The NECC 9th Annual Summit Poster Presentations

Community Education

Survey of Public Health-Based Community Education and Primary Prevention Programs: Opportunities for Improved Collaboration
Corey R. Fehnel, MD, MPH – Rhode Island Hospital, Brown University Alpert Medical School; Richard P. Goddeau, Jr., DO – University of Massachusetts Medical School, UMass Memorial Medical Center; Rita Zanichkowsky – American Stroke Association; Marie McCune BSE, RN – Mount Auburn Hospital, on behalf of The NorthEast Cerebrovascular Consortium (NECC) Primary Prevention and Community Education Work Group
Our goal is to improve public awareness of stroke risk, prevention, symptom recognition and 911 activation, to enhance measurable results of community education. With that in mind, we developed a survey for structured interviews with Department of Health/CDC leads across The NECC region, to compile information on how they develop, fund, implement and evaluate state or local stroke awareness campaigns, and (for mandated states) what they require of hospitals in this regard. Responses will aid in the development of future guidelines for prevention, community education and funding strategies.

Notification & Response of EMS

Confounding Primary Impressions Among Patients Who Experienced CVA/Stroke in the Pre-Hospital Environment
Robert Bauter, NREMT-P; Paul Scalzo, NREMT-P; Scott Matin, NREMT-P; Peter Dworsky, NREMT-P; Philip Shepherd, NREMT-P; Rob Clawson, NREMT-P; Charlie Livezey, MICP; Gary Ruggiero, EMT; James Tanis, MD – MONOC
The goal was to determine which patient presentation(s) commonly confound paramedics in the identification of CVA/Stroke in the pre-hospital environment. Paramedics in our system are initially trained to evaluate for CVA/Stroke utilizing the Cincinnati Stroke Scale per state guidelines and system standard of practice; however, there are no specific continuing education (CEU) requirements regarding CVA/Stroke care.

Hospital-Directed Feedback to Emergency Medical Services Improves Prehospital Performance
Bryan Choi, MD – The Miriam Hospital; Devin Tsai, DO – Newport Hospital; Celia Gomes McGillivray, RNP, ACNPC-AG, BC-RN, MSN, MPH, CHES – The Miriam Hospital; Caryn Amedee, BSN, RN – Rhode Island Hospital; Jo-Ann Sarafin, MS, RNP – Rhode Island Hospital; Brian Silver, MD – Rhode Island Hospital
A potential way to improve pre-hospital stroke care and patient handoff is hospital-directed feedback for emergency medical service (EMS) providers. We evaluated whether a hospital-directed EMS stroke follow-up tool improved documentation of adherence to the Rhode Island state pre-hospital stroke protocol for EMS providers.

Acute Stroke Treatment

EMS By-Pass: A Process to Decrease DTCT and DTN time
Erica Frangione-Edfort, DNP, NVRN-BC, RN-BC, FAHA – CarePoint Health Bayonne Medical Center
The purpose of the EMS By-Pass process is to enable rapid identification and management of Code Stroke patients for potential t-PA administration. The objective is to improve current practices to decrease DTCT time and DTN time for Code Stroke patients.

An Innovative Approach to Decreasing Door to tPA Times
Margaret Thornton, RN, MSN, CEN – The Valley Hospital; Lenka Mysliwiec, RN, MSN, APN-BC – The Valley Hospital
The concept of the “Neuro ED RN” was created to decrease door to tPA times. On each shift, one RN is responsible for caring for patients that present with acute onset of stroke symptoms. These RNs were given specific training in the algorithm for stroke treatment, stroke recognition, and utilizing a POC INR. The “Neuro ED RN” has drastically improved our treatment times for Acute Ischemic Stroke.

Beat the Clot: Decreasing Door to rt-PA Times to 60 Minutes or Less
Joyce Harris, RN – North Shore Plainview Hospital
“Beat the Clot” is an initiative our hospital initiated 01/01/2013. At the close of 2012, we re-evaluated our “Door to rt-PA times in 60 minutes or less” and noted there were opportunities for improvement. There were times when our stroke team missed the 60 minute mark by just a few minutes and we were determined to improve this. We had already incorporated several of the Target Stroke Best Practice strategies into our Stroke Code process. After some Stroke Team brainstorming we decided to do a PDSA pilot and incorporated a 60 minute count down clock timer. We hypothesized this external time prompt would help the team be cognizant of passing minutes during the “golden hour”.

Temporal Changes in NIHSS Documentation and Stroke Severity Among Patients Treated with Thrombolysis in the Massachusetts Coverdell Registry
Gabrielle Parkinson, MS – Massachusetts Department of Public Health; Lee Schwamm, MD, FAHA – Massachusetts General Hospital; Laura Coe, MPH – Massachusetts Department of Public Health
The Massachusetts Paul Coverdell National Acute Stroke Registry (MA Coverdell Program) has been funded by the Centers for Disease Control and Prevention and implemented by the Massachusetts Department of Public Health since 2004. It has assisted Primary Stroke Service designated hospitals in Massachusetts with monitoring and improving the quality of care for acute stroke patients. In the Massachusetts Coverdell Registry, the most commonly documented reasons for non-treatment with IV tPA are rapidly improving stroke symptoms and stroke “too mild”. We examined stroke severity of patients with these documented reasons, as well as their odds of being discharged home from the hospital in order to assess their validity as reasons for non-treatment with IV thrombolysis.

Subacute & Secondary Prevention for Stroke

Enhancing Depression-Risk Screening Among Post-Stroke Patients during Acute Hospitalization
Tracey L. Collins, DNP, RN, CNRN, NEA – Portsmouth Regional Hospital
Approximately 33% of stroke patients will experience post-stroke depression. However, research shows depression could be a risk factor for stroke, similar to being overweight. Therefore, screening acute stroke patients for depression and initiating interventions within the acute hospital setting could assist with earlier detection of symptoms, resulting in reduced symptom development and enhanced outcomes post-stroke.


Effects of Age, Aphasia Severity, Duration of Stay and Amount of Speech Language Pathology Treatment on Language Outcomes of Adults with Aphasia Due to a Stroke After Inpatient Rehabilitation
Rebecca Foote, MS, CCC-SLP – Spaulding Rehabilitation Hospital; Anthony Guarino, PhD – Institute of Health Professions, Massachusetts General Hospital; David Caplan, MD, PhD – Massachusetts General Hospital
The purpose of this study was to assess the effectiveness of individual and group Speech Language Pathology therapy in addition to inpatient rehabilitation length of stay on increasing the Functional Independence Measure verbal expression score for adults with aphasia due to a stroke while controlling for age and initial severity of aphasia. This retrospective data analysis included 2,224 adults. The study provides evidence that younger age and milder language impairments are associated with improved language outcomes.

Implementing Evidence-Based Guidelines to Address Stroke Risk Factors in Acute Rehabilitation
Claudia Wheeler, DO; Roni Probert, CRRN; Melissa Fournier, PT; Sue Desillier, PT; Patricia Franklin, RN; Rachel Alexander, PTA; Denise Simas, PT – Vanderbilt Rehabilitation Center
Implemetation of evidence-based guidelines to address a plan to manage stroke risk factors in the acute rehabilitation setting at a CARF-accredited Stroke Specialty Program at discharge as Individualized Stroke Eduation plan for each patient. Risk factors addressed include deconditioning, diabetes, hyperlipidemia, hypertension, physical activity and stroke prophylaxis. Staff, patient and caregiver education are the keys to successful Individualized Stroke Education Program.

Selection of Post-Acute Rehabilitation Facilities in the Northeast: A Survey of Discharge Planners
Alyse Sicklick, MD – Gaylord Specialty Healthcare; Joel Stein, MD – Department of Rehabilitation and Regenerative Medicine, Columbia University, Division of Rehabilitation, Weill Cornell Medical College, and NewYork-Presbyterian Hospital; Robin Hedeman, OTR, MHA – Kessler Institute for Rehabilitation; Janet Prvu Bettger, ScD – Duke University School of Nursing; Zainab Magdon-Ismail, EdM MPH – American Heart Association/American Stroke Association; Lila Martin, BS, on behalf of The NorthEast Cerebrovascular Consortium Rehabilitation Work Group
The process of determining the level and type of post-acute care for stroke patients’ has not been adequately studied. We surveyed stroke discharge planners regarding this process, and examined the factors perceived to influence the selection of post-acute care. Findings suggest non-clinical factors may disproportionately affect post-acute care decision making for stroke survivors.

Continuous Quality Improvement (CQI) Initiatives

An Integrated Approach of Patient Care Process for Suspected Strokes Results in Decreasing Door to Computed Tomography (CT) Times – A Collaborative Initiative Between Needham EMS and Beth Israel Deaconess Hospital – Needham
Adam Houk, RN, EMT-P – Beth Israel Deaconess Hospital – Needham Emergency Department; Edward Ullman, MD, FAAEM – Beth Israel Deaconess Hospital – Needham, Medical Director Needham Fire Department; Jason Pierce, RN, NR/CCEMT-P – Needham Fire Department; Gay Calo, RN – Beth Israel Deaconess Hospital – Needham
Creation of a collaborative plan of care with the local EMS System to improve the efficiency of care provided to the suspected stroke patient by reducing door to CT time.

Stroke: Early Intervention = Better Outcomes: Assessing the Effectiveness of Stroke Education Among Skilled Nursing Facility Staff in Massachusetts
Hosana Mamata, MPH candidate; Claudine DeJoie-Stanton, COTA/L; Gabrielle Parkinson, MS – Massachusetts Department of Public Health
The Massachusetts Paul Coverdell National Acute Stroke Registry (Massachusetts Coverdell Program) has been funded by the Centers for Disease Control and Prevention and implemented by the Massachusetts Department of Public Health since 2004. It has assisted Massachusetts healthcare providers in improving quality of care for acute stroke patients through collaboration across the continuum of care. In 2013, the Massachusetts Coverdell Program identified a delay in patients arriving to the emergency room with signs and symptoms of stroke from nursing homes. It is often reported that patients are kept at the nursing home for observation for several hours after symptom discovery before calling an ambulance to transfer the patient to the hospital. This delay causes the patient to arrive at the emergency room beyond the critical time window for treatment, namely for treatment with IV tPA. In an effort to decrease delays, we sought to educate SNF staff throughout Massachusetts on timely, accurate recognition and response to stroke signs and symptoms.

The New York State Coverdell Stroke Quality Improvement and Registry Program: Using a Learning Collaborative to Improve the Timely Delivery of tPA
Anna Colello, Esq; Kate Rose Bobseine, MPH; Bethany Hawke, MPH; Kathy Wales; Ian Brissette, PhD – New York State Department of Health
The New York State Department of Health (NYS DOH) is funded by the Centers for Disease Control and Prevention through the Paul Coverdell National Acute Stroke Registry to partner with hospitals to improve care for acute stroke in the in-hospital setting through the implementation of quality improvement (QI) activities. The NYS DOH Coverdell Learning Collaborative was developed to promote improvements in five evidence-based process/performance measures embedded within the American Heart Association (AHA) Get With The Guidelines – Stroke (GWTG). This poster describes the implementation and evaluation of the components of the Learning Collaborative that aimed to encourage improvements in the timely delivery of tPA. Preliminary data suggest a Learning Collaborative is a promising approach to engaging a large group of hospital teams in QI efforts to improve timely administration of tPA. Qualitative data on strategy implementation, successes, and barriers provide suggestions for how best practices can be put into action and institutionalized.

Closing the Communication Gap – The Acute Stroke Worksheet Brings it all Together
Marsha Nowak, RN, BSN; David Kuster, RN; Shirley J. Duane, FNP; L. Guterman, MD; Amanda Kelly; Cheryl Conover – Mercy Hospital of Buffalo; Christine Juliano (Posthumously) – Quality & Patient Safety Data Center
Every stroke patient has a unique presentation and path to recovery. Nurses recognized the need for a concise form that communicates the total picture, course of treatment and educational needs of the stroke patient. A tool was created and embraced by the entire staff which has improved patient care and job satisfaction in the stroke unit.

Quality Improvement Project to Increase FIM (Functional Independence Measure) Change in the Stroke Population for Locomotion and Stair Negotiation in an Acute Rehabilitation Hospital
Stacey Zalanowski, DPT; Debra Clooney, DPT; Leah Fenton, CTRS – Spaulding Rehabilitation Hospital
The patients’ outcomes on the Stroke Program at Spaulding Rehabilitation Hospital in Boston as measured by the FIM are lower than the national and regional averages. A quality improvement project aimed at improving FIM outcome scores was perfromed as part of a formalized collaborative learning improvement program. The program ran for 5 months and included 7 structured learning sessions focusing on analysis of a problem, strategizing to implement change, and reviewing the results of the project. A careful analysis of the problem was performed followed by implementation of interventions to address inaccurate scoring of the FIM and a lack of up to date communication between the interdisciplinary team. The interventions were reviewed and a plan for further development was created.

Development and Introduction of a Performance Improvement Tool to Enhance Door-To-CT Times for the Acute Stroke Patient
Deborah B. Benvenuto, RN, BS, MBA, CRNI; Justine DeFronzo, RN, BSN, MBA – Emerson Hospital
Managing the timely arrival of the ER patient with suspected stroke symptoms means access to equally timely diagnostic tools. One acute care diagnostic tool is the initiation and completion of the CT in less than 20 minutes after patient arrival. This presentation will describe the process for recognition of a learning deficit for the ER staff resulting in demonstrable improvement with the education and implementation of the Door-to-CT care path algorithm.

Facilitating Processes to Address Patient and Family Satisfaction with Discharge Planning on an Inpatient Stroke Rehabilitation Unit
Lynne Brady Wagner, MA, CCC-SLP; Ann Caberoy, MS, RN – Spaulding Rehabilitation Hospital
Patient/Family satisfaction is an important quality measure in clinical care. The Stroke Rehabilitation Program at Spaulding Rehabilitation Hospital has attempted many initiatives to address the challenge of enhancing satisfaction. Patient/Family satisfaction with the discharge processes, measured by Press Ganey, is lower for discharge processes relative to other aspects of care on the unit. The unit worked together to develop the beginning of a process improvement project to analyze and address areas of opportunity for increased satisfaction.