In 2020, the World Health Organization identified stroke as the second most common cause of all deaths globally.1 Approximately 2 million brain cells die during each minute of an ischemic stroke.2 When an ischemic stroke is allowed to run its course of approximately 12 hours, the victim ages 36 years, in effect, overnight.2 Think about it this way: If you went to sleep tonight, and woke up tomorrow 36 years older, would you be able to care for yourself? Would you be able to care for your family? And would your family be able to care for you?
Stroke programs require allocation of specialized personnel, equipment, and supplies. Care must be delineated along ischemic and hemorrhagic pathways, with secondary and preventive arms. These considerations mean that personnel must be proficient in stroke care. For the novice nurse, a stroke protocol is a mechanism to ensure appropriate and timely care by providing standardized practice expectations, time frames, and interventions. Stroke program initiatives improve patient outcomes and limit rehabilitation costs. An effective stroke program can provide the best opportunity for a stroke victim to return to their life with minimal deficits.
In 2011, I was designated the Stroke Coordinator (SC) for Midland Memorial Hospital in Midland, Tex. During my tenure as SC, I earned my Certified Stroke RN (CSRN) certification (2016), was appointed to the Texas Council on Cardiovascular Disease and Stroke by the Texas Governor (2015 -present) and was the Chair for Texas Cardiovascular Disease and Stroke Partnership (2013-2016). This article addresses tactics to standardize stroke care by using a stroke designation certification process. The discussion below integrates my own lessons learned when developing a stroke program, through the program's planning, processes, interventions, and outcomes.
Do your research
Guidelines
Become familiar with current stroke guidelines.3-6 New guidelines are available approximately every 5 years, with revisions interspersed between the comprehensive versions, usually via the Stroke journal, published on behalf of the American Heart Association.7 Further, the SC must be proficient in regulatory requirements for certification(s) to which the organization aspires. A few of the most common accreditation organizations are The Joint Commission, Det Norske Veritas, and State Health Services.8-10 They include “stroke-ready,” “primary,” and “comprehensive” program certifications.10 Additionally, the Centers for Medicare & Medicaid Services payment program requires regular stroke Core Measures submissions based on diagnosis-based coding and billing.
Core Measures are quality initiatives to reward or penalize organizations monetarily for specific diagnoses commonly found among Medicare participants, such as acute myocardial infarction, heart failure, and stroke.11 Any organization participating in Medicare is required to submit data on Core Measures with the data published via Hospital Compare (www.cms.gov).
Resource allocation
Consider expenses associated with any program. These can include fees, human resources (training and education costs or time in motion requirements), supplies, new equipment, and preexisting equipment use time. Include air and ground ambulance in program costs. Contingency protocols must be developed, approved, and implemented to align with stroke care expectations. Integration of the stroke alert into other emergency-type programs may alter or stretch emergency response teams' capabilities. Many members of the teams participate in multiple emergencies, such as acute cardiac emergencies, trauma, and rapid response teams.
Community
An effective stroke program begins with a community assessment. What does the average community member know about stroke signs and symptoms, care, and prevention? Include personnel in emergency medical services (EMS) delivery; hospital acute care; home care, including home health; and rehabilitation services, both inpatient and home-based. Finally, supportive community services focused on management of long-term stroke deficits including cognitive, functional, emotional, and economic effects for survivors and caregivers must be considered.
I started with identifying existing resources and assessed understanding of stroke signs and symptoms. The community needs assessment must be conducted annually for most stroke certifications. Personally, this was one of the most difficult elements to quantify. See Protocol evaluation for a description of our community assessment indicator.
Program development
Program gap analysis and planning
First, I learned everything I could about best practices for stroke care and programs.3-10 Then, I approached stroke stakeholders. EMS proficiency is necessary for a successful stroke protocol implementation. In some cases, local EMS stroke protocols need to be updated, and necessary supplies and equipment, including stroke-specific prehospital evaluation tools, need to be made available. I met regularly with the EMS quality improvement paramedic to evaluate EMS care and to discuss possible improvements with long-term outcomes in mind.
