Primary Stroke Center: A Journey to Certification

Primary Stroke Centers were established in 2003 by The Joint Commission as a result of recommendations from the Brain Attack Coalition and the American Stroke Association. Mount Nittany Medical Center, located in State College, PA, began the journey toward Primary Stroke Center certification in 2010, and achieved the designation on June 19, 2014. 

Mount Nittany Medical Center is a 260-bed acute care facility under the umbrella of Mount Nittany Health. Offering medical, surgical, diagnostic, and community services to a mostly rural population, the nearest hospital is 28 miles away, and the nearest Primary Stroke Center is 40 miles away. The Medical Center serves as the primary acute care facility for four counties, and the secondary service area includes six counties. 

The Medical Center employs more than 1,400 healthcare professionals and support staff, who complement 260 credentialed physicians across more than 40 specialties and subspecialties. 

Mount Nittany Health is uniquely positioned adjacent to The Pennsylvania State University, which means that services are available to a student population of more than 40,000 undergraduate students and thousands of graduate students. State College is also a popular retirement destination. 

In 2013, there were 50,000 visits to the emergency department and over 12,000 inpatient discharges. There were a total of 215 patients discharged in 2013 with a stroke diagnosis, including 164 inpatients and 51 observation patients. Data from 2013 shows hypertension as the largest comorbidity (68.3%), followed by diabetes (32.9%), and atrial fibrillation (22%). The National Stroke Association recognizes that atrial fibrillation is more common in people over the age of 60, and considering that the population of retirement-age people is continuing to rise in State College, it can be expected that the number of people with atrial fibrillation will also increase. Because of the Medical Center’s location and demographics, in 2010, leadership recognized the need for the creation of a stroke program to ensure a future of high-quality care for the community. 

The initial step toward certification was the formation of a multidisciplinary team dedicated to providing excellent stroke care. This team consisted of representatives from nursing, medicine, emergency medical services, rehabilitation, laboratory, radiology, the quality department, and administration. The position of part-time stroke coordinator was created and a nurse was hired into the role, performing coordinator duties two days per week. Out of the stroke operations committee, the core stroke team was formed, consisting of the stroke program medical director, the medical director of the emergency department, the stroke coordinator, the stroke program nurse manager, and the critical care educator. In 2011, hospital leadership established the Neurosciences Steering Committee to oversee the Stroke Program and provide administrative support. This year also marked the beginning of participation in the American Heart Association’s Get With The Guidelines Registry, allowing for tracking of patient information and outcomes to improve practice.  

In July 2012, the Pennsylvania legislature enacted the Primary Stroke Center Recognition Act, also known as Act 54. This act required emergency medical service providers to quickly identify and transport potential stroke patients to facilities that have stroke protocols in order to provide timely and effective treatment. Achieving certification as a Primary Stroke Center became a corporate goal at this point for Mount Nittany Medical Center, which provided further administrative support to the stroke program. During this time, a partnership was established with the Penn State Milton S. Hershey Medical Center, who offers advanced neurointerventional and neurosurgical services. A telestroke program was implemented with this facility to provide 24-hour consults to patients by a stroke neurologist during a stroke alert. Because Mount Nittany Medical Center does not have a neurologist located on-site 24 hours a day, this technology ensures a fast and thorough assessment until an in-house neurologist sees the patient. Air and ground transport agreements are in place with two larger facilities should this consultation reveal a need to transfer the patient to a medical facility that offers more invasive interventions.

To ensure that patients receive appropriate stroke care, it was crucial to create improved access to timely thrombolytic therapy. With the cooperation of many departments — emergency medical services, the emergency department, radiology, laboratory, pharmacy, and more — two stroke alert processes were developed: one for patients arriving to the emergency department with stroke symptoms, and one for patients already hospitalized, whose symptoms are discovered after admission. These stroke alert processes were put into place after educating all departments and performing dry runs, and they continue to be refined as needed. To further standardize care of the patient with a stroke, policies were developed, outlining the personnel, roles, and responsibilities during a stroke alert. The stroke operations committee reviews the policies and protocols on a yearly basis. 

The collaboration with the laboratory, pharmacy, and radiology departments was crucial to expedite the care of stroke patients and to ensure quality care. The stroke operations team worked with the laboratory to provide point of care (POC) testing in the emergency department for blood glucose and INR levels. All blood work sent during a stroke alert has a green sticker attached, indicating a high priority. The pharmacy has a dedicated emergency department pharmacist who is available on weekdays, with the responsibility of mixing tissue plasminogen activator (tPA) for eligible patients. This pharmacist also tracks tPA use and is a key member of the stroke operations committee. The radiology department has two CT scanners located near the emergency department, and the staff was trained to clear and reserve a CT scan table when a stroke alert is called. Mount Nittany Medical Center contracts with an after-hours radiology group to provide immediate interpretation of CT scans on stroke alerts at all times. Feedback is given to each of these departments regarding timeliness of procedures. 

