Spectrum Health Butterworth Hospital (SHBW) has provided exceptional stroke care to the Grand Rapids community and in 2006 was designated as a Joint Commission Primary Stroke Center (PSC). As a PSC, Butterworth is required to demonstrate the provision of evidenced-based care for our ischemic stroke population. Specifically, the performance measures are reportable to the Joint Commission and include:
- Venous Thromboembolism (VTE) Prophylaxis use and compliance for all stroke patients.
- Appropriate medication prescription to reduce secondary strokes for the inpatient stroke population.
- Education on stroke risk factors provided to the patient and family to reduce secondary strokes.
- Provide rehabilitation assessment to our stroke patients to ensure they are able to meet their optimum functional outcome post-stroke.
In 2015, Spectrum Health Butterworth chose to further enhance their specialty stroke designation. With executive support, an interdisciplinary team began the journey to achieve Comprehensive Stroke Certification (CSC). In addition to PSC performance measures, CSC includes surgical intervention for both ischemic and hemorrhagic stroke patients; a dedicated Neuroscience Intensive Care Unit in which stroke patients may receive essential cerebral monitoring; specialty-trained neurovascular physicians and surgeons; specialty-trained nurses that deliver high-level evidenced based stroke care; community outreach to prevent stroke; and robust participation in research to advance and continuously improve the care provided to stroke patients.
What did this challenge mean for nursing?
Nurses have been key stakeholders in deciding to pursue the highest certification possible for stroke care. From the bedside staff to executive leadership, from the Emergency Department to Interventional Radiology, to the Neuroscience Intensive Care Unit, to the 7 South Stroke Unit, nurses have been vital in driving the necessary work forward to achieve CSC. To say “it takes a village,” could not be more true.
Many nurses have participated in process improvement events that greatly impacted the patients we serve. For example, in addition to the Joint Commissions requirements, Spectrum Health Butterworth chose to set a high bar for medical and surgical time metrics for emergent stroke interventions. The tenet “TIME IS BRAIN” is paramount in the care of our stroke patients; for every one minute the brain does not have blood flow to an area, 2 million neurons die. The Emergency Department nurses were pivotal in reducing the time from when a patient arrives to the ED to alteplase administration, which is an intravenous medication that breaks up blood clots. An interprofessional team, including nurses, participated in Plan, Do, Study, Act cycles. They worked through the process of assessing the patient, managing blood pressure, transferring the patient to radiology for a CT, and administering alteplase, with a goal of completing these interventions in 45 minutes or less. The SHBW Emergency Department achieved and has sustained an average speed to medication delivery of 48.5 minutes. The Emergency Department nurses partner with the nurses, in Interventional Radiology to swiftly transfer patients eligible for mechanical clot extraction to the Interventional Radiology Suite. To watch the nurses and interdisciplinary staff prepare to receive an emergent stroke patient is incredible. All team members have defined roles and responsibilities and must function in a timely and seamless manner, with a common goal to save the patient’s brain. The national goal for patient arrival time to procedure start time is 80 minutes. At SHBW the median time is 72 minutes.
As patients transition to the inpatient setting, the quality of nursing care remains high. Nurses have fostered collaborative relationships with the physicians to ensure an environment in which the patient receives evidenced-based care. All Neuroscience nurses are required to have at least 8 hours of stroke education every year to ensure they gain the most current evidence-based stroke care knowledge. Furthermore, Spectrum Health Butterworth has adopted the recommendations of care from the American Stroke Associations (ASA) Clinical Practice Guidelines and has embedded them into nursing practice. For example, the guidelines recommend that nurses complete a dysphagia screen on all stroke patients prior to providing the patient with anything by mouth. This critical measure helps to reduce the risk of aspiration and prevent aspiration pneumonia. By providing a dysphagia screen, nurses are ensuring that incidental harm does not reach our patients.
Spectrum Health also participates in the Stroke Get With The Guidelines® (GWTG) database, which monitors specific care elements that every person who has experienced a stroke should receive. In order to become a Comprehensive Stroke Center, the Joint Commission requires two additional metrics for monitoring. Again, SHBW surpassed the requirements and tracked 13 additional measures included in GTWG database. Spectrum Health Butterworth was awarded the Get With The Guidelines® Stroke Silver Plus achievement award, exceeding the required 85% compliance for all 7 for the award measures for 12 consecutive months. Spectrum Health also received ASA’s Target: Stroke Honor Roll Elite Plus Quality Award, exceeding the requirement for 75% compliance for 5 out of 8 quality metrics for 12 consecutive months. These metrics include:
These are the highest awards possible based on length of participation in the GWTG program. Achieving gold status is a goal for 2018. Nurses have been actively engaged in the community as to provide education on stroke risk factors, signs and symptoms of stroke, lifestyle changes to prevent stroke, and the importance of seeking emergent medical attention if stroke is suspected. In 2017, Spectrum Health nurses provided stroke awareness and prevention education at the Grand Rapids Health and Wellness Expo, Stroke Awareness Night at a Griffins hockey game, the Annual Stroke Awareness Golf Outing and to students at a local Grand Rapids high school. In addition, nurses helped to plan and volunteered at the inaugural Spectrum Health Stroke Camp for stroke survivors and their caregivers.
Obtaining Comprehensive Stroke Certification is a significant undertaking that requires a dedicated interprofessional team. Nurses in various roles from multiple units were instrumental in this work. In May 2017, SHBW was awarded the first Comprehensive Stroke Certification in West Michigan from the Joint Commission.
Interdisciplinary Comprehensive Stroke Team:
All Emergency Department Charge Nurses
All Neuro IR Charge Nurses and Neuro IR Nurses
All Neuroscience ICU Nurses
All 7 South Stroke Unit Nurses
All 4 South Neuroscience Nurses
Doreen Marcinek, DNP, BSN, RN Director Inpatient Clinical Operations Radiology
Carol Sadat, MSN, RN, NE-BC Director Emergency Services for Butterworth, Blodgett Hospital & ED OBS
Nicole L. Wills, MSN, MBA, RN, NE-BC Director of Orthopedics and Neuroscience
Theresa M. Price, MSN, RN, CNRN Accreditation Specialist
Stephanie Mullennix, MSN, RN, CEN Emergency Department Clinical Nurse Specialist
Tricia Tubergen, BSN, BS, RN, CMSRN Neurovascular Nursing Practice Associate
Ross Busman, BSN, RN Specialist, Clinical Database
Amy Geers, BSN, RN Specialist, Clinical Database
Allison Blair, BSN, RN, CCRN Adult Critical Care Nurse Educator
Linda Richards, BSN, RN Interventional Radiology Nurse Educator
Jean Wysocki, BSN, RN Neuroscience Nurse Educator
Angie Frye, BSN, RN, CNRN 7 South Neurosciences Manager
Andrea Goosen, BSN, RN, CCRN Neuroscience Critical Care Unit Nurse Manager
Jim LaForge, MSN, BSN, RN, CRN Manager Interventional Radiology
Jeff Skinner, MHA, BSN, RN, CEN Butterworth Emergency Department Nurse Manager