The NECC 8th Annual Summit Poster Presentations

Emergency Medical Services

Collaborative Efforts in Promoting EMS/EMT Acute Stroke Care Education
Jason R. Clum, RN – Albany Medical Center; Jennifer Galvin, RN – St. Peter’s Hospital; Christine Ball, RN – Northeast Health; Margie Panetta, RN – Ellis Hospital; Michelle Sellie – Ellis Hospital; and Anna D. Colello, Esq. – NYS DOH
The purpose of this is to show how the collaborative efforts of multiple stroke centers in a geographic proximity can work together to pool resources and experience to improve pre-hospital care by providing continuing education opportunities to EMT/EMS agencies that provide services within their region. The group represents 9 hospitals within the greater Albany, NY area, who along with representatives from the New York State Department of Health and the American Heart Association/American Stroke Association, come together every other month to share best practices and to work together to put on an annual EMS/EMT stroke education event that leads to the improvement of stroke care.

Acute Stroke Treatment

DRAGON Score Outperforms 7 Other Hemorrhagic Transformation Scores in Ischemic Stroke Patients Treated with Thrombolysis
David Asuzu – Yale University; Karin Nyström, MSN, APRN, FAHA – Yale-New Haven Hospital; Nai-Fang Chi, MD; Joseph L. Schindler, MD – Yale University; Janet Halliday, RN, BS – Yale University; David M. Greer, MD – Yale University; David Pritchard, Pharm D. – Yale-New Haven Hospital; Kevin Sheth, MD – Yale University
Symptomatic hemorrhage is a major complication after IV thrombolysis. This research study examined 8 stroke risk scoring instruments to predict symptomatic intracerebral hemorrhage in patients undergoing intravenous tPA. Using logistic regression and a Receiver Operating Characteristic (ROC) analysis, we determined that the DRAGON risk scores overall best at predicting symptomatic intracerebral hemorrhage in our population, and be useful for guiding therapy in acute stroke.

Impact of Emergency Medical Services (EMS) Stroke Assessment and Pre-Notification on In-Hospital Stroke Time Targets in Massachusetts
Mirian Barrientos, MPH, CPHQ – Massachusetts Department of Public Health; Erin Kulick, MPH – Massachusetts Department of Public Health; Laura Coe, MPH – Massachusetts Department of Public Health
The Massachusetts Paul Coverdell National Acute Stroke Registry 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 and Emergency Medical Service (EMS) agencies in MA with monitoring and improving the quality of care for acute stroke patients. In Massachusetts, Emergency Department (ED) pre-notification is required by the state regulations for EMS transport called the EMS Stroke Point of Entry Plan. MA EMS Regions 1, 3 & 5 formalized the process for assessing and pre-notification through the implementation of a standardized Stroke Alert Policy (SAP). We sought to determine the impact of the SAP on the timeliness of in-hospital stroke evaluation and care.

Decreasing Door-to-Needle Time and the Potential to Improve Patient Outcomes
Angela McCall-Brown, MSN, APN, BC – Overlook Medical Center; Lyn Bertsch, – Overlook Medical Center
“Time is Brain” and while treatment of acute ischemic stroke patients with intravenous tissue plasminogen activator (tPA) potentially reduces long-term disability, the benefits of tPA are time dependent. Treatment often does not happen quickly enough. Current American Heart Association and American Stroke Association recommend treatment with tPA within 60 minutes of the patient’s arrival in the emergency department. Using the Six Sigma methodology Overlook Medical center found that reducing our Door to CT time was key in reducing our overall Door to rtPA times. Patients who the Emergency Department received pre-notification were taken directly to CT on the EMS stretcher resulting in a decrease of our Door to rtPA average time to 39 minutes.

Sub Acute care and quality Improvement

Strategies to Improve Dysphagia Screening for Stroke Patients: Best Practices from the Massachusetts Coverdell Program
Joanne Carney LaBelle, RN, MS, HRM, CPHQ – Massachusetts Department of Public Health; Mirian Barrientos, MPH, CPHQ – Massachusetts Department of Public Health; Bonnie K. Andrews, MPH, CPH – Massachusetts Department of Public Health; Laura J. 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 MA with monitoring and improving the quality of care for acute stroke patients. MA Coverdell data shows varying rates of dysphagia screening among hospitals. We sought to examine strategies employed at hospitals with high screening rates to identify best practices.

Continuous Quality Improvement (CQI)

Does the Presence of Neurology Affect Door to Needle Time in Patients with Stroke?
Donna Kurowski MD –Mount Auburn Hospital Cambridge MA; Marie McCune BSE, RN – Mount Auburn Hospital Cambridge MA
The purpose of this study was to review data to determine if the presence of neurology availability affect door to needle times and tPA being given to eligible patients. The poster will show the time differences of patients being seen by neurology.

Reducing Ellis Medicine’s tPA Door to Needle Times by Using a Stroke Resource Nurse
Margie Panetta, RN, CNRN, Stroke Program Director, and Michele Sellie, Stroke Coordinator – Ellis Medicine, Schenectady, NY; Richard Brooks, MD; Bill Owens, Neurosciences PA; Laurie Murphy, RN, BS, CNRN, CMSRN, LNC; Erica Garrison, RN, CNRN, CMSRN; Jan Libertucci, RN and Denise LaFarr, RN- Ellis Medicine, Schenectady, NY
At Ellis Medicine we have reduced our average door to needle time by over 10 minutes in the first half of this year. We have implemented an exciting new initiative, a Stroke Resource Nurse.

