Jane Morris, MD
Greetings to all interested in improving the care of stroke patients!
I am honored to have been elected the first chair of the Maine Stroke Alliance (MSA) and would like to take this opportunity to share a bit of my background and my vision for what I would like to accomplish in the coming years.
I joined Maine Medical Partners Neurology in 2011 as the Assistant Medical Director of Stroke and the first Neurohospitalist with the explicit goal of helping Maine Medical Center become the first Comprehensive Stroke Center in Maine. I became the Medical Director of Stroke in 2015, and in 2017, we attained our CSC goal. In 2015 we also launched the MaineHealth TeleStroke Network, which provides emergent stroke consultative service to 8 smaller hospitals, with a 9th soon to onboard. With these accomplishments and seeing so many stroke patients from across the state of Maine and eastern New Hampshire, I became interested in not only improving stroke care at these hospitals but wanting to enhance stroke care across the state.
Realms of Stroke Care
Stroke care spans many environments, from the community and EMS to acute management in the Emergency Department and hospitals to post-acute care involving rehabilitation efforts, secondary stroke prevention, and community reintegration. Every step along this path contains opportunities to improve care with the ultimate goal of providing the best possible outcome for each individual patient. (Figure 1)
Figure 1: Realms of Stroke Care
In 2017 a wonderful group of dedicated folks from around the state began to meet quarterly in our state capital to discuss how we could improve stroke care in Maine. We galvanized around the idea that we, as a state, could do better for our stroke patients if we had a more consistent, coordinated, and integrated system of stroke care. The accumulating publications of landmark studies on the efficacy of mechanical thrombectomy for acute large vessel occlusive (LVO) stroke cannot be understated and procured a sense of urgency to improve our system, as for patients to receive the benefits of this treatment; they need to be in a center where this procedure can be provided. We have made progress along the way, including creating a Maine EMS statewide severity-based triage algorithm, EMS Inter-facility documentation support, and EMS interfaculty stroke order set, all of which can be found in the resources section of this website. However, there remain many more opportunities to improve organization at the state level with engagement from the community, EMS, Life Flight of Maine, critical access hospitals, and smaller regional hospitals to identify these patients quickly and transport them to where they need to be. While prehospital and emergent care of stroke has been where the MSA has primarily been focusing its efforts and energy thus far, there is much more to do. I would like to expand the breadth and depth of our commitment to improving the other realms of stroke care.
MSA Mission Statement
To create a coordinated system of stroke care throughout Maine that addresses stroke education and prevention, acute and subacute stroke treatment, stroke recovery, rehabilitation, community reintegration, and secondary stroke prevention.
My goals for the MSA in the next 2 years are as follows:
1. Set standards for acute stroke care across the state
2. Advocate for a regional system of integrated stroke care, such as supporting efforts to enhance EMS services and creating a statewide stroke communication center to assist patients requiring emergent transfers
3. Grow the membership of MSA, with particular attention to enhancing committees addressing the multifaceted aspects of care of the stroke patient and their caregivers (Figure 2)
Goal 1: Set the standards
For this goal, we must ask ourselves 2 questions:
• What is the current state of acute stroke care in Maine?
• What should the future of acute stroke care look like in Maine?
In 2017 the MSA conducted a survey on the current state of stroke care in Maine. Some of the key takeaways for me from this survey included that all acute care hospitals in Maine are engaged in stroke care. Still, there is variability in practice, processes, and availability of stroke expert input. The majority of hospitals (56%) did not have a designated acute stroke response team, a third of hospitals had no access to a neurologist for acute stroke evaluation, and many patients are not receiving thrombolysis within 60 minutes (which the AHA/ASA now recommends be less than 45 minutes).
I would like to embark upon another updated survey of stroke care in Maine, but this time, I would like to do it in a more hands-on, systematic way with explicit goals for what will be done with the information.
What we want:
• An integrated, coordinated, patient-centered, clinically effective, cost-effective regionalized system of care that optimizes outcomes following stroke.
