Kari Moore, MSN, APRN

Chair, SEQIP

10th Anniversary 2009-2019

Bonita Bobo, BSN, RN, HHSHDSP Program Manager

Risk Factors: KY and the US

39.4%

38.1%

24.6%

12.9%

34.3%

92.5%

83.0%

57.3%

32.3%

33.0%

17.1%

10.5%

31.6%

89.5%

81.9%

63.2%

0% 20% 40% 60% 80% 100%

High Blood Pressure

High Cholesterol

Tobacco Use (CurrentSmoker)

Diabetes

Obesity

Health CareAccess/Coverage

Eat Vegetables one or moretimes a day

Eat Fruit one or more timesa day

2017 Prevalence of Risk Factors

US

KY

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS Prevalence & Trends Data [online]. 2015. [accessed May 20, 2019]. URL: https://www.cdc.gov/brfss/brfssprevalence/.

SEQIP Participating Hospitals

Baptist Health Floyd

Baptist Health Louisville*

Baptist Health LaGrange

Baptist Health Lexington*

Baptist Health Paducah*

Cardinal Hill Rehab Hospital

Ephraim McDowell Regional Medical Center

Fleming County Hospital

Frankfort Regional Medical Center

Georgetown Community Hospital

Greenview Regional Hospital

Hardin Memorial Health

Harlan ARH

Highlands Regional Medical Center

Jackson Purchase Medical Center

Jewish Hospital*

King’s Daughters Medical Center*

Lake Cumberland Regional Hospital*

Morgan County ARH

Norton Audubon Hospital*

Norton Brownsboro Hospital

Norton Hospital*

Norton Women’s and Children’s Hospital*

Our Lady of Bellefonte Hospital

Owensboro Health Regional Hospital*

Pikeville Medical Center*

Saint Joseph Hospital

St. Elizabeth Edgewood*

St. Elizabeth Florence

St. Elizabeth Ft. Thomas

Sts. Mary and Elizabeth Hospital*

The Medical Center-Bowling Green*

Three Rivers Medical Center

UK Healthcare*

University of Louisville Hospital*

(Founding Members*)

Data Review

Stroke Measures

SEQIP KY Stroke Registry Volume

4358

5058

57796278

7819 7907

8941 88199408 9563

10015

2726

0

2000

4000

6000

8000

10000

12000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Nu

mb

er

of

Re

gist

ry C

ase

s

Stroke Types

77.5%

9.0%

3.0% 9.2%

0.8%0.4%

Stroke Type

Ischemic stroke

Transient ischemic attack (<24 hours)

Subarachnoid Hemorrhage

Intracerebral Hemorrhage

Elective Carotid Intervention only

Other

SEQIP Demographics - AGE

0.0%

6.7%

32.8%

48.9%

11.5%

SEQIP 2008: Age

<18 18 - 45 years

46 - 65 years 66 - 85 years

>85 years

0.0%

6.5%

33.6%

48.1%

11.7%

SEQIP 2018: Age

<18 18 - 45 years

46 - 65 years 66 - 85 years

>85 years

SEQIP Demographics - RACE

87.6%

10.9%

0.3%

0.1% 0.0%

0.6% 0.5%

SEQIP 2008: Race

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderUnknownHispanic

84.6%

9.8%

0.5%0.1%

0.0%

4.3% 0.6%

SEQIP 2018: Race

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderUnknownHispanic

SEQIP Demographics - Gender

45.1%54.9%

SEQIP 2008: Gender

Male Female

49.3%50.7%

SEQIP 2018: Gender

Male Female

Stroke Core Measures

97.2% 99.6%92.3%

97.8%92.4%

98.9% 99.5% 99.7% 97.2% 97.7%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Per

cen

tage

of

Pat

ien

ts

IV Alteplase Arrive by 2 Hour Treat by 3 Hour

59.6%52.7% 50.4%

77.6%83.7% 83.7%

89.9%80.1%

92.7% 88.5%81.7%

74.2% 76.9% 79.1% 82.6%86.6% 88.6% 89.4% 88.3% 90.3% 91.0%

86.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Kentucky SEQIP All Hospitals

IV Alteplase Arrive by 3.5 Hour Treat by 4.5 Hour

33.9%38.6% 38.6%

50.7%

59.3%65.4%

73.3%70.2%

77.5% 77.5% 75.8%

34.9%

58.9%63.2% 65.9%

70.1%74.4% 76.0% 79.0%

82.5%85.6% 83.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Kentucky SEQIP All Hospitals

IV alteplase in Ischemic Stroke Door to Needle ≤ 60 Minutes

27.3%24.4%

41.7%

33.3%30.2%

23.2%25.2%24.5%

49.3%

68.3%73.4%75.6%

79.4%83.5%84.0%

87.0%

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Perc

ent

Trea

ted

wit

hin

Ben

chm

ark Target Stroke

I

KY: 44.5% in 2012 KY: 78.4% in 2016

National Target Stroke Maps

ISC Oral Presentation - 2016

IV alteplase in Ischemic Stroke Door to Needle ≤ 45 Minutes

18.2%

8.9%

20.4%

8.1% 7.4% 7.5%10.1%

8.2%

13.2%

20.6%

27.4%

34.8%38.7%

41.1%

49.6%53.9%

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Perc

ent

Trea

ted

wit

hin

Ben

chm

ark

Target StrokeII

Decreasing DTN Times with TS

Time Frame Median DTN(minutes)

DTN Range (minutes) Average DTN(minutes)

