Comprehensive Stroke Services, from the Ambulance to Discharge and Beyond

As director of Wake Forest Baptist Medical Center’s Primary Stroke Center, Cheryl Bushnell, MD, associate professor of neurology, leads a dedicated stroke service that provides top-notch regional care with a national reputation for excellence.

Bushnell and her team of renowned clinical and research specialists have spearheaded a full set of process improvements and research breakthroughs that are on the cutting edge of best practices for stroke care throughout the continuum.

Stroke Care Begins with EMS Technicians

Patients lose two million brain cells each minute after they have a stroke. Decrease the amount of time from arrival at the emergency department to the administration of tissue plasminogen activator (tPA), and the patient’s chances for recovery are greatly improved. But before tPA can be safely administered, essential lab tests and CT scans must be completed.

“One of the most innovative things we’ve done at Wake Forest Baptist,” Bushnell said, “is to streamline the process once a patient gets to our emergency department.”

To accomplish this, Bushnell and colleagues have begun collaborating with EMS drivers in the field.

“We provide EMS technicians with blood drawing kits,” said Bushnell. “When they are putting in patients’ IV units in the field, they draw the blood that we need for our lab testing. Upon arrival, patients now go directly to the CT scan, while their blood is immediately sent to be processed for lab results.”

This process improvement has greatly reduced Wake Forest Baptist’s door-to-CT scan, door-to-lab-result, and lab-to- needle times. The improvement is now being shared with other hospitals and medical centers throughout the region as a simple and effective way to significantly improve stroke patient care.

Preventing Stroke in the “Stroke Belt”

Stroke specialists at Wake Forest Baptist have worked closely with the North Carolina Stroke Association (NCSA) to develop a wide range of stroke preventative tools and educational materials. One such tool is the Stroke Risk Identification Program, developed by Charles H. Tegeler IV, MD, professor of neurology and director of Wake Forest Baptist’s Telestroke Services, and colleagues, in partnership with the NCSA. This robust screening and response tool has helped numerous hospitals and health care providers across the state identify, educate and follow up with patients at high risk for future stroke.

“Programs like the Stroke Risk Identification Program are being spread throughout the state via the North Carolina Stroke Association,” Bushnell said. “These programs are exceptional ways to promote secondary prevention and educate patients once they leave the hospital.”

[Read: Targeting Stroke in the Stroke Belt]

Defining the Barriers to Adherence After Discharge

Leading stroke centers must provide exceptional care for patients in the acute stage. Effective testing, medication management, surgery and other neurointerventions are essential components of successful treatment plans. But equally important is the post-acute phase. What happens after a patient is discharged from a hospital?

Bushnell is co-principal investigator of the Adherence Evaluation After Ischemic Stroke-Longitudinal (AVAIL) Registry, a registry of more than 2,500 adult patients who have been admitted to hospitals with ischemic stroke or transient ischemic attack. What Bushnell and her colleagues have discovered from the dataset is that one quarter of all stroke patients discontinue one or more of their prescribed secondary stroke prevention medications within three months of hospitalization.

The problem, Bushnell notes, is one of education. “People who didn’t understand why they were taking their medications or how to refill them were the ones who were most significantly likely to stop their medicine,” she said. “That tells me we need to spend more time talking to patients and understanding what their barriers to taking their medications are. Too often we just label patients as noncompliant but don’t understand what their issues are.”

Bushnell’s research group is developing a new intervention that will do just that. In the study, currently in its pilot stage, a non-health professional queries patients with individualized questions about medications and treatment. This person directly answers patients’ questions or obtains answers from medical specialists.

The research group has already obtained valuable qualitative feedback from the pilot study’s participants, giving them a clearer understanding of stroke patients’ barriers to adherence. Their next step is to develop educational materials for primary care physicians and patients.