The creation and use of order sets related to stroke was recognized as a best practice for quality patient care. In 2012, stroke order sets were created, following collaboration with the information services department and the multidisciplinary team. Currently, Mount Nittany Medical Center uses six order sets for stroke patients. Four order sets focus on the inpatient side: inpatient hemorrhagic stroke, inpatient ischemic stroke with tPA, inpatient ischemic stroke with tPA on day 2, and inpatient ischemic stroke without tPA. Two order sets are focused in the ED: initial ED evaluation for stroke patients, and tPA administration for stroke patients. Feedback is provided to physicians regarding use of the order sets and changes are made as needed. When computerized physician order entry (CPOE) was implemented in 2013, it provided physicians with a simple way to ensure all necessary orders were in place, and it created an easier method to track use. To assist with the transition of care from the hospital to discharge, stroke-specific discharge instructions were also created, which included the required stroke education topics, and information on follow-up appointments. During 2012 and 2013, the stroke coordinator position was vacated, filled, and vacated again, until a contract was made through a consulting company for an interim coordinator. In 2014, a full-time stroke coordinator was hired.  

Rehabilitation is recognized as a key component of quality care for patients diagnosed with stroke. Mount Nittany Medical Center has a dedicated in-house rehabilitation department, and therapists from physical, occupational, and speech therapy are consulted on all patients with a stroke diagnosis. The dysphagia screen was developed using the expertise of speech therapists, and an educational video was created to demonstrate how the screen is performed. It is through a strong partnership with the rehabilitation department that patients are able to receive early therapy and have improved outcomes. 

Staff education was a focus since the beginning of the program in 2010. Ensuring that all staff recognizes the signs and symptoms of a stroke was, and remains, a priority. Use of an online learning management system allowed for stroke education to be distributed across the Medical Center to every department. Currently, all employees, including volunteers, are required to complete yearly stroke education using the learning management system, with focused education provided to the emergency department and designated stroke units. All new employees receive information during orientation, and a simulation lab is used throughout the year to provide  hands-on experience, which includes use of telestroke.

Mount Nittany Medical Center receives patients from multiple community ambulance companies. Working with an emergency medical services liaison who is based in the emergency department, education was provided to all of the companies regarding the stroke program and the stroke alert process. A feedback system was developed for ambulance companies who are interested in information about stroke patients they deliver to the emergency department.

Data gathered from 2013 suggested that approximately two-thirds of patients admitted to Mount Nittany Medical Center for stroke arrived without the use of emergency medical services, possibly causing a delay in treatment. Providing public education programs and information regarding early recognition of stroke and use of emergency medical services became a priority. The stroke coordinator attends community events and provides personalized stroke risk screenings and stroke education. During May’s stroke month celebration, Mount Nittany Health partners with the local rehabilitation facility to provide community education to employees and the public, including physician-led discussions. 

The stroke operations committee recognized that care of the patient with stroke does not end once the patient is discharged, and this requires care planning that is team-based and individualized to the patient’s needs. Multidisciplinary stroke rounds are performed twice weekly at a minimum, and involve the primary nurse, rehabilitation, dietary, the stroke coordinator, and case management. In addition, daily discharge rounds are performed on all patients throughout the hospital. Education packets are given to all patients with a diagnosis of stroke or TIA, which provide information regarding diagnosis, post-hospital care, and prevention, and the staff nurses tailor this information to meet the patient’s specific needs. A large rehabilitation facility is located seven miles from Mount Nittany Medical Center, which has achieved Disease-Specific Care Certification in stroke rehabilitation from The Joint Commission. 

Primary Stroke Center certification was achieved through careful planning, extensive collaboration, and dedication to care of patients with a stroke or TIA diagnosis. Future priorities include efforts to enhance community education through events and publications, continued development of staff education on evidence-based practices in stroke care, and evaluating methods to provide smooth transitions from hospital to beyond the clinical walls.

Bonus Video Content!

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• Conducting a Successful Screening and Implantation of the S-ICD System
• De Novo ICD Implant Using the Aquamantys® Bipolar Sealer for Pocket Hemostasis
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• Biventricular ICD Upgrade and Capsulectomy with TYRX™ Absorbable Antibacterial Envelope and PEAK PlasmaBlade®
• Subcutaneous ICD (S-ICD™ System) Implant with Dr. Martin Burke
• Device Pocket Management - How to Maximize Life of Leads
• CRT-D Pulse Generator Replacement/Capsulectomy Using PEAK PlasmaBlade
• Chronotropic Incompetence: Prevalent, Relevant, Treatable
• Advancements in Fluoro Reduction for the Electrophysiology Lab
• Arctic Front Advance™ Cardiac CryoAblation Catheter: Simply Cool
• Initial Experiences with the ThermoCool® SF Catheter Webinar
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• Hemodynamic Support During Complex VT Ablation: Use of Impella 2.5
• Maximizing integration with EP navigator’s real-time 3D image acquired in lab and Biosense Webster’s Carto 3
• Philips Advanced Tools in Practice — Recorded Live Case with Pierre Jaïs, MD in Bordeaux-Pessac, France

References

1. National Stroke Association, Afib-Stroke Connection, accessed 9/8/2014.
2. Primary Stroke Center Recognition Act, P.L. 549, No. 54, Cl. 35 (2012).
3. Yanko J. Certified stroke centers: A 2012 update. EP Lab Digest. 2012;12(5):26-28.