The three-year grant will allow the coordination and expansion of existing efforts to improve stroke-related health outcomes. Kentucky health care systems and community providers will work together to implement comprehensive stroke systems for those at high risk for stroke and those who have had a stroke. 

“This program will allow expansion of our statewide efforts to serve rural and underserved citizens of the Commonwealth, to reduce disparities and monitor our progress,” said Kerri S. Remmel, chair of the , director of and co-chair of the KHDSP Task Force. “The program will facilitate continuous quality improvement in the full continuum of care from the moment a patient has a stroke through their emergency services, hospitalization and rehabilitation to their outpatient preventive care. We are extremely enthusiastic about collaborating with our partners in the Coverdell Program to improve stroke systems of care in Kentucky.”

“This award validates the voluntary efforts of stroke center personnel, EMS representatives, community partners, KHDSP staff and colleagues in public health, as well as all other stakeholders who have worked tirelessly across geopolitical boundaries in a collaborative effort to advance stroke systems of care in our state,” said Kari Moore, chair of the  (SEQIP) and project co-investigator. “We are excited to continue to build upon these efforts supported by the Coverdell award.”

KHDSP and SEQIP have made significant strides over the last 10 years improving stroke systems of care in the Commonwealth and growing access to stroke care by increasing the number of certified stroke centers in the state, increasing delivery of acute stroke treatments that can reverse or minimize stroke deficits and sharing best practices to help facilitate care delivery during hospitalization and after discharge.

This grant will coordinate and expand existing efforts in Kentucky to improve stroke-related health outcomes by working with Kentucky health care systems and community providers to implement comprehensive stroke systems for those at high risk for stroke and those who have had a stroke. 

The Coverdell award also will allow the group to target areas of the Commonwealth that are disproportionately affected by stroke, such as the Appalachian counties. The mortality rate due to stroke in that region is 14% higher than the national average and 8% higher than the rest of the state.

“This award could not come at a better time, because Kentucky has among the highest rates of stroke-related deaths in the country,” said , chairman of the  and principal investigator on the project. “Over 2,000 Kentuckians die from stroke or stroke-related complications each year. Health behaviors and conditions that contribute to stroke are present at high rates in Kentucky with contributions from smoking, obesity, diabetes, hypertension, excessive alcohol use and physical inactivity. Although there are several existing stroke programs in Kentucky, we are excited that this project will coordinate and expand upon these efforts to improve stroke outcomes for Kentuckians.”

As part of the Coverdell initiative, the Kentucky Stroke Improvement Cooperative (KSIC) will be created to provide leadership for improving the quality of stroke care in the Commonwealth. Building from the KHDSP Taskforce and SEQIP, the UK and UofL Stroke Programs and the SCN, this group will lead the collaborative effort to transform Kentucky’s stroke care and outcomes by improving health approaches and practices.

Since its inception in 2005, The Coverdell Program has funded programs to ensure that all Americans receive the highest quality stroke care, a leading cause of death and long-term disability, by supporting coordinated stroke systems of care.

Joining nine other states currently funded by the Paul Coverdell National Acute Stroke Program, Kentucky’s program will:

• Increase access and participation in the statewide Kentucky Heart Disease and Stroke Prevention Task Force from the current 38 hospitals to help close the gap in stroke care for high burden populations. In addition to focusing on hospitals, the project will expand participation to encompass the community, primary care clinics, EMS, rehabilitation centers and long-term care facilities.
• Expand coordination between existing programs including the Kentucky SEQIP, the statewide UK/Norton Healthcare Stroke Care Network, and the 36 certified stroke centers in Kentucky.
• Increase access, understanding, utilization, and compliance with evidence-based performance measures of the .
• Expand existing systems of care to coordinate and extend access to rural and underserved populations.
• Increase the dissemination of evidence-based guidelines for improvement of hypertension, obesity and diabetes control, which are the leading risk factors for stroke disproportionately affecting high-burden populations.
• Reduce stroke disparities and deaths over the long term and improve outcomes throughout Kentucky with a focus on Appalachia and underserved communities at highest risk.

