IF YOU BUILD IT, THEY WILL COME: BUILDING A SUCCESSFUL STROKE PROGRAM IN A COMMUNITY EMERGENCY DEPARTMENT PRESENTED BY: KATIE BUCK MSN CEN AGCNS-BC CAROLINAEAST MEDICAL CENTER

2 Disclosures

Katie Buck has no relevant financial or nonfinancial interest to disclose. Disclosure will be made when a product is discussed for an unapproved use. This continuing education activity is managed and accredited by AffinityCE in cooperation with SOC Telemed. AffinityCE and SOC Telemed staff as well as Planners and Reviewers has no relevant financial or nonfinancial interest to disclose. Commercial Support was not received for this activity.

3 Learning Objectives

Objective 1: Discuss why the introduction of a Code Stroke Pathway significantly increased alteplase administration Objective 2: Learn why initiating a nurse-driven neurological emergencies order set improved DTN Times Objective 3: Review how staff incentives helped improve DTN benchmarks

4 A Burning Platform

• New Bern, North Carolina is part of the stroke ‘belt buckle’ of the stroke belt. • Stroke is the 4th leading cause of death in North Carolina. • North Carolina leads the country at #10 for IMAGE INSERT stroke mortality rate. • Sweet tea and fried vegetables are considered a food group. • Low healthcare literacy and challenges with access to care. • Stroke mortality rate increasing.

5 About Us…

CarolinaEast Medical Center Is:

∙ A 350 bed community based hospital. ∙ Primarily serves a Tri-County area. ∙ Ranked among the top 5 hospitals in North Carolina for 2 consecutive years. ∙ The Center for Medicare and Medicaid Services (CMS) has awarded the hospital a 5 star ranking since June 2016. ∙ We strive to strengthen the health of our community, continue to build on our culture of excellence, and are committed to patient safety and high- quality care.

6 If You Build It, They Will Come: Our Stroke Program Story

Bring All The Players To The Field Call a Code Stroke Overhead • Emergency Department leadership and staff, • A BIG part of our protocol that was a change including unit secretaries and techs. As well as from previous practice was to announce the radiology, lab, providers, inpatient units, nursing Code Stroke overhead in the ED. informatics. • We leveraged our ED Unit Based Council to help • This took some time to get accustomed to make decisions on the proposed protocol. and now is second nature to our team. • This helped involve staff, allow their voice to • This is a nurse driven process be heard, and learn the ‘WHY’ behind what we were creating. Education and Active Surveillance Put the Protocol on Paper • Mandatory mock code strokes. Providers encouraged to attend. • Criteria includes LKWT < 4.5 hours • Process for EMS, Triage, and Minor Emergency • Constant follow up with staff to give arrivals kudos and opportunities for improvement. • Pathway includes tasks to be completed by role and times to meet the metrics

7 They Did Come…

Did more patients come OR did our staff have improved recognition of potential Code Stroke patients? Alteplase Treatment Rate 2010-2018 It was probably a little bit of both… 40 ED Stroke Program Began • We saw a 1600% alteplase treatment rate 35 increase in 8 years. 12/2016 30 • Total strokes we consulted SOC for 25 increased 523% over the same period of

time. 20 Alteplase • Door-to-needle average 2015: 85.7 15 minutes 10 • Door-to-needle average 2018: 53.3 5 minutes 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 • This was a decrease of 37%! tPA/Stroke 2 13 16 13 20 16 28 30 34

8 Keys To Success and Best Practices

Code Stroke Box Laminated Dosing Card

• Nurses calculate and write down the infusion, waste, • IV start supplies bolus, and total dose with a • Waste and bolus dry erase marker as soon as supplies they weigh the patient. • Alteplase • They do this with all Code • Nicardipine drip Stroke patients before it has • Labetalol IVP been determined that alteplase will be • Calculation card recommended.

• Designed a Stroke tab in the EMR to improve consistency with documentation • It helps them become more familiar with the drug • Going from 1 weigh bed to 18 weigh beds and a wheelchair scale. calculation and also allows • Nurse driven order set them to take ownership in • EMS patients go straight to CT the dose when confirming with the ED provider and • Stroke resource binders neurologist. • NIHSS cards on SOC cart to assist with the neuro exam • Waste and bolus stickers to label syringes and avoid medication errors • Code Stroke sticker for bloodwork to help lab prioritize testing

9 Neurological Emergencies Order Set

• The initial purpose of the order set So, what happened to our Nurses working was to ensure a CT order was placed so it would be read quicker and the door-to-needle times? at the top of images pushed to SOC. They improved greatly!! their scope of • It also has an order to consult SOC, which allowed our unit secretaries to practice drives initiate the consult without the order from the doctor and a verbal 2017 DTN Average: 73.6 minutes request from the RN saving precious consistent time. • After making the consult, the high-quality secretaries would place the SOC cart 2018 DTN Average: 53.3 minutes in the patient’s room. This saved the nurse time and allowed quicker outcomes. IV placement and preparation for possible alteplase administration. That is a 27% decrease in our DTN!! • The lab orders were entered faster, which means faster results!

10 Financially Speaking…

227% ROI

11 Community Impact

12 Building a High-Performing Team

Incentives for a patient well cared for have gone a long way in strengthening the clinical quality of our program.

Gold and silver brain pins are awarded for meeting door to needle time goals.

Gold  DTN < 45 minutes Silver  DTN < 60 minutes

All team members who contributed to the care of the stroke patient receiving alteplase in the acute phase are awarded a pin.

This includes the nurses, provider, unit secretary, tech, and radiology staff.

13 Raising the Bar

How we use the SOC metrics to meet and exceed DTN Times:

• We follow the Arrive to Consult and Recommend to Bolus times. • Goals decided by our staff: • Arrive to Consult < 15 IMAGE INSERT minutes. • Recommend to Alteplase Bolus < 10 minutes. Celebrate Success 2nd Qtr 2019 Arrive to Consult: 13.8 minutes Recommend to Alteplase Bolus: 9.6 minutes COMPARED TO 1st Qtr 2019 Arrive to Consult: 36.1 minutes Recommend to Alteplase Bolus: 12.9 minutes

14 The Future of Our Program

• Focus on increased recognition of posterior strokes. • Move thought process from deficit to disability and consider each patient’s quality of life individually. • Obtain Primary Stroke Center. IMAGE INSERT • Improve our process with obtaining a CTA to rule in a possible LVO. • Continue to build a strong outreach program. • Improve our Door In-Door Out metric. • Dedicated CT room for the ED.

15 Thank You

Our patients Our staff Our providers Our lab Our radiology department Our ICU And more…

Built a stroke program with outcomes beyond our imagination!

16 Questions

17 To Claim CE Credit

If you would like to receive continuing education credit for this activity, please visit: https://soc.cds.pesgce.com

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