In rural settings, EMS may be a voluntary group, with no equipment or supplies. They call for air or ground ambulance, as needed. Distance impacts stroke severity and long-term outcomes and should be included in the regional stroke program planning. If the stroke victim's location is more than 30 minutes from the closest stroke center, the patient should be air-lifted, not transported via ground ambulance. That means your hospital needs to have a helipad, or equivalent.
The EMS personnel located in my facility's region strongly influenced the stroke program. They're responsible for the initial care of patients in small frontier communities, identification of the appropriate receiving hospital (in many cases more than 30 miles away from the initial contact), and transportation needs. Smaller hospitals were able to perform initial computed tomography (CT) scans, and initiate I.V. alteplase, then referred to a higher level of care hospital. EMS had to master stroke BP management during transport.
Cerebral clot retrieval services are usually located in densely populated areas. In my case, transportation was at least an hour by fixed-wing aircraft or up to 8 hours by ground ambulance. The SC must thoroughly understand patient demographic constraints and available services.
Program success depends on physician support and involvement. To increase awareness and promote stroke program involvement, I attended medical staff meetings, medical department meetings, surgery department meetings, and the medical staff quality committee. I conducted introduction presentations, and as the program evolved, I led progress and success information sessions. I convened the stroke committee quarterly and reported as a medical department subcommittee, inviting members of each specialty that influenced stroke care, as well as members of risk and quality management, administration, nursing, rehabilitation, and the stroke program. We included neuro-telehealth physicians as the program evolved. During the first, “well-attended” meeting, I asked the stakeholders to provide suggestions to improve current stroke care.
I created a stroke meeting, which met monthly with other stakeholders in leadership positions at the institution, including an EMS representative. Other important contributors were invited as needed. The first few meetings were dedicated to resource allocation for stroke alert emergencies and designing an effective throughput process. For example, the organization had a successful trauma program, which included CT for all traumas. The stroke meeting was the venue to designate the most effective use of CT bed time. For this discussion, the Trauma Coordinator was invited. Ultimately, stroke patients were allowed to CT before trauma.
We designed a stroke protocol for both ischemic and hemorrhagic stroke—a flowchart making decisions based on a “yes” or “no” question, with an accompanying intervention. Expected time frames were associated with each step of the flowchart. For example, the first 10 minutes included the question, “Was the time of onset more than 4.5 hours ago?” If “yes,” the protocol recommended no I.V. alteplase with medical management. If “no,” “Perform head CT without contrast immediately.”
Next, we created a stroke program policy that delineated all expectations for the stroke program. Finally, using identified process, quality, and outcome indicators, we created the stroke quality scorecard. The stroke protocol and the stroke program policy was reviewed, revised, and approved by all required organizational bodies.
Protocol education
Stroke education was made available, sometimes mandatory, 1-2 months prior to when stroke program policy and protocol was set to “go live.” Physician education was conducted through continuing medical education program(s). EMS personnel was invited, but they preferred an EMS-specific program conducted at their training center. All members of the stroke team were required to attend a 4- or 8-hour training. The presentation included general stroke information and an intense review of the stroke protocol and program. For nurses, the last 4 hours covered the National Institutes of Health Stroke Scale (see On the web).12 Continuing education was awarded, as possible, for attending disciplines.
Protocol implementation and awareness
Two weeks before the stroke program “go live” date, we conducted mock stroke emergency drills. Response times and staff actions were monitored, recorded, and used to provide remediation and specialized training, as needed. The week the program went live, I attended as many hours as possible. I made brief presentations for community groups, such as senior centers and business-supported health fairs across the region to raise stroke awareness and teach about stroke recognition, prevention, and rapid activation of EMS assistance. I brought printed materials and banners to community health programs to give the stroke program a local presence. My organization created an annual Stroke Awareness Walk in May (US Stroke Awareness Month), usually with local media coverage. At each venue, I asked the question, “What are the signs of stroke?,” providing remediation and stroke prevention information. This type of event attracts attendees from all ages and demographics, so it's important to engage everyone through different activities like quizzes on the signs of stroke. If, after listening to me talk and perhaps reviewing the printed materials provided, they could recall two signs of stroke, they earned a prize.
