10th anniversary 2009-2019 - kentucky heart disease ......kari moore, msn, aprn chair, seqip 10th...
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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