As the state’s first , UofL Hospital meets the highest standards of stroke care, and continually raises the bar. Prompt treatment with intravenous Alteplase (IV t-PA) is associated with better outcomes, lower mortality and shorter length of stay for patients with ischemic stroke. One of the key stroke treatment guidelines established by the American Heart Association and American Stroke Association is the administration of IV t-PA within 60 minutes of arrival at the hospital for patients with ischemic stroke. The staff at UofL Hospital continually works to improve this time, aiming to deliver IV t-PA to eligible patients within 45 minutes.  

Deidra Gottbrath, RN, BSN, leads a team of specialized stroke clinical resource nurses on staff at UofL Hospital to help ensure that eligible stroke patients receive IV-tPA as quickly as possible. It can be challenging to determine whether a patient’s symptoms are due to a stroke or another condition. Gottbrath, who is certified in critical care and stroke care, provides the added resource to help expedite this process.

“From the moment we start participating in care, the ultimate focus becomes treating the stroke. That sounds simple, but there are a lot of complex cases that involve stroke symptoms,” Gottbrath said. “We don’t wait until we are sure it is a stroke before we apply that urgency. We focus on treating every case with stroke symptoms as though it is a stroke until we firmly rule out a stroke and let go of that urgency.”

Paula Gisler, RN, PhD, is director of the UofL Hospital Stroke Program and helped define the stroke clinical resource nurses’ role. “These nurses are a resource to patients and physicians to drive care for all stroke patients. They do whatever it takes to get stroke patients appropriate care to achieve the best outcomes.”

The stroke clinical resource nurse supports emergency room nurses to assess potential stroke patients, facilitate scans, get IV-tPA medication prepared, and work with family members. They keep lines of communication flowing among emergency room nurses, doctors, the stroke team, the radiology staff and other providers.

“We are the string that ties the story together so it makes a complete circle, rather than leaving threads that might be woven together later,” Gottbrath said. “Because we focus solely on that one patient and situation, because that is our priority, we can offer the resource of locating family members to get the full story to get the patient treatment.”

Gottbrath and the other stroke clinical resource nurses follow patients beyond the emergency room, advocating for patients and keeping the lines of communication open throughout their stay. They provide education for patients and their families, as well as bedside nurses who care for stroke patients outside of the stroke unit.

“We are involved in the daily discussions of what type of rehab is appropriate for a patient and communicating that back to the families,” Gottbrath said. “We are there from the scariest moment to looking forward to going home or to rehab. We see the full circle of care.”

Kerri Remmel, MD, PhD, director of the UofL Hospital Stroke Center and chair of the UofL Department of Neurology, says Gottbrath and her colleagues are invaluable assets to stroke care.

“Deidra and the other stroke clinical resource nurses provide an exceptional service to our patients,” Remmel said. “They are vital in keeping the focus on stroke care for those patients and making the connections that have led to even more improvements in the care we provide.”

Door-to-needle times reduced 

Gottbrath and Tina Walsh, RN, BSN, another stroke clinical resource nurse at UofL Hospital, compiled research data showing that since the introduction of stroke clinical operations nurses in 2016, door-to-needle times at UofL Hospital have shortened by an average of 2.5 minutes for eligible patients receiving IV t-PA at the hospital. In addition, eligible patients receiving IV t-PA within 45 minutes of arrival increased from 37 to 49 percent. Gottbrath presented the data at the International Stroke Conference earlier this year.

Although the UofL program does not yet have stroke nurses on duty around the clock, having these nurses in the hospital has led to faster door-to-needle times even when a stroke nurse is not in the building.

“This position has encouraged and educated the staff so that even when we are not physically present, stroke care is fresh on people’s minds – they remember the urgency of it,” Gottbrath said.

Gisler expects UofL Hospital will have a stroke clinical resource nurses on duty around the clock by the end of 2018.