Protocol evaluation
The stroke quality scorecard included program evaluations ranging from the minute the patient entered the system (including EMS time and onset times) to 90-day outcomes (measured by the modified Rankin Score [mRS]). There were process, quality, and outcome indicators for every level and stroke team member. Every patient who was “discharged to home” was called within 7 days to evaluate adherence with medication regimen and follow-up appointments, and to answer concerns and questions. I made calls at 30 and 90 days, evaluating their mRS score for patients discharged home or to a rehabilitation facility. These 90-day mRS scores were an outcome measure for the scorecard.
The stroke quality scorecard was reported and discussed at all stroke program meetings. Because the stroke program fell under quality improvement, its minutes and discussion were covered by confidentiality. Care failures were discussed, and names were forwarded to the appropriate oversight body or person.
For example, the “door to CT read time” graph was sensitive to multiple disciplines. EMS was expected to notify the ED at stroke identification. Nurses called the CT technologists immediately, allowing CT bed clearance. ED physicians evaluated the patient at the door, or soon after. Nurses conducted the NIHSS within 15 minutes of door time, or as soon as possible. Radiology cleared the CT scanner room in preparation for the patient's arrival, performed the head CT without contrast, and transmitted the results to the radiologist. We opted for a “wet read,” meaning the file had not been finalized for storage before the radiologist reviewed it and called the results to the ED physician. We didn't have 24-hour coverage at the hospital for radiology. Instead, we used an off-site radiology read for off-hours. The ED physician should have the CT results within 25 minutes. We pushed for 20-minute turnaround times. Think about that expectation. Think about the number of people involved in meeting the goal: EMS teams, ED physician, ED nurse(s), CT technologist, and radiologist. It's a team effort!
Certification process
When we felt our stroke program and protocol was functioning at a high level, we applied for certification. I completed the application, obtained the fee, and submitted our request to our accreditation body. It was accepted and the site visit was scheduled; in our case, in conjunction with the usual hospital visit. The stroke program certification process added an extra day to the site visit. I was available and present with the surveyors for the entire day. Initially, the surveyor asked for a list of personnel with their designation, then selected the files they wanted to see. While I was touring the facility, quality management and human resources pulled the files.
They wanted to tour the stroke units to track patient-flow through the system. As we progressed, the surveyors spoke with staff. After the tour, we reviewed the staff files. I, and other select members of the stroke program leadership, answered questions when requested. Next, the surveyor wanted to see the protocol and program policy. Finally, the surveyor wanted to see the supporting data. I used running-12-month graphs of all the quality, process, and outcome indicators. The year-long graphs illustrated the program's positive evolution.
One of the indicators most difficult to quantify was community needs assessment and our outreach's effect. I used a graph that compared EMS activation rates versus private vehicle arrivals before and after the community education annually. The graph indicated that before the community outreach, most arrived via private vehicle; however, afterward, the majority arrived via EMS. The surveyors loved it. They told us that they were going to take our quality indicator and use it as a best practice for community outreach evaluation(s).
It can be done
The time spent as an SC was very satisfying, both professionally and personally. Professionally, I made measurable differences in stroke victims' and survivors' lives. We improved the 90-day mRS scores for stroke survivors. Personally, the women in my family have been stricken with stroke for generations. My great-grandmother, grandmother, and mother died from stroke and its sequelae.
We began our efforts for stroke certification in December of 2011 and achieved stroke certification in August of 2012. In 2013, we were awarded the American Stroke Association Get with the Guidelines silver medal, and in 2014, we won the gold medal.14 It can be done. Success depends on the total commitment of the entire team, but passion and grit of the SC greases the wheels. I believe that our success was a team effort; I merely pointed out the path. Good luck to you and your team. The future of standardizing care rests in your hands.
On the web
American Heart Association's Get With the Guidelines for Stroke:
www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke
American Stroke Association:
www.stroke.org/
CMS core measures (Stroke):
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures
Det Norske Veritas (DNV) Stroke Care Certification Programs:
www.dnv.us/assurance/healthcare/stroke-certs.html
National Institutes of Health Stroke Scale (NIHSS):
https://learn.heart.org/lms/nihss
Stroke, a journal from the American Heart Association:
www.ahajournals.org/journal/str
The Joint Commission Stroke Certification:
www.jointcommission.org/accreditation-and-certification/certification/certifications-by-setting/hospital-certifications/stroke-certification/