• The goal is to improve stroke care across Maine, not just at designated stroke centers.
• This includes supporting community hospitals to continue to care for appropriate stroke patients.
Ask yourself What are the stroke resources currently available at your facility?
How well are they working?
Is your hospital meeting acute stroke standards?
Where are the gaps in care?
What can be done better? How do we get there?
Stroke Treatment Assessment Teams (STAT)
I envision the creation of a new program based on the system already familiar to hospitals from engagement with the Trauma Advisory Committee, called Stroke Treatment Assessment Teams (STAT). These teams will:
• Identify designated Stroke Champions (at least one physician and one nurse) to serve as a contact point and spearhead local quality improvement efforts.
• Provide an onsite assessment for every hospital in Maine regarding current stroke care to identify gaps and recommend process changes as needed.
• Assist sites with developing protocols and pathways and provide education to staff where needed.
• Advocate and assist in creating methods of data collection, abstraction, and analysis where needed.
• Advocate for needed staffing & equipment upgrades where needed.
• Provide education to EMS and ED staff around optimizing stroke care as requested.
Goal 2. Advocate for a more coordinated system of stroke care
What if every person in Maine had a clear Stroke Plan in place?
• That means that in any location in Maine, if someone developed symptoms of a stroke, EMS would perform a standardized assessment, including an LVO score, and follow routing protocols to expedite transfer to the most appropriate facility with pre-notification.
• Prior to arrival at the most appropriate location, a team that had received stroke-specific education and training would be prepared to receive the stroke patient with clear pathways and protocols to optimize assessment and diagnosis.
• Assessment, workup, and treatment would be appropriate and timely.
• If that patient required advanced stroke treatment, a transfer protocol would be in place for ensuing the patient receives the most appropriate level of care.
• The Emergency Medicine provider would only have to call one number to be connected to a centralized communication center that would know what the current available resources were, including options for ground and air transportation and receiving hospital bed availabily, to expedite transfer to the most appropriate facility to minimize delays in transfer times.
• Transfer would occur using appropriate EMS transfer processes & protocols utilizing order sets and standardized inter-facility communication, either electronically or on paper.
• For those transferred, upon arriving at the receiving facility, care will be efficient and organized to ensure the patient receives the best acute care possible.
Goal 3. Growing the MSA
In 2020 the MSA made the first efforts to expand our reach beyond the acute care phase by creating subcommittees. COVID has thwarted efforts to advance the goals of these subgroups, but with waning demands from the pandemic, I am hopeful these can get back on track. (Figure 2). We now have this website, and all of our meetings will have a virtual option which will hopefully assist with widespread participation by preventing the need for travel and improving the ease of connecting with others. While the sky is the limit, there are many opportunities that I can currently envision these groups have for impacting stroke care (Figure 2).
Figure 2: MSA Subcommittees
Table 1: Opportunities to improve stroke care in Maine
Community education and primary stroke prevention
· Initiate population-based approaches to stroke prevention throughout Maine
· Enhance public education on stroke recognition and calling 911
· Enhance primary care provider education throughout Maine regarding primary and secondary stroke prevention, stroke treatment, and available stroke care services in Maine
· Identify or develop educational material for primary care providers to give to their patients including local resources for stroke prevention (health coaches, dieticians, medication assistance programs, tobacco cessation services, etc.)