A native of southern Indiana, Gottbrath originally planned to become a physician, but she did not feel as engaged in that career path as she expected. She followed her sister’s suggestion to try nursing and discovered it gave her the interaction with patients that she enjoyed.

“As I delved into it, I felt more connected to nursing,” she said. “The minute I started nursing school I thought, ‘This is what I’ve been missing. This is the connection to medicine I always wanted.’”

“Every day is so different and so challenging but so rewarding. Now I can’t image doing something different.”

Re-certification as a CSC, the highest designation of care for stroke patients awarded by The Joint Commission, the primary independent accrediting body for health-care systems in the United States, assures patients that the physicians, nurses and other providers at UofL Hospital are fully prepared to quickly assess and treat patients suffering from all types of strokes using the most advanced treatments available. The Joint Commission re-certified the UofL program for two years, the maximum time period allowed for certification.

“We are proud to serve the citizens of our region with the highest level of integrated stroke care. We will continue to set the bar in Kentucky and Southern Indiana when it comes to stroke prevention and treatment,” said Kerri Remmel, MD, PhD, chair of the Department of Neurology at the UofL School of Medicine and director of the University of Louisville Stroke Program.

Patients are treated by the highly trained and specialized physician faculty members of the UofL School of Medicine, including neurologists, neurosurgeons, cardiologists, emergency medicine providers, neuro-radiologists, vascular surgeons, hospitalists and neuro critical care providers. The multidisciplinary team also includes advance practice nurses, social workers, rehabilitation specialists, case managers and dietitians.

Comprehensive stroke centers such as UofL have the ability to care for patients suffering a stroke, 24-hours a day, 7 days a week, and perform procedures that may not be available elsewhere. When a patient arrives in the emergency department at UofL Hospital, examination, laboratory studies, cardiac tests and state-of-the-art imaging studies can be performed within minutes of a patient’s arrival.

Highlights of the UofL Stroke Program include:

• Rapid delivery of clot-busting drug – The UofL Stroke Program achieved the highest award status from the American Heart Association/American Stroke Association, Target: Stroke Elite Plus Honor Roll, in 2016 for prompt IV administration of the clot-busting drug ). UofL met the standard of administering the drug to more than 75 percent of patients who qualify within 60 minutes of arrival to the hospital, and to more than 50 percent of eligible patients within 45 minutes of arrival.
• Clot-removal techniques – UofL neurointerventional specialists can rapidly open blocked blood vessels by removing blood clots and quickly restoring neurological function to patients.
• Aneurysm treatment – UofL neurosurgeons and interventional specialists are experts with the latest treatments for brain aneurysms, whether with surgery or minimally invasive endovascular coiling techniques.
• Tele-stroke consultations – UofL neurologists provide their expertise to hospitals in outlying communities in Kentucky and Southern Indiana in real time via tele-stroke services. Using a 5-foot, 6-inch-tall robot, physician specialists in Louisville can interact and converse with a patient, the patient’s family, and on-site physicians and nurses through a live, two-way audio and video feed. The remote connection allows neurologists at UofL to more quickly determine the best treatment protocol for patients in their home hospitals and allow them to be treated with IV t-PA or other treatments quickly when appropriate.
• Post-stroke support – In addition to inpatient care, the UofL Stroke Program provides stroke survivor and caregiver support to improve patients’ wellbeing as they resume their daily lives.
• Community education – UofL Stroke Program team members reach out to educate community members about reducing the risk of stroke by monitoring their blood pressure and maintaining healthy habits.

Even prior to its designation as Kentucky’s first certified Comprehensive Stroke Center in 2012, the UofL Stroke Program achieved the highest recognition with the American Heart Association/American Stroke Association, receiving the Get with the Guidelines Stroke Gold Plus Award for the last 11 years. The recognition is awarded for meeting performance guidelines for the treatment and management of stroke patients from hospital admission to discharge.