Summit 2011 Posters

The NECC 6th Annual Summit Poster Presentations

Racial and Ethnic Stroke Risk Factors as Predictors of Stroke Subtypes: Large vs. Small Vessel Stroke

Tefera ‘tito’ Gezmu, MPH – Bloustein School of Public Policy; Dona Schneider, PhD MPH – Bloustein School of Public Policy; Kitaw Demissie, MD PhD – Bloustein School of Public Policy; Yong Lin, PhD MS Bloustein School of Public Policy; Stephen Marcella MD, MPH – Bloustein School of Public Policy; Jay Shah BS Ross University; and Martin Gizzi MD PhD – NJ Neuroscience Institute

Stroke registry data from a comprehensive stroke center were used in a multivariable regression analysis to predict the risk of developing large artery atherosclerosis vs. small artery occlusion by racial-ethnic groups. The interaction between racial-ethnic categories and stroke risk factors may provide an approach for identifying possible mechanisms that enable clinicians to predict subtypes of stroke following acute stroke admissions.

Clinical Presentation and Mortality of Spontaneous Intracerebral Hemorrhage Patients with Hypothyroidism

Alexandra L. Czap, MD Student, University of Connecticut School of Medicine and Stroke Center at Hartford Hospital; Louise D. McCullough, MD/PhD, and University of Connecticut Health Center and Stroke Center at Hartford Hospital; Ilene Staff, PhD, Stroke Center at Hartford Hospital

A retrospective analysis of a tertiary stroke center database was performed to analyze the severity and outcome of hypothyroid patients with spontaneous intracerebral hemorrhage (ICH) from January 2004-April 2010. Hypothyroidism and physiologic normalization of the hypothalamic-pituitary-thyroid axis with thyroid replacement demonstrated improved admission presentation and decreased mortality in the setting of ICH.


Assessing the Impact of Pre-hospital Care on Hospital Acute Stroke Care using Linked Clinical Datasets

Katrina D’Amore, MPH; Erin Kulick, MPH – Massachusetts Department of Public Health (MADPH); Mirian Barrientos, MPH – MADPH; Laura Coe, MPH – MADPH

We assessed the impact of pre-hospital care on hospital process and outcome measures by linking clinical datasets. We explored aspects of pre-hospital response to stroke such as response- and on-scene times as well as accuracy of stroke identification in the field. Relationships between those variables and in-hospital acute stroke care measures were also explored.

Hospital Pre-notification of Stroke Patients by Emergency Medical Services Improves Stroke Time Targets

James S. McKinney III, MD – UMDNJ Robert Wood Johnson Medical School; Judith Lane, BSN,RN – Robert Wood Johnson University Hospital Virginia Roberts BSN, RN – Robert Wood Johnson University Hospital; Win Toe, MD – UMDNJ Robert Wood Johnson Medical School; Pamela Ohman-Strickland PhD3 – UMDNJ School of Public Health; and Mark A. Merlin DO, EMT-P – UMDNJ Robert Wood Johnson Medical School

This study evaluated the effects of pre-hospital notification of suspected stroke patients on stroke time targets. We used the RWJUH Brain Attack data base which includes all patients in whom a brain attack was alerted in the emergency department over an 18 month period. We found that pre-hospital notification of suspected stroke patients reduces time to stroke team arrival, CT scan completion, and CT scan interpretation. IV thrombolysis occurred twice as often in the pre-notification group.


Uninsured patients who suffer stroke have longer length of stay despite lower NIHSS on admission

Martin Gizzi, MD, PhD, FAHA – JFK Medical Center; Jay M Shah, MS-III – Ross University; Christopher DelMaestro – Drew University; Akash Patel, MD – JFK Medical Center; Daniel Korya, MD – JFK Medical Center; Mohammad Moussavi, MD – JFK Medical Center; Jawad Kirmani, MD – JFK Medical Center

Uninsured patients admitted for stroke had a lower NIHSS on admission but a longer length of stay. We documented poorer control of stroke risk factors at the time of admission but similar quality of acute stroke care while hospitalized. Initial review suggests that the longer length of stay reflects difficulty with rehabilitation placement in patients without insurance. Poor primary prevention and increased LOS among the uninsured add to the burden on – and cost of – acute care health services.