· Enhance the MSA Website to include more stroke education & resources for primary care providers
Acute stroke care: Prehospital
· Training/refresher courses on standardized stroke scales (CPSS, FAST-ED) with LVO education on the importance of rapid triage & treatment
· Prehospital triage, pre-notification & routing protocols
· Develop, enhance, and adhere to protocols for inter-facility transport
· Utilization of the Stroke Transfer Order Set & inter-facility communication document
· Utilize EMS data collection to drive systematic improvements in care
· Advocate for enhanced EMS funding, training, and hiring to meet the needs of the population served
Acute Stroke Care: Emergency Department
· Stroke Treatment Assessment Team evaluations
· Identifying stroke Nurse and Physician Champions in every ED to focus attention on stroke care
· Streamline questioning around thrombolysis eligibility and information regarding risks and benefits
· Utilize Lean Processes to optimize the efficiency of stroke care
· Establishing Direct-to-CT processes
· Education on CT/CTA, LVO scores, acute stroke management
· Stroke system protocols and education as part of orientation and annual training
· Stroke recognition education for EM providers
· Access to timely thrombolysis and expedient transfer as needed
· Advocate for a centralized communication center to assist in expedited transfers
· Stabilization and possible transfer for many patients with ICH or SAH
· Proper monitoring and management of blood pressure, blood glucose, neurological status, cardiac status
· Establish a system for local data collection, review, and action on QI opportunities
Subacute Stroke Care: Hospital Management
· Identify Stroke Champions in every hospital
· Create a system of education on stroke for inpatient provider
· Review/revise local protocols for stroke management, local order sets, transitions of care
· Encourage the creation of designated stroke units at hospitals that admit stroke patients
· Ensure education regarding proper initiation of secondary prevention strategies (medical, surgical, endovascular)
· Ensure proper and thorough evaluation to assess the cause of stroke
· Ensure appropriate measures are taken to address and minimize potential complications of a stroke (aspiration pneumonia, DVT/PE, bedsores/skin breakdown, etc.)
· Encourage hospitals to seek Joint Commission certification for their appropriate level of stroke care based on size and resources
· Assist in the development of resources for best discharge practices, including the use of a stroke discharge order sets, patient education, and arranging follow up
Chronic Stroke Care: Rehabilitation and Community Education
· Assess the availability of physical, occupational, and speech therapists at all hospitals; provide education support, and resources where needed
· Assess the availability of physiatrists and neurocognitive rehab specialists; assist in connecting patients with necessary rehabilitative specialists
· Ensure all patients undergo the proper assessments for rehabilitation needs
· Assist in stroke education and resources at acute and subacute rehabilitation facilities
· Assist in providing stroke education to the staff at skilled nursing facilities regarding stroke recognition, post-stroke care, and secondary stroke prevention
· Assist in transitions of care and ensuring follow up with appropriate specialists, which may include primary care, neurology, physiatry, psychiatry, vascular surgery, neurosurgery, cardiology, and/or others
· Assist in the developing systems and identifying local resources that may improve reintegration into the community (vocational rehab, adaptive driving, adaptive sports, transportation services, assistance with psychosocial needs, etc.)
· Assist in identifying adherence to secondary stroke measures (health coaches, dieticians, medication assistance programs, tobacco cessation services, etc.)
· Acute inpatient rehab facilities that treat stroke patients should seek Disease-Specific Care Certification from The Joint Commission for stroke rehab where appropriate
Stroke Data, Research, Technology, and Innovation
· Work towards the establishment of a statewide stroke database for quality improvement purposes
· Define data elements of interest
· Identify the mechanism of data collection and maintenance
· Identify means for data analysis and action
· Provide data feedback to providers involved in patient care
· Serve as a potential source for research
· Seek grants and collaboration to support a research initiative
· Create innovative technological solutions to barriers in stroke care (telehealth, phone applications, wearable biotechnology, etc.)
A stroke can be a devastating event. However, we have a tremendous opportunity to impact the trajectory of a patient’s illness and literally alter the fate of their oxygen-deprived brain cells—this is a common problem with highly effective treatments and the potential for significant recovery with good medical care. We can impact at all stages of the disease process, from primary prevention to mitigating the initial injury with thrombolysis and thrombectomy, avoiding preventable complications in the hospital, optimizing rehabilitative and reintegration efforts, and preventing recurrent strokes.
Let’s work together to ensure every person who suffers a stroke in Maine gets the best care possible!