Stroke: The Under-treated Cardiovascular Disease

Howard Regional Health System (HRHS) formed a Community Stroke Coalition to educate the public and standardize medical protocols Q: You experience sudden numbness or weakness in your face or on one side of your body. You become confused and have trouble speaking or understanding or maybe have trouble walking or seeing in one or both of your eyes. What should you do? A: Call 9-1-1 immediately. You may be having a stroke. The advice may sound simple to those of us entrenched in cardiovascular health, but to the average public, the tip just might be life-saving. That’s because, according to the American Heart Association, the majority of the population know when they are having a heart attack but are typically unable to articulate two symptoms of a stroke. At Howard Regional Health System in Kokomo, Indiana, we became painfully aware of this statistic last year. A routine check of our thrombolytic drug usage raised a big, red flag. The number of patients receiving thrombolytic therapy for the treatment of heart attacks far exceeded the number of those receiving thrombolytic therapy for the treatment of strokes. We realized that some of the discrepancy came about due to the fact that more patients meeting the criteria for treatment with thrombolytics presented at the hospital with the signs and symptoms of heart attacks than with strokes. However, upon a closer look, we also realized this simple truth: We have done an excellent job of educating our public on the signs and symptoms of heart attack but that same population didn’t know when they were having a stroke. For a community our size, approximately 75,000 residents, we knew patients were not presenting to the emergency room soon enough for us to intervene to prevent or lessen a stroke. Stroke is our nation’s number three killer, affecting nearly 700,000 Americans every year, and the leading cause of severe, long-term disability. Based upon national data, we know that patients who receive care within the first three hours of experiencing symptoms have a far greater chance of preventing or lessening the severity of a stroke. Armed with that information, we became proactive and formed the Community Stroke Coalition in May of 2003. Stroke Coalition We knew the Coalition needed to involve the entire community, including physician champions, third party payers, business leaders, surrounding health care providers, emergency medical services, critical care nurses, and rehab personnel. Additionally, we partnered with the American Heart Association (AHA) and our preferred vendors to help supply community educational materials. Our first meeting, held on May 15, 2003, included close to 30 healthcare and community representatives. We soon discovered our mission was actually twofold: to educate our population on the signs and symptoms of a stroke and to standardize protocols between the various healthcare facilities. Almost immediately, our community education began. We strategically placed six billboards throughout the community encouraging residents to call 9-1-1 should they experience a stroke symptom. At the same time, newspaper articles and radio spots emphasized what those symptoms are. Educational materials were distributed at the Howard County Fair, the AHA Heart Walk and the United Auto Worker (UAW) sponsored Howard County Health Fair. Additionally, knowing that up to 40% of strokes are caused from blockages and vulnerable plaque in the cerebral carotids, we were able to provide free carotid ultrasound screenings to 250 people who were identified at the health fair to be at highest risk (high cholesterol and high blood pressure). Of them, 40% presented with mild to moderate disease and 4% presented with critical/severe disease. Standardizing Protocols Educating the public was one matter, but educating ourselves as healthcare professionals was also a major component of our plan. Our community has two hospitals providing acute care. Our Neurology coverage options were the same for both hospitals. In comparing the medical protocols being utilized in both emergency rooms, differences were noted in the inclusion/exclusion criteria and relative contraindications. We obtained several examples of stroke medical pathway models. Using our physician champions, outcomes director and emergency room management, we began standardizing the medical protocols between the two hospitals, utilizing the AHA Guidelines for Treatment of Stroke and the National Institute of Health (NIH). HRHS utilized the National Institute of Health Stroke Scale (NIHSS) certification for education and training. We made it mandatory for all HRHS nurses to obtain this stroke certification provided through our Staff Development Department. The grand idea was to get both of the hospitals in the community and all local emergency medical personnel using the same procedures whenever a stroke patient enters one of the emergency rooms. This would help assure standardization of acute care for stroke patients in our community. (Please see previous examples of our standardized protocols: Suspected Stroke ER presentation and Acute CVA/t-PA treatment.) Scorecard After just five meetings of our stroke team, we were able to standardize medical protocols between the two hospitals, and raise public awareness about the nation’s number three killer and number one disabler of adults. Last year, only 3 patients meeting the criteria to receive thrombolytic therapy for the treatment of stroke presented to HRHS within 3 hours of the onset of their symptoms. Since the formation of our Community Stroke Coalition and the proactive efforts to educate the public and each other, we have seen an increase in the number of patients presenting with stroke symptoms within that window of time, increasing their chances of receiving life-saving thrombolytic therapy. We still have a long way to go before our service area is as knowledgeable about stroke as they are about heart attack, but thanks to a concerted community effort, we’re making a difference, one patient at a time. For more information, please contact Sheree Schroeder at: Sheree Schroeder, RN, BSN, RDCS, FASE, Executive Director, Cardiovascular Service Line Howard Regional Health System, Kokomo, IN 46902 765-453-8618, sschroed@howardregional.org

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