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Georgia Sets Standard in Stroke Response

January 7, 2014

If the U.S.’s stroke belt was an actual belt, then Georgia would sit squarely on the buckle. The state has the ninth-highest stroke death rate in the nation and nearly 3,800 Georgians died from a stroke in 2008 alone.

But even as Georgia sits high in national rankings for strokes, the state’s system of care for people who have strokes is also attracting national attention and praise. The Georgia Coverdell Acute Stroke Registry program focuses on improving care for stroke patients both in Georgia hospitals and before they get there.

Michael Frankel, M.D., chief of neurology and medical director of the Marcus Stroke and Neuroscience Center, who created the program at Atlanta’s Grady hospital in 2001, said the registry has vastly improved how stroke patients receive care in the state by emphasizing that treating strokes takes a team effort.

“There are several states with stroke registries, but ours is widely recognized for its depth of collaboration and cooperation in improving stroke care,” Frankel said. 

More than 60 Georgia hospitals participate in the Coverdell stroke registry, from the state’s primary stroke centers to local hospitals in rural areas. The program is a partnership between the Georgia Department of Public Health (DPH), Emory University, the American Heart Association/American Stroke Association the Georgia Hospital Association and the Centers for Disease Control and Prevention (CDC). All told, the hospitals in the Coverdell system reach about 10,000 Georgia stroke patients each year.

“We’re quite proud of the hard work that’s being done and the whole system of care, starting from EMS to hospital discharge and rehab,” said James Lugtu, principal investigator and quality improvement director for the Coverdell Stroke Registry.

The Coverdell registry and its partners are using that system of care to try to win the race against time that defines stroke care. A stroke happens when blood flow to the brain is disrupted, whether by a blood vessel blockage or the rupture of an artery. The longer the brain goes without blood and oxygen, the greater the likelihood for permanent injury and long-term disability, unless blood flow is quickly restored.

“Making a rapid and accurate diagnosis of stroke symptoms is essential for determining what type of treatment is required to minimize brain damage and to prevent another stroke,” Frankel said.

Often the first health professionals who try to make that determination are paramedics. When they arrive on the scene, EMS responders must quickly evaluate a patient’s symptoms -- disorientation, confusion or an inability to speak, for instance -- to determine whether that person may have had a stroke and when. Thanks to the collaboration between the Coverdell registry  and DPH’s Office of EMS and Trauma, all Georgia EMS responders have received special training from stroke experts to screen patients for stroke symptoms and determine the last time they were known to be well. That information helps the paramedics determine what the patient may be facing, what kind of care they need and which hospital they need to visit. 

Keith Wages, director of the Office of EMS and Trauma in the Georgia Department of Public Health, said the steps sound simple, but they have made a major difference in how EMS professionals deliver pre-hospital care, which can drastically alter a person’s outcome after a stroke.

“From our standpoint, it’s been our most successful endeavor in terms of seeing a change in service delivery,” Wages said. “We’re able to get the patient to the right place in the right amount of time.”

Once paramedics make their assessment and transport the patient, they issue a stroke alert, letting the hospital know they will be arriving with a potential stroke patient. Lugtu said that heads-up is another simple way to help improve hospital care for stroke patients. 

“In patients with certain kinds of strokes, we have what’s called the golden hour,” a 60-minute window in which a patient must receive a drug called t-PA, which dissolves blood clots blocking blood flow to the brain, he said. “The earlier you give contact to hospitals that they’ll be seeing a stroke patient, the more time they have to get ready to treat that patient and the better the outcome.”

Already, these simple steps have made a difference for Georgians who have strokes. Between 2010 and 2012, the number of patients transported by EMS to hospitals after a stroke increased by 44 percent. When the registry began in 2001, fewer than 10 percent of stroke patients received the clot-busting drug t-PA; today, 86 percent of eligible patients get the drug.

Lugtu said Georgia hospitals are also getting closer to delivering care within the golden hour of stroke care. In 2010, the average “door-to-needle time” – the time between a patient’s admission to a hospital and injection of t-PA – was 73 minutes.

“That was actually pretty good,” Lugtu said. “Most hospitals anywhere in the country don’t meet the 60-minute goal.”

But in 2012, Georgia’s average door-to-needle time decreased to 66 minutes. Lugtu said he expects that data from 2013 will show even faster care. A recent Coverdell analysis also showed that stroke patients who go to a hospital in the registry are much less likely to die.

A key aspect of the Coverdell registry is process improvement, using research and feedback to improve the system and communicating those findings to partners around the state. Wages said that kind of feedback is invaluable in helping EMS improve its services.

“The medics then do a better job treating and transporting the next patient. It’s that cycle of learning and working together that I think has made the difference,” he said.

For more information about the Coverdell stroke registry, visit the program’s page on DPH’s website.