The Incredible Journey

After more than a year of intense focus on upgrading its stroke care, DeKalb Medical, Decatur, Ga., goes under the Joint Commission’s scrutiny.

On-site evaluators will walk hospital halls and observe caregivers, scroll through patient records, and talk to nurses, physicians and other staff about their training and ability to provide standardized, top-notch care for patients experiencing “brain attack,” or stroke.

If they like what they see, DeKalb Medical will earn the Joint Commission’s Advanced Certification for Primary Stroke Centers – a gold seal of approval that will recognize countless hours of effort and education to position the facility as an expert in stroke care.

“It’s an exciting time,” said Chika Ugwuoke, MSN, NP. “It will be a whole day of anxiety, but we are confident about our stroke program.”

Hospital-Wide Effort

As stroke coordinator nurse practitioner, Ugwuoke has played a pivotal role in DeKalb Medical’s journey to stroke certification. Alongside neurologist Joey Boiser, MD, who is also Dekalb Medical’s stroke program medical director, and chief nursing officer Susan E. Breslin, DNP, RN, NE-BC, FACHE – and backed by an interdisciplinary team – they have stayed abreast of current evidence-based best practices, implemented them, and then analyzed how well staff performed them. When necessary, processes have been tweaked along the way, and performances re-tracked and evaluated again.

As a result, Ugwuoke can confidently say of her hospital: “We are equipped to care for stroke patients, and we have the data to prove it.” Specific achievements include faster, more thorough care in the emergency department, the launch of a dedicated stroke unit with specialized nursing care, and stroke literacy throughout the hospital that is higher than ever.

“Everyone involved stepped up to meet this goal,” said Breslin. “Nurses in the emergency department and the inpatient areas all had to understand the signs and symptoms of stroke and be able to respond quickly. Triage nurses had to fine tune their assessment skills to identify patients who may be experiencing stroke symptoms. Everyone from the security officer to the registration clerk had to be knowledgeable about the signs and symptoms of stroke to alert nursing of a potential stroke patient.

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LEADING THE WAY From left, first row: Chanique Jones, RN, educator ED; Tammy Poulnott, LMSW, CCM, director; Susan Breslin, RN, CNO; Chika Ugwuoke, NP, stroke coordinator; Amber Winkis, manager of emergency services. Second row: Patricia Black, RN, executive director of critical care; Melissa Smith, manager of inpatient radiology; Roz Heath, director of laboratory services; Sharon Mawby, RN, executive director of medical-surgical services. Third row: LeRoy Walker, VP of human resources; Donna Payne, RN, nurse educator medical-surgical services; Denise Sweeney, RN, executive director of emergency services; Ed Morgan, director of radiology; Roletta Hall, RN, manager of medical telemetry unit; Sharene Jupiter, laboratory information systems coordinator.

“This has been an incredible journey for our organization.”

Improving Door-to-Needle Time

Advancements in stroke care have been implemented across the medical center, which last year treated more than 350 patients for stroke. Last October, DeKalb Medical garnered a bronze-level Get With the Guidelines-Stroke Award from the American Heart Association for scoring 90 consecutive days of 85% or higher adherence to Get With the Guidelines-Stroke achievement indicators to improve patient care and outcomes. Just three months later, it was bumped to the Get With the Guidelines-Stroke silver-level status, which recognizes 12 consecutive months of adherence.

A key focus of DeKalb Medical’s efforts has been increasing the speed of care in its emergency department.

The American Stroke Association’s Target: Stroke guidelines encourage administration of the intravenous clot-busting drug tissue plasminogen activator (tPA) to patients with acute ischemic stroke within 60 minutes of arrival. To reach that goal, the hospital developed a treatment timeline for patients with symptoms of stroke. Within 10 minutes of arrival, the patient undergoes a preliminary assessment and has labs drawn. By minute 25, the patient receives a CT scan; by minute 45, lab and CT scan results are ready for the physician. The physician then has a 15-minute diagnostic window to determine whether the patient is a candidate for tPA.

“We have quickly identified our opportunities and embarked on process improvement journey to provide safe and efficient care for our patients,” said Ugwuoke. “We have seen a dramatic improvement in our performance measures.”

An effort has also been made to enhance collaboration between ED physicians and neurologists.

“For every stroke patient, we are asking the emergency department physician to collaborate with a neurologist,” Ugwuoke said. “Best practices say that when patients come in with stroke, you get a neurologist involved as soon as possible.”

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IMPROVING DOOR TO NEEDLE: Leon Martin, MD, ED physician (left) works with nurses Milena Nikolova, RN, and Jairon Howard, ED tech to quickly assess a patient.

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DEDICATED STROKE UNIT: Joey Boiser, MD, a neurologist and medical director for stroke program (right), and Ugwuoke re-evaluate a patient who has been moved to a unit staffed by stroke specialists.

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EDUCATION: Educational materials and talks are provided to staff at an internal education fair. photos by Chris Hamilton Photography courtesy DeKalb Medical

Recently, the medical center received an excellence award from the Georgia Department of Public Health for bettering its tPA administration time. Between 2012 and 2013, the ED logged a 20% improvement.

Dedicated Stroke Unit

To enhance specialized care of patients upon admittance, the medical center established a dedicated stroke unit last June. The unit is currently staffed by 20 nurses.

“Best practices call for placing all stroke patients in one area and training the nurses to deliver that specific care,” said Ugwuoke. “When you cohort stroke patients on the same unit, they have better outcomes.”

In addition to taking classes on the care of stroke patients, nurses earned certification in administering the NIH Stroke Scale (NIHSS). The 11-item assessment tool, administered upon patient admission and discharge, measures the level of impairment caused by stroke.

“This assessment gives us a picture of how the patient is doing neurologically,” Ugwuoke explained.

Anupama Jacob, BSN, RN, has worked on the specialized stroke unit from its start and has seen the difference it has made in patients’ lives.

“The unit is important because the nurses are specialized to care for the patients who have been traumatized by stroke and need our help,” she said. “The staff has well-placed protocols to care for the patients. Upon admission, we provide them with all the education to help for recovery and prevention.”

Outreach and Education

In addition, DeKalb Medical has made an effort to raise awareness of the signs and symptoms of stroke in the community through educational materials and talks to caregivers and residents alike.

Teaching the acronym FAST (Facial drooping, Arm weakness, Speech difficulty, Time to call 911), educators at DeKalb Medical hope to improve stroke literacy beyond the hospital walls.

“The more we can do to educate the community on early recognition and a prompt 911 call, the more lives we can save,” said Breslin. “Everyone knows time is muscle in the care of the heart attack patient. In the case of stroke, time is brain.”

With so many improvements initiated, the agenda going forward is to streamline and sustain them, according to Ugwuoke.

“In my opinion, sustainability is the hardest part of any process,” she said. “So we are going to keep our eyes on process improvement initiatives that we’ve established to make sure that it remains meaningful to our patients.”

Because, in the end, the patients are the reason behind the journey to primary stroke center status. While advanced recognition from the Joint Commission certainly carries prestige, Ugwuoke seems more concerned with the message that it conveys to the public.

“It is announcing that we are striving for perfection, excellence and quality in care delivery for stroke patients,” she said. “It gives the community confidence that should they or their loved ones be faced with such a devastating event, they can be comfortable coming here. That’s why I am in healthcare to begin with. The quality of care means everything.”

Jolynn Tumolo is a freelance writer.

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