Improving Stroke Education for Patients and Families
Quinn Alfinito-Renta, MSN,RN,CNRN – Montefiore Medical Center; Hyacinth Charles, ANP, RN – Montefiore Medical Center and Margaux Giardino – Montefiore Medical Center
Stroke Education empowers patients and their families to reduce stroke risk, recognize signs and symptoms of acute events and disseminate knowledge of stroke within their communities. A nurse-driven quality improvement initiative at our institution has resulted in improved compliance with federal and state mandated stroke education. Continued improvement is expected with the introduction of electronically generated stroke education upon discharge for all patients regardless of diagnosis.

Impact of a Six Sigma Code Gray Pilot Program on Door to Alteplase Time
Olasunkanmi Arogundade APN-C; Christine Gosford, PharmD; Richard Klemm RN; Gayle Walker-Cillo RN; Charlene Welsh RN; Stuart Fox MD
Currently, the average door to alteplase (tPA) time for patients with an ischemic stroke at Morristown Medical Center is 56 minutes. Although we are under the national guideline of 60 minutes, we strive to be an industry leader in stroke care.

Comparison of Stroke Codes in the Emergency Room and Inpatient Setting
Rocio C Garcia-Santibanez, MD – Neurology Resident; John Liang, MD – Neurology Resident; Amy Walker – Stroke Program Coordinator; Irene Boniece, MD – Director – Yarmon Stroke Center and Chief, Divisions of Neurocritical Care and Stroke, Beth Israel Medical Center, New York
Outcomes of acute stroke management are time dependent. Time to treatment may depend on the patient’s location. Stroke codes ending in tPA administration or endovascular intervention in the emergency room and inpatient setting were compared. There was a significant delay in the time to CT-scan and to tPA administration in the inpatient setting.

Stroke Percutaneous Endoscopic Gastrostomy (PEG) Decision Making Protocol Initiation Project
Dawn Beland, RN, MSN, Stroke Center, Hartford Hospital Christa San Luis, MD Neurology, University of CT Harpreet Kaur, MD PGY-2 Neurology, University of CT Louise McCullough, MD Neurology, University of CT and Hartford Hospital Ilene Staff, PhD, Research, Hartford Hospital
There are no guidelines available regarding PEG placement timing in both ischemic and hemorrhagic stroke patients. Despite several factors investigated as predictive factors of PEG placement in patients with MCA AIS or SICH, decisions on long term artificial nutrition remain very difficult. The PEG Decision Making Protocol was created with the following goals in mind: 1) to promote safe and timely discharge to rehabilitation, 2) enable proper and timely follow-up with speech and gastrointestinal services and 3) to encourage early involvement of the palliative care team to support and assist the stroke patients’ families in decision making.


Opportunities and Strategies to Develop a Culture of Safety in a Restraint-Free Environment in a Rehabilitation Hospital
Laleh Jamshidi-Azad, RN, CRRN- Kessler Institute For Rehabilitation
Using National patient safety goals and The Joint Commission standards of practice, we identified an opportunity for improvement on our “safety practices” on the Neuro Unit. With continued need for restraint use (as high as 27 restraint days per month) we focused our attention to our “restraint practices” realizing that restraint use has a negative impact on patient satisfaction and is often a barrier to safe discharge home. Our vision was to change the unit’s culture, having a proactive staff utilizing alternative methods for maintaining patient safety every time and improving patient and family satisfaction and quality of care while eliminating negative response to restraints. Our systemic and multifaceted approach for creating a culture change included a multidisciplinary education on our initiative, strategies for bringing nurses closer to bedside and strengthening the RN/Nursing assistant team work. As the result of these measures and teamwork, between January 2012 to January 2013, we were able to eliminate our restraint use while increasing our discharge to home rates.

The NorthEast Cerebrovascular Consortium presented the following two posters at the International Stroke Conference, February 2013, Honolulu, HI. They were displayed at the 8th Annual Summit Poster Session.

Patient-Centered Predictors of Rehabilitation Care After Acute Stroke

Joel Stein, MD, Janet Prvu Bettger, ScD, Alyse Sicklick, MD, Robin Hedeman, OTR, MHA, Zainab Magdon-Ismail, Ed.M., MPH, Lee H. Schwamm, MD
Rehabilitation plays a key role in helping stroke survivors return to the community. Assessment of rehabilitation needs in the acute hospital is widely acknowledged as important, but has not been well defined. This poster highlights the results of The NECC Rehabilitation Work Group’s pilot study which examined the feasibility of completing a standardized assessment of stroke patient rehabilitation needs and the relationship with discharge destination.

Hospital Participation and Performance in Stroke Systems of Care: Results from The NorthEast Cerebrovascular Consortium (NECC) Region
Charles R. Wira III, MD; Zainab Magdon-Ismail, Ed.M, MPH; Shannon Melluzzo, BA; David Day, BS; Louise D. McCullough, MD, PhD; Joel Stein, MD; Lee H. Schwamm, MD; Toby Gropen, MD on behalf of The NorthEast Cerebrovascular Consortium
Significant regional variations exist in the delivery of healthcare, including the delivery of care for acute ischemic stroke. The objective of this poster was to evaluate if implementation of The NECC has been associated with increased participation in the American Heart Association’s (AHA) Get With the Guidelines® – Stroke (GWTG-S) and higher performance ratings of acute care hospitals (ACH) and critical access centers (CAC).