) in October 2013 it marked the third successful statewide program designed to improve healthcare in Mississippi. Besides the Stroke Program, MHCA worked in partnership with MSDH to develop the STEMI System of Care for heart attack patients. All three Systems of Care, Trauma, STEMI and Stroke are under the direction of MSDH Bureau of Acute Care Systems, Heather Muzzi.
According to Dee Howard, RN-BSN, Executive Director of the Mississippi Healthcare Alliance, the organization focused on stroke for their latest statewide system of care because it is the leading cause of long-term disability and the 5th most prevalent cause of death among Mississippi adults.
“Stroke and its aftermath on the quality of life of a patient is devastating,” Howard explains. “With Mississippi leading the nation in the incidence of stroke, it made sense for MHCA to develop a coordinated program of care to improve outcomes and save lives.”
Establishing a program of care for stroke involved identifying the capabilities of Mississippi hospitals. Criteria were established for Level 1, 2, 3 and 4 hospitals so medical and emergency service personnel know where patients presenting with stroke symptoms should be taken to be rapidly diagnosed and treated. Patients treated at Level 3 hospitals with clot buster drug Activase should be transferred to a Level 1 or 2 stroke center for higher level of care.
“Timing is everything when we are dealing with a stroke,” Howard continues. “Getting a patient to the right place as quickly as possible can make a tremendous difference in their chance to survive and recover. We are already seeing excellent results since the program went into full effect early last year.”
The MSDH Stroke Advisory Committee, chaired by Rebecca Sugg, M.D., was formed for the purpose of providing guidance and direction to the Department in the implementation and execution of the state’s stroke plan. The MSDH Stroke PI Committee, chaired by Ruth Fredericks, M.D., is also a vital part of the stroke system. Every participating hospital and EMS provider is required to participate in the system PI process. The appropriateness, quality, and quantity of all activities of the stroke system must be continuously evaluated. Rules & Regs Committee Chairman Keith Jones, M.D., helps craft specific guidelines for the program.
Recently, when Performance Improvement was reviewed at the statewide level and compared to the national average, it was noted as with all systems of care, Mississippi patients tend to arrive to hospitals in their own private vehicles rather than by ambulance. Dialing 911 is important especially when people experience stroke symptoms. MHCA is helping to increase public awareness with its Dial Don’t Drive campaign across the state. The good news is, that Mississippi’s in-hospital mortality rate from stroke is now below the national average – MS 4.2% and nation-wide 5.9%.
Anyone can have a stroke at any age. Chances of having a stroke increase if you have certain risk factors like high blood pressure, high cholesterol, heart disease, diabetes, sickle cell disease, and a previous stroke or Transient Ischemic Attack (TIA). Lifestyle choices, such as unhealthy diet, physical inactivity, obesity, over indulgence of alcohol, and tobacco use, can also influence your stroke risk.
“A big part of what MHCA does is education,” notes Howard. “It is so important for people to know what symptoms to look for when it comes to stroke. To make it easy to remember, think F-A-S-T: F – Face drooping; A – Arm weakness; S – Speech difficulty; and T – Time to call 911. If you believe that you or a loved one is having a stroke, remember that stroke is an emergency! Have an ambulance take you to the closest, most appropriate hospital that is ready to treat strokes emergently.”
According to Howard, the biggest barriers to proper stroke treatment are:
• Late presentation of patients 12-24 hours after initial stroke symptoms.
• Only 3-5% of patients arrive at the hospital in time to be considered for Activase treatment.
• Many patients do not pay attention to the warning signs of stroke and delay getting to the hospital or drive themselves.
• Symptoms may be difficult to recognize in some cases.
• Family/friends/bystanders fail to recognize emergent need for dialing 911.
• Physician hesitancy to treat.
“The most important message we can give our fellow Mississippians about stroke is a simple one,” adds Howard. “First, know the warning signs. Dial 911 IMMEDIATELY if you suspect a stroke. And think FAST – Face – Arm – Speech – and Time. If we all remember these important steps, together we can significantly reduce the rate of disability and death from stroke in Mississippi and stop this horrendous waste of Mississippi’s greatest resource, its people.”
DID YOU KNOW?
What organizations/individuals make up the Mississippi Healthcare Alliance? MHCA is a volunteer network of physicians, nurses, hospital administrators, and EMS professionals representing Mississippi hospitals working together to improve outcomes for patients who suffer from heart attack and stroke.
What is the purpose of the MHCA? To improve the health status of Mississippians and unite stakeholders to bring about an alignment of efforts that reduce morbidity, mortality, and cost associated with problematic disease process that plague our community.
How do the state’s three statewide systems of care make Mississippians safer? They establish common protocols for first responders to identify certain life-threatening conditions, provide specialized treatment in the field, and transport patients to the facility best able to render appropriate care quickly.
Why was a coordinated stroke program necessary in Mississippi?
• Stroke is the leading cause of long-term disability among adults in Mississippi.
• Stroke is the 5th leading cause of death in MS.
• Mississippi’s new stroke rate is the eighth highest in the nation.
How many hospitals are currently participating in the Stroke Program? 66. These hospitals are designated as Level 1, 2, or 3 based on their capabilities to care for stroke patients.
What are the primary differences in capabilities between Level 1, 2, 3 and 4 hospitals?
Level 1 (Highest level of care) must have the following:
• A Neurologist, neurosurgeon and endovascular specialist available 24/7.
• CT imaging within 25 minutes with results in 45 minutes.
• Complete rehabilitation services available within 24 – 48 hours of admission.
• Helicopter landing site on campus.
• Operating room and support staff available 24/7.
• Participation in the American Heart Association (AHA) “Get With The Guidelines” (GWTG) Stroke Registry.
Level 2 must have the following:
• All of the requirements of Level 1 EXCLUDING endovascular capabilities.
Level 3 must have the following:
• The capability to rapidly diagnose, treat with Activase when patient is a candidate, and stabilize patient for transfer to a Level 1 or 2 hospital.
• ED physician, other qualified physician available 24/7 to diagnose and initiate appropriate treatment.
• CT imaging within 25 minutes with results in 45 minutes.
• Lab services available 24/7.
• Transition plans established for rapid transfer to Level 1 or 2 hospital.
• Acute stroke-trained providers capable of directing IV Alteplase administration.
• Participate in the AHA GWTG Stroke Registry.
• Incapable of diagnosing and treating stroke and must be bypassed by EMS
What Mississippi hospitals are designated as Level 1 and Level 2 stroke care facilities? Level 1 St. Dominic Hospital, Jackson; University of Mississippi Medical Center, Jackson Level 2 Baptist Medical Center, Jackson; Forrest General Hospital, Hattiesburg; Greenwood-Leflore Hospital, Greenwood; Memorial Hospital, Gulfport; North Mississippi Medical Center, Tupelo; Singing River Health Systems, Pascagoula; Singing River Health Systems, Ocean Springs. For a complete list of Level 3 and 4 hospitals in your area visit www.mshealthcarealliance.org/stroke-hospitals.