Pre Target Stroke 73 0-5343 108.8

Phase I 64.5 0-697 71.9

Phase II 46 0-2821 51.9

From Pre TS to Phase 2, the mean decreased by 56.9 minutes (95% CI: 40 42, 73.3754) with a significance level of p<0.0001

National GWTG-S Data

Presented by L. Schwamm, AHA Webinar April 2019

Time Trend in DTN Times within 60 and 45 Minutes Pre-TS, TS Phase I, and TS Phase II

y = -0.0006x + 0.2881

y = 0.035x - 0.6542

y = 0.0075x + 0.4258

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 5 10 15 20 25 30 35 40 45 50 55 60 65

Per

cen

t o

f P

atie

nts

Quarter

DTN ≤ 60 Minutes

KY SEQIP Pre Target Stroke

KY SEQIP Target Stroke I

KY SEQIP Target Stroke II

y = -0.0032x + 0.1372

y = 0.0106x - 0.1949

y = 0.0133x - 0.2622

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 5 10 15 20 25 30 35 40 45 50 55 60 65

Per

cen

t o

f P

atie

nts

Quarter

DTN ≤ 45 Minutes

KY SEQIP Pre Target Stroke

KY SEQIP Target Stroke I

KY SEQIP Target Stroke II

SEQIP Alteplase Use

• Alteplase use in eligible patients arriving by 2 hours and treated by 3 hours: 56.2% pre TS vs 80.7% post TS intervention (p <0.0001)

• Alteplase use in eligible patients arriving by 3.5 hours and treated by 4.5 hours: 24.9% pre TS vs 55.1% post TS intervention (p <0.0001)

• Alteplase use among all acute ischemic stroke patients: 4.8% pre TS vs 7.8% post TS intervention (p <0.0001)

IV Alteplase Complication Rate

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Rate of Symptomatic Intracranial Hemorrhage for AIStreated with tPA

Rate of Life-Threatening, Systemic Hemorrhage forAIS treated with tPA

Outcomes Pre Target Stroke vs Phase I and Phase II

Pre-Target Stroke

Target Stroke Phase I

Target Stroke Phase II

OR (95% CI) Pre TS vs Phase I p-value

OR (95% CI) Pre TS vs Phase II p-value

OR (95% CI) Phase I vs Phase

II p-value

2004-2009 2010-2013 2014-2018

n=14944 n=23489 n=41085

In Hospital Mortality 9.74% 7.45% 7.04% 1.94 (1.80, 2.08) <0.0001 1.13 (1.06, 1.21) 0.0002 0.94 (0.89, 1.00) 0.0571

Discharge Home 37.04% 44.61% 47.42% 1.37 (1.31, 1.43) <0.0001 1.5 (1.48, 1.59) <0.0001 1.12 (1.08, 1.16) <0.0001

EMS Prenotification 9.84% 8.13% 16.38% 0.81 (0.75, 0.87) <0.0001 1.79 (1.69, 1.91) <0.0001 2.21 (2.10, 2.34) <0.0001

Ambulatory Status Independent 38.04% 24.62% 38.06% 0.53 (0.51, 0.56) <0.0001 1.00 (0.96, 1.04) 0.039 1.88 (1.82, 2.00) <0.0001

Arrive by EMS 49.76% 25.10% 37.42% 0.34 (0.32, 0.35) <0.0001 0.60 (0.58, 0.62) <0.0001 1.77 (1.71, 1.84) <0.0001

Discharge Disposition

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

2011 2012 2013 2014 2015 2016 2017 2018 2019

Home Hospice - Home

Hospice - Health Care Facility Acute Care Facility

Skilled Nursing Facility (SNF) Inpatient Rehabilitation Facility (IRF)

Long Term Care Hospital (LTCH) Intermediate Care facility (ICF)

Expired Other

• 60-70% of pts d/c to home or ARF• < 10% mortality

Stroke Mortality 2007-2009

Stroke Mortality 2014-2016

CDC Vital Signs Decline in Stroke Death Rates

Centers for Disease Control and Prevention; 2018 Vital Signs

Stroke Chain of Survival

Acute Stroke, ACLS

Current SEQIP Initiatives

• Standardized Community Messaging

• EMS

• Stroke Core Measures – Hospitals

• IV Thrombolytic Therapy

• Post Discharge Care

Standardized Community Messaging

• Signs and Symptoms of Stroke– Calling 911 for suspected stroke symptoms

• Vascular Risk Factors– Nutrition– Sodium– ETOH– Physical Activity– Smoking – Diabetes– Cholesterol– Hypertension

• Home Blood Pressure Self Monitoring

• Resources will be available on HDSP Task Force Website– Will be able to customize with organization logo

Kentucky Board of EMS (KBEMS)

• KBEMS provides oversight and recommended transport protocols– Local agencies can fully adopt, partially adopt, or create their own protocols

that must be approved by KBEMS Medical Director

• Kentucky Board of EMS Stroke and Cardiac Subcommittee• Created 2013 and meets quarterly

• Revised Recommended Stroke Transport Protocol September 2017 to include severity scale – C-STAT based on survey feedback from first responders

• Interfacility transfer guideline post alteplase added to protocol February 2018

• First KBEMS Annual Report 2017

• Algorithm for Stroke Prenotification created September 2018

• Working to standardize data collection points for reporting

EMS Prenotification

0%

10%

20%

30%

40%

50%

60%

Bas

elin

e

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

20

17

20

18

Perc

ent

of

Pati

ents

Time Period

Inter-facility rt-PA transfer protocol

KBEMS 2017 Report