Lack of Knowledge of the Risks of Stroke in Women using Hormonal Contraceptives

Angela N. McCall-Brown, MSN, APN-C, Overlook Medical Center; Stephanie Rizzo, BSN, RN, CNRN, Thomas Jefferson University Hospital

Stroke education in young women has routinely focused on hypertension, diet and obesity, hypercholesterolemia, family history, irregular heartbeat, smoking and diabetes. The lack of specific understanding of the increased risk of stroke related to women’s use of oral contraceptives use strongly indicates that better strategies to educate women at risk are needed. Being aware of the combination of risk factors, and age association with hormonal contraceptives and stroke may facilitate better preventative care and reduce the incidence of stroke for women.

Revising Code Stroke Algorithms to improve use of IV t-PA and Door to Needle Times in Stroke, a Retrospective Review

Shelly Ozark, MD – Rhode Island Hospital; Caryn Amedee, BSN, RN – Rhode Island Hospital; Jo-Ann Sarafin, MS, FNP-BC – Rhode Island Hospital; Brian Silver, MD – Rhode Island Hospital; and Benjamin Barnes, MD – Rhode Island Hospital

Target: Stroke strategies were utilized in an effort to increase use of IV t-PA and improve door to needle times to less than 60 minutes. Code Stroke (internal stroke alert system) was implemented March 8, 2010. Analysis of the protocols resulted in modifications that improved door to needle times.

Experience Using a Two-Tiered Model of Triaging Patients with Acute Stroke Symptoms

Lincoln Abbot, MD, FACEP, Hartford Hospital; Dawn Beland, RN, MSN, CCRN, CS, CNRN, Hartford Hospital; and Max Goldstein, MD, Hartford Hospital

The responsibilities of the Stroke Team and Emergency Department staff were adjusted to manage increased emergency consults for potential patients with stroke. A two-tiered system for evaluation was developed: Activated and Non-activated. This system reduced the burden on the Stroke Team despite an increase in volume.

A retrospective review of functional outcomes in patients receiving Endovascular Interventions (including tPA and Comprehensive Rehabilitation Treatment in Maine)

Archana Mahimkar, MS MBA- Maine Medical Center

Maine Medical Center (MMC), a primary stroke center enhanced its stroke care capabilities to include 24/7 endovascular access in August 2010, prior to which patients with endovascular needs were transferred to out-of-state hospitals. Recently an evaluation project was undertaken to review the functional outcomes for severe stroke patients receiving Endovascular Intervention (EVI) combined with Comprehensive Rehabilitation Treatment (CRT) and to identify the impact that these interventions and subsequent inpatient rehabilitation stay made for patients. Rehabilitation Treatments took place at New England Rehabilitation Hospital (NERH), a free standing rehabilitation hospital with JCAHO Disease Specific Certification in Stroke Rehabilitation. The objectives for this evaluation project were: 1) To retrospectively analyze the number of patients who get evaluated using a standardized scale to assess level of impairment caused by a stroke; 2) To describe and catalogue the functional outcome data of patients with severe strokes who received EVI (including tPA) and CRT; and 3) To determine whether severe stroke patients that receive EVI and CRT have improved outcomes at discharge compared to regional averages.

Measurement of Time Synchronization in the Emergency Department

Dennis P. McKenna, MD – Albany Medical Center; Wayne Triner, DO, MPH – Albany Medical Center; Amy Little, MD – Albany Medical Center; Deborah Jewell, MS, ANP – Albany Medical Center

We conducted a convenience sample study to measure the accuracy of methods used to provide a time record of clinical activities. Time sources utilized by staff and biomedical and other devices were compared to a Green Mountain time synchronized watch. We found that time sources utilized by staff were not statistically different from the synchronized watch. There was a wide range of time difference in biomedical and other devices.

Effect of arrival during shift change on process, treatment, and outcome in acute ischemic stroke

Olga P. Fermo, MD – University of Connecticut School of Medicine; Ilene Staff, PhD – Research Program, Hartford Hospital; Louise D. McCullough, MD, PhD – Department of Neurology, University of Connecticut Health Center

This study examined how presentation with acute ischemic stroke during different time periods effects stroke care and patient outcome. The length of time to initiate intra-arterial tPA was significantly longer at night compared to day. Patients who presented to the ED at night with stroke were more likely to die or be discharged to hospice care than those during the day. Presentation with stroke during shift change, weekend, and summer had no apparent effect on care and outcome.

Sex Differences in Stroke Outcome for Octogenarians Receiving Statins

Neer Zeevi, MD – Lawrence and Memorial Hospital; George A Kuchel, MD – UConn Health Center; Nora S Lee, MD – Hartford Hospital; lene Staff, PHD – Hartford Hospital; Louise D. McCullough, MD, PHD; UConn Health Center

A retrospective review of the Stroke Center at Hartford Hospital database shows that statin drug pretreatment in men over 80 years is associated with improved stroke severity at onset. Elderly women had the most severe strokes, with outcome not influenced by pretreatment with statins.


Falls in Inpatient Stroke Patients

Joan Alverzo PhD CRRN – Select Medical Corporation – Kessler Institute for Rehabilitation; Anna Barrett, MD – Kessler Foundation; Peii Chen PhD – Kessler Foundation; Pasquale G. Frisina, PhD – Select Medical Corporation – Kessler Institute for Rehabilitation; Robin Hedeman OTR, MHA – Select Medical Corporation – Kessler Institute for Rehabilitation;Annie Kutlik – Select Medical Corporation – Kessler Institute for Rehabilitation; Mahesh Lellella MBBS – Kessler Foundation; Cristin McKenna – Select Medical Corporation – Kessler Institute for Rehabilitation; and Jeffrey Yangang Zhang PhD – Kessler Foundation

Falls in stroke patients represent a significant source of morbidity. Accurate identification of patients at high risk of falling may enable appropriate distribution of fall prevention resources which will in turn enhance care quality and in turn facilitate patient recovery. Our results suggest that stroke patients who fall during their inpatient stay can be identified within the first 24 hours of admission to acute rehabilitation. Improved identification of patients at high risk for falls may help stroke inpatient facilities to focus fall-prevention resources most appropriately.


Assessing the Effectiveness of a Free Water Education Program on Knowledge of Oral Care

Christina Piscopo MA, CCC-SLP – Kessler Institute for Rehabilitation and Kathryn Daley, RN, MPA – Kessler Institute for Rehabilitation

Implementing care standards to safely increase free water intake and encourage meticulous oral care may assist in preventing dehydration and may also improve other aspects of post-stroke health. Our results suggest that interdisciplinary education and specific training in safe free water hydration techniques and oral care for all disciplines including RN’s, RA’s, Physical, Occupational Therapists and Speech-Language Pathologists may introduce or enhance knowledge of quality care standards.

Emerging Challenges for Stroke Outcomes Evaluation: A Public Health Agency Perspective

Abate Mammo, PhD – New Jersey Department of Health and Social Services (NJDHSS); Debra Virgilio, RN, MPH – NJDHSS; Emmanuel Noggoh, MS – NJDHSS

Concerns of AHA/ASA, Joint Commission and CDC’s Paul Coverdell are centered on “harmonizing” consensus measures with little attention given to performance evaluation. Consensus measures, which are processes of care indicators, have two major limitations. First, they will soon reach 100% in most hospitals making them less useful for evaluation. Second, the measures do not adjust for patient mix thereby making hospital evaluation difficult. This paper minimizes these limitations by employing statistical approaches and by adjusting for patient mix such as age, sex, race/ethnicity and pre-existing health conditions of patients.

Hospital Participation in a Voluntary Stroke Quality Improvement Collaborative in Massachusetts

Laura J. Coe, MPH – Massachusetts Department of Public Health (MADPH); Katrina D’Amore, MPH – MADPH; Zainab Magdon-Ismail, EdM, MPH – American Stroke Association; Lee H. Schwamm, MD, FAHA – Massachusetts General Hospital

SCORE is an acute stroke quality improvement (QI) program funded by the Centers for Disease Control and Prevention’s Paul Coverdell National Acute Stroke Registry and implemented by the MA Department of Public Health in partnership with the American Stroke Association. Since 2005, SCORE has assisted designated stroke service hospitals in MA in monitoring and improving the quality of care for acute stroke patients. We sought to evaluate the sustainability of hospital participation in a QI initiative.

Description of case identification methods and abstraction processes used by hospitals participating in the Massachusetts Paul Coverdell National Acute Stroke Registry

Mirian Barrientos, MPH – Massachusetts Department of Public Health (MADPH); Laura J. Coe, MPH – MADPH; Erin Kulick, MPH – MADPH; Joanne LaBelle, RN, MS, CPHQ, HRM – MADPH

SCORE is an acute stroke quality improvement (QI) program funded by the Center for Disease Control and Prevention’s Paul Coverdell National Acute Stroke Registry and implemented by the MA Department of Public Health and the American Stroke Association. Timely identification and care of acute stroke patients is critical for improving patient outcomes. We sought to describe what methods the participating hospitals use for case identification and abstraction compared to performance on the defect-free care summary measure.

New Jersey Stroke Coordinators Collaborating to Improve Stroke Care: Review of Three Quality Indicators

Dana Reiner RN, MSN, APN-C, CNRN – St. Josephs Regional Medical Center; Florence Chukwuneke RN, BS – JFK Medical Center, NJ Neuroscience Institute and in conjunction with the New Jersey Stroke Coordinators Consortium (NJSCC)
In 2008 New Jersey Stroke Coordinators Consortium (NJSCC) a formal network of stroke program coordinators from over 40 hospitals was formed to provide a forum for supporting, mentoring and for sharing best practices. During quarterly general meetings, focus groups and via emails members identify gaps in knowledge and barriers to provide evidenced based stroke care and strategize on ways to overcome them. The purpose of this study was to analyze the impact of NJSCC collaboration on three selected quality indicators: Door to IV rt-PA in 60minutes, Dysphagia Screen and Stroke Education.

The following two posters were presented by The NorthEast Cerebrovascular Consortium at other venues and are being shared at The NECC 6th Annual Summit:

National Institutes of Health Stroke Scale (NIHSS) Use in the Northeast

Megan Mazza, MPH, CPHQ; Zainab Magdon-Ismail, EdM, MPH – American Stroke Association (ASA); Shannon Melluzzo, BA; Laura Coe, MPH – Department of Health; Lee Schwamm, MD, FAHA – Massachusetts General Hospital; Toby Gropen, MD, FAHA – Long Island College Hospital

The Northeast Cerebrovascular Consortium (NECC) surveyed stroke coordinators at American Stroke Association Get With the Guidelines – Stroke hospitals in The NECC Region. The survey sought to analyze patterns of use and barriers to hospital based implementation of the NIHSS.

Presented at the International Stroke Conference, Los Angeles, CA – February 2011

Are stroke patients being assessed for rehabilitation in the acute hospital?

J. Prvu Bettger, ScD, FAHA (Duke University, Durham, NC), J. Stein, MD (Columbia University, New York, New York), Z. Magdon-Ismail (American Heart Association Founders Affiliate)

The NECC has implemented a pilot project to determine the proportion of stroke registry hospitals meeting the clinical guideline and quality of care performance indicator for conducting a standardized assessment for rehabilitation; to explore what standardized measures are used by those hospitals in compliance?

Presented as a poster and an oral presentation at the American Congress of Rehabilitation Medicine & the American Society of Neurorehabilitation Conference, Montreal, Canada